The Role of Gender in Nurse-Resident Interactions: A Mixed-methods Study

Introduction The role of gender in interprofessional interactions is poorly understood. This mixed-methods study explored perceptions of gender bias in interactions between emergency medicine (EM) residents and nurses. Methods We analyzed qualitative interviews and focus groups with residents and nurses from two hospitals for dominant themes. An electronic survey, developed through an inductive-deductive approach informed by qualitative data, was administered to EM residents and nurses. Quantitative analyses included descriptive statistics and between-group comparisons. Results Six nurses and 14 residents participated in interviews and focus groups. Key qualitative themes included gender differences in interprofessional communication, specific examples of, and responses to, gender bias. Female nurses perceived female residents as more approachable and collaborative than male residents, while female residents perceived nurses’ questions as doubting their clinical judgment. A total of 134 individuals (32%) completed the survey. Females more frequently perceived interprofessional gender bias (mean 30.9; 95% confidence interval {CI}, 25.6, 36.2; vs 17.6 [95% CI, 10.3, 24.9). Residents reported witnessing interprofessional gender bias more frequently than nurses (58.7 (95% CI, 48.6, 68.7 vs 23.9 (95% CI, 19.4, 28.4). Residents reported that gender bias affected job satisfaction (P = 0.002), patient care (P = 0.001), wellness (P = 0.003), burnout (P = 0.002), and self-doubt (P = 0.017) more frequently than nurses. Conclusion Perceived interprofessional gender bias negatively impacts personal wellbeing and workplace satisfaction, particularly among female residents. Key institutional stakeholders including residency, nursing, and hospital leadership should invest the resources necessary to develop and integrate evidence-based strategies to improve interprofessional relationships that will ultimately enhance residency training, work climate, and patient care.

role in establishing positive interprofessional relationships, 12 less is known regarding the role of gender, particularly for interprofessional relationships.
Gender disparities persist within the medical field for both nurses and physicians, with studies documenting continued salary disparities for both professions. [19][20][21] There is also evidence of significant differences in faculty evaluation of female and male trainees with respect to milestone achievements during residency, 22,23 which may be attributable to unconscious gender bias. Similarly, female gender is associated with more negative nursing evaluations of resident physicians; 24,25 however, limited data exist to explain factors that contribute to this disparity. 26 Research on the intersection of gender on resident/nursing interactions and leadership styles during resuscitations reveals that female residents express higher stress levels and discomfort when exhibiting directive leadership styles, despite this often being perceived as the most effective style; furthermore, female residents report needing to negotiate interactions, "gain trust," or choose less assertive behaviors during interprofessional interactions than their male counterparts. 10,[27][28][29] However, the impact of gender bias on interprofessional relationships is not as well studied, 10,30,31 in particular the extent to which gender bias occurs in interactions between resident physicians and nurses. During residency, physicians develop behavioral practice patterns that may last throughout their careers. The aim of this study was to explore and understand perceptions and experiences of gender bias in the context of interprofessional relationships between emergency medicine (EM) residents and nurses. This study builds on emerging literature exploring the ways in which gender shapes interactions between nurses and physicians during residency training. 10 Our findings can inform strategies for improved interprofessional collaborative practice during residency training. participation in the qualitative portion of this study were limited to those with more than two years of institutional experience. The research team's resident members [EC, AC] contacted eligible participants from a roster of 42 residents, while the research team's nurse members [JV, LN] contacted a convenience sample of 31 nurses from both institutions who were eligible and who had indicated in informal conversations that they would be willing to participate. After an individual expressed their willingness to participate, scheduling was taken over by the team's social scientist [NZ], who conducted interviews and focus groups.
Semi-structured interviews were piloted with three individuals (one female nurse and two residents, one male and one female) to refine interview and focus group guides. Subsequently, focus groups were conducted with residents, separated by gender. Due to scheduling challenges, five nurses from two different institutions opted to participate in individual interviews rather than as part of a focus group. Between June-October 2019 interviews and focus groups were conducted by a trained interviewer [NZ] with no professional role in the residency or either ED. Questions focused on providers' perceptions and experiences of how gender affects interprofessional interactions (Appendix 1). Interviews ranged from 20-40 minutes; focus groups lasted 90 minutes. Interviews and focus groups were recorded with consent of participants and transcribed verbatim using a transcription service (TranscribeMe, Inc., Oakland, CA).
We analyzed using inductive and thematic content analysis, 32 allowing dominant themes to emerge. Free-text responses from the electronic survey (see below) were also coded and included in qualitative analysis. The research team developed a codebook from successive rounds of reviewing transcripts. Each transcript was coded for themes independently by two of four authors [EC, LN, JV, NZ] using a web-based, qualitative data analysis tool (Saturate, Jonathan Sillito, Brigham Young University, Provo, UT). An experienced qualitative researcher [AC] led resolution of coding discrepancies with research team input.

