Between March and April 2024, interviews were conducted with 11 medical registrars. These took place, on average, eight months following the simulation course (range three to 12 months). Interviews lasted an average of 31 minutes. Themes were identified relating to the four cognitive domains of psychological empowerment in the workplace; meaning, competence, self-determination and impact, with subthemes developed within