Reflexivity
Reflexivity in qualitative research refers to researchers' consideration of how their sociocultural values and experiences influence study design and analysis. Qualitative data was collected by a social scientist [

Phase II: Quantitative Study
An anonymous electronic survey, developed through an inductive-deductive approach informed by the interviews and focus groups, was administered via Research Electronic Data Capture (REDCap, Vanderbilt University, Nashville, TN) and distributed via institutional email to all EM residents (60 individuals) and EM nurses at both hospitals (159 at one facility and 203 at the other), regardless of experience level. Up to two reminders of the invitation to participate were sent over the course of one week. Respondents were asked about the perceived frequency with which gender affects both their personal and witnessed interactions with colleagues across professions. Participants were also asked about how interprofessional gender bias affects the workplace with regard to job satisfaction, patient care, personal wellness, burnout, self-doubt, and patient safety. We collected basic demographic and professional experience data. Complete survey questions are available (Appendix 3).
For the purpose of exploring the impact of seniority on perceptions of gender bias, postgraduate year (PGY)-1 and -2 residents are considered "junior," while PGY-3 and -4 residents are considered "senior." Nurses with >4 years of experience were considered "senior," while those with fewer years of experience were considered "junior." We analyzed data in Stata 15.0 (StataCorp, LLC, College Station, TX), and included descriptive statistics and between-group comparisons using Student's t-tests for continuous data and two-sample Wilcoxon rank-sum test for ordinal data.

Ethics
This study was reviewed by the local institutional review board and determined to be exempt from further review (Protocol #2019P000147). Funding to support this research was provided by the Massachusetts chapter of the American College of Emergency Physicians 2018 Resident Research Grant. We report qualitative findings following the Standards for Reporting Qualitative Research guidelines. 33

RESULTS
This study included 20 participants in the first, qualitative phase, and 134 respondents to the quantitative survey. The findings from each phase are described below, and in Tables 1-5.

Qualitative Data
A total of 20 individuals participated in the qualitative portions of this study (see Table 1). Individual interviews were conducted with eight participants: six nurses (three female and three male, two from one institution and four from the other), and two residents (one female and one male). Focus groups were gender-specific with seven male residents in one group and five female residents in the other.  Table 2.

I. Communication
The theme of how gender shapes communication in interprofessional relationships emerged from data collected from both residents and nurses, particularly among females of each group. Examples of how gender shapes interprofessional communication significantly differed between nurses and residents. Female residents perceived questions from nurses about patient care as a threat to their decision-making and expertise. Female nurses identified feeling that female residents are more approachable about patient care questions and are more collaborative in their language and behavior than male residents.

II. Examples of Gender Bias toward Nurses
Nurses offered two major examples of witnessed or experienced interprofessional gender bias. They described male residents dismissing female nurses' perspectives about patient care and emphasized that this occurs much more frequently than with female residents. Dismissive behaviors included residents not being willing to engage in conversation about nurses' concerns about orders, lab values, or plans of care. The second example centered on the perception that male nurses receive more respect than female nurses. Both female and male nurses perceived that resident physicians,   Approximately 80% of emergency medicine (EM) nurses in the study population identify as female; exact numbers were not available as this was beyond the scope of IRB-approved data collection.

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At the time of this study, 23 of 60 EM residents identified as female (gathered through personal correspondence with ECM and AC), yielding a 47.8% response rate among female EM residents. M, male; F, female; % respondents indicates response rate within professional group; SD, standard deviation; PGY, post-graduate year.
And I went into the room, I saw that the patient was unstable, and I said--or could be unstable. And I said, "Hey, do you think we should--" and it's never a, "Do this," it's always like, "We should--" or "Can we--" The way we phrase things is also very different. I imagine it probably varies between men and women. But I think, again, going back to that--you have to kind of do a shared decision making. I'm never commanding anybody to do anything, so it's like, "Do you think we should get more IV access on this patient?" and she was just like, "No. This patient is totally stable, doesn't need it. I'm not doing it." -Female resident [Focus Group 1, speaker 4] Female and male nurse interactions with female residents vs male residents "Well, when I'll question a dosing of a medication and asking for an explanation and if feels like--I don't want to put words in someone else's mouth but I think sometimes the male doctor has maybe kind of sometimes brushed me off and sometimes explained but maybe not in a thorough way that I would like. Whereas I feel like some of the female residents have been more open to explaining the situation and their rationale and they go into more in depth and stuff than maybe some of the male doctors have and stuff. Where they have been more dismissive at times and stuff about why they're doing things and stuff." -Male nurse [Interview 4] "And for the most part, there's always going to be somebody --there's always new and up-and-coming residents that will turn to the nurse and say, "What do you think?" And there have been. And in that case, I will say I've had more female residents ask me that than the male docs. I mean, there's one here and there. Don't get me wrong. But more of the female residents will say, "What do you think?" -Female nurse [Interview 5]

II. Examples of gender bias toward nurses
Dismissal of female nurse's concerns about patient care "I've been called sweetie, hon, etc., more times than I can count. Been referred to as 'just a nurse,' and my input regarding patient care, decision-making or patient's condition has been dismissed." -Female nurse [Survey, open response, respondent 70] "I think sometimes the male doctor has maybe kind of brushed me off, and sometimes explained but maybe not in a thorough way that I would like. Whereas I feel like some of the female residents have been more open to explaining the situation and their rationale, and they go into more in depth and stuff than maybe some of the male doctors have." -Male nurse [Interview 4] "So let's say they put in an order and you disagree with it…Guy doctor will get all offended, not change it. You have to go above him usually and go to an attending in order to advocate for your patient, while a female resident will be like, "As a female RN, I sometimes feel like some male physicians will not make eye contact with me when I am asking for a med request or patient questions, rather than females, who usually do look me in the eye. I do understand that we are all busy and focused on documenting and charting, but I feel disrespected when that eye contact is inconsistent.

Role of Gender in Nurse-Resident Interactions
Cleveland Manchanda et al. "I think I've probably seen more of the female nurses being more aggressive towards some of the female residents than male residents, I think in general. I think I've seen them be more critical of their same gender, so." Male nurse [Interview 4] "I think that I commonly get more preferential treatment from nurses because I'm male. I think that especially within-a great example is when nurses will say that they have more confidence in your decision-making than they do in one of your female colleague's decision-making.

III. Examples of Gender Bias toward Residents
When residents were asked for specific examples of witnessed or experienced gender bias toward residents, two major examples were described. First, female and male residents alike perceived that female residents receive more "pushback" from nurses of both genders. This included nurses questioning residents about orders and plans, disregarding residents' plans, or not supporting residents in performing procedures. While residents held these perceptions regarding patient care in general, some reported the dynamics as more obvious and upsetting to female residents when they occurred during trauma and critical care resuscitations. Secondly, both female and male residents perceived that male residents have greater ease establishing friendly and collegial relationships with female nurses. With the exception of a few female nurses with whom male residents had difficult interactions, male and female residents perceived female nurses to be more friendly with male residents and interested in socializing with them outside the hospital. Female residents felt that they had to work harder and be more deferential toward female nurses to build relationships with them over time.
Participants from both professions recognized that gender alone did not account for their or others' experiences of being dismissed or questioned. Rather, residents reported that gender had a lesser impact on interprofessional interactions as they progressed through training and gained more institutional experience.

IV. Responses to Gender Bias
Several suggestions emerged within the theme of responses to interprofessional gender bias. Both residents and nurses identified filing "safety reports," the institutional standard for addressing quality concerns, as a potential course of action. However, residents identified their lack of anonymity as a major deterrent to pursuing this option. Nurses identified filing a complaint with the human resources department as an alternative. However, no respondents reported having taken these steps. Both nurses and residents gave examples of discussing biased interactions with their same-profession colleagues, including the emotional impact of these problematic experiences.

Quantitative Survey
In total, 134 individuals (32% response rate) completed the survey, including 104 nurses (28.7% response rate) and 30 residents (52.6% response rate) ( Table 1). Participating nurses were 84.6% female, while 36.7% of resident respondents were female. The gender balance of respondents roughly reflected that of each of these groups (approximately 80% female nurses at each institution; 38.5% of residents identified as female, yielding a 47.8% response rate among female EM residents). None of the respondents identified as non-binary. Among nurses, four individuals preferred not to indicate their gender, and their data were omitted from between-gender comparisons. The mean age of nurse respondents was significantly older than residents (36.7 vs 29.4 years, P <0.001). Most (80.6%) respondents selfidentified as White, although the resident cohort had greater racial diversity ( Table 1).

Perceptions of Gender Bias in Interprofessional Interactions
Perceptions of the frequency with which respondents both experienced and witnessed interprofessional gender bias were evaluated on a 100-point scale, labeled from "never" (0) to "always" (100) ( Table 3). Among all respondents, females more frequently reported experiencing interprofessional gender bias than males (mean frequency 30.9, 95% confidence

Perceived Manifestations of Interprofessional Gender Bias
Several questions explored the perceived manifestations of interprofessional gender bias that emerged from qualitative data, including the following: having a concern raised about oneself to a superior; having an order ignored; being given less trust; having one's role confused by a cross-professional colleague; and being called a term of endearment by a cross-professional colleague. With the exception of having orders ignored, resident physicians reported experiencing each of these manifestations of gender bias significantly more frequently than their nursing colleagues (Table 4). No significant differences were identified between female and male nurses; however, female residents experienced each of these significantly more frequently than their male resident colleagues.

Impact of Gender Bias in Interprofessional Interactions
Respondents were asked about the frequency with which interprofessional gender bias affected several aspects of their work experience and patient care. Residents, when compared with nurses, more frequently felt gender bias negatively affected job satisfaction (P = 0.002), patient care (P = 0.001), personal wellness (P = 0.003), burnout (P = 0.002), and selfdoubt (P = 0.017). Female residents felt gender bias affected these areas more frequently than their male colleagues, and more frequently than female nurses (Table 5). No significant between-gender differences were found among nurses on these factors, nor between male nurses and male residents.
Seniority did not modify any of the aforementioned relationships. The perceived negative impact of gender bias on job satisfaction increased with seniority among female residents (P = 0.01), but seniority was not otherwise associated with significant differences in the perceived impact of interprofessional gender bias.

DISCUSSION
Gender shapes the professional experiences of healthcare providers, including medical students, 2 resident physicians, 10,28 and nurses. 20,21 The extent to which gender bias shapes interprofessional interactions between residents and nurses remains incompletely described, although existing literature suggests that female gender identity may complicate interprofessional interactions. 10 Power and privilege are created and justified through multiple social identities: Gender operates not alone but in conjunction with sexuality, race, ability, and other social identities to advantage some and disempower others. 34 By design, this study focused specifically on the ways in which gender affects interprofessional interactions between resident physicians and nurses in the emergency department (ED).
Our study is situated in an understanding of gender through gender socialization theory, 35 which posits that humans learn femininity and masculinity through social interactions, primarily with their families, peers, and groups. We become socialized into traditionally binary gender roles and identities, which create differential societal expectations for males' and females' behaviors. These expectations of gender roles permeate all environments, from the household to the workplace. In medicine, for example, women are expected to display caregiving and communicative capacities, while men are expected to display leadership and decision-making capacities, stemming from traditional gender roles within the household and society at large. Particularly early in residency, informal learning occurs in interprofessional relationships. 3 This learning may shape long-standing behaviors and can affect professional identity development. As women now make up almost half of resident physicians across specialties, 36 it is more important than ever to understand the ways that gender and gender bias affect interprofessional relationships. This study reveals that both nurses and residents view gender as an important factor influencing interprofessional interactions; however, the perceived manifestations and impact of gender differed sharply between the two professional groups. This was most notable in qualitative data revealing how gender shapes communications between EM nurses and residents. While EM nurses expressed frustration with male residents, who were viewed as more dismissive and less collaborative when approached with a patient care question, female residents felt that frequent questioning of their clinical plans by nursing colleagues, and particularly from female nurses, reflected a lack of trust of female physicians. These starkly different perceptions of the same interactions build on prior literature demonstrating that physicians and nurses have disparate experiences of their interprofessional interactions with regards to communication and collaboration. 4-8,10,12 While the intent behind nursing-initiated communication with residents is to improve patient care, this study revealed that for female residents in particular such interactions may increase self-doubt and insecurity. Understanding these differing perspectives highlights the need for further collaborative and longitudinal discussions between the two groups, particularly among females early in residency training, in order to bridge this gap and find ways to both mitigate problematic interactions and clarify the intent and goals of such conversations. 26 Examples of gender bias shared by both residents and nurses reveal persistent and stark differences in how male and female health professionals experience the workplace. While males were more willing to attribute negative interprofessional interactions to personality differences, females more often identified gender as a defining factor in shaping these relationships. These findings were further underscored in the survey findings, as females of both professions reported experiencing interprofessional gender bias more frequently than their male counterparts (among female vs male nurses, mean frequency 26 . Female residents reported both experiencing and witnessing interprofessional gender bias to a much greater degree. Female residents more frequently reported perceiving the various manifestations of gender bias in their cross-professional interactions (Table 4), and similarly were far more likely to report that this adversely affected their experiences in the workplace ( Table 5).
The perceived negative impact of interprofessional gender bias on female residents in the ED may in part result from female residents taking on stereotypically gender-discordant professional roles, 26,37-39 through which they are expected or encouraged to take on more typically male characteristics. The persistent and pervasive negative effects of gender bias in interprofessional interactions may have implications for patient care and patient safety. Effective communication across professional lines is a key component in the delivery of high-quality care; there is ample evidence that disrespect and poor team dynamics can harm patients. 8,[11][12][13][14][15][16] Across both professions, participants in the qualitative study expressed a sense of limited agency in addressing instances of perceived gender bias, which translated into a sense of apathy, frustration, or both. Both residents and nurses felt that additional years of experience may mitigate challenges in interprofessional interactions. Although the study was not primarily designed to explore the interaction

Role of Gender in Nurse-Resident Interactions
Cleveland Manchanda et al.
between seniority and the various manifestations of interprofessional gender bias explored in this study, in quantitative analysis no such correlation emerged. Further investigation into the relationship between years of professional experience and the ways in which gender shapes interprofessional interactions may prove fruitful.
Educators and leaders within medicine may find it useful to look to the business world for examples of how gender shapes workplace interactions. Much has been written about gender and leadership in business, including the ways in which stereotypically female leadership styles, which in some sectors may be more democratic and participatory, rely more on communication and relationship building. 40,41 Men may benefit from adopting some of these collaborative styles in business, 42 and this may be true for clinicians of both genders in medicine. Relational coordination, a "mutually reinforcing process of communicating and relating for the purposes of task integration" described by Gittell et al, has proven effective in healthcare settings both for improving quality of care and job satisfaction among clinicians. 43 Fostering strong interprofessional relationships between early-career physicians and nurses, particularly between females, may increase job satisfaction and mitigate perceptions of gender bias.
During residency, physicians not only learn medical knowledge and procedural skills, but also develop leadership styles and other patterns of behavior that can persist throughout their careers. Strong inter-professional relationships are integral to providing excellent patient care. [11][12][13][14][15]17,18 Fostering collaborative interprofessional communication and strong nurse-physician relationships while in residency may result in attending physicians who promote and model more collaborative behaviors throughout their careers. Support from nursing leadership in EDs to foster positive, genderinformed interactions between EM nurses and the residents who work alongside them is equally important to fostering a collegial and respectful work environment for all healthcare providers. Educators and administrators -physicians and nurses alike -must consider and endeavor to understand the ways in which gender affects these interactions. 38 Several strategies for improving interprofessional communication between residents and nurses have been explored by others, including structured "huddles," 44 simulation exercises, 45 and collaborative "time-outs" prior to patient discharge, 46 with variable efficacy. Further work is needed to understand, develop, and implement strategies for mitigating the negative impact of gender bias in interprofessional interactions; study participants suggested several possible interventions, which may warrant additional exploration through future research. Most of our study participants perceived gender bias in the clinical environment but demonstrated a reluctance to report this bias. Effective and safe mechanisms to report incidents and to ensure accountability and follow up of these occurrences should be explored.
In this study we identified a variety of suggestions for improving other aspects of interprofessional interactions. One interesting recommendation for improving cross-professional female allyship was to establish mentoring pairs between a female nurse and incoming female resident during intern orientation. Other means of increasing awareness could include workshops, video learning, and simulation exercises. At a local level, the findings from this study have led to the formation of a working group at one of our institutions, through which nurses and residents are exploring strategies for improving communication and assuring mutually respectful interactions. Further study of the effect of gender bias in interprofessional interactions between resident physicians and nursing colleagues should include the ways in which this occurs across specialties and throughout the career cycle of clinicians.

LIMITATIONS
This study has several limitations. First, it was conducted only at large, urban, training hospitals hosting a single residency training program. Findings may not be transferrable to other training environments. The qualitative data was gathered by a social scientist unaffiliated with either the residency program or the hospitals; however, her gender (female) may have influenced the information shared by participants. Similarly, the qualitative analysis team included only female researchers, which inevitably shaped our interpretation of this data. Nursing perspectives were proportionally less represented in the qualitative portion of this study due to logistical challenges in recruitment. Similarly, response bias may have influenced our findings, particularly for the quantitative portion of this study. While the gender balance of respondents was similar to that of eligible participants in both professions, the opinions of study participants may differ significantly from those who chose not to respond to invitations for either interviews/focus groups or the emailed survey.
Lastly, our study included few participants whose backgrounds are historically and contemporarily underrepresented in medicine. The intersection of race and sexuality with gender identity inevitably affected our findings; further study is warranted to understand the ways in which other forms of social identity influence interprofessional relationships.

CONCLUSION
Gender shapes interprofessional interactions between resident physicians and nurses. The perception of gender bias contributes to dissatisfaction in the workplace, the effects of which are felt by both male and female nurses and residents, but disproportionately more by females of both professions. Female residents more frequently report experiencing the negative impacts of gender bias in their interprofessional relationships, raising concerns for their residency training and overall wellbeing. Key institutional stakeholders including residency, nursing, and hospital leadership should invest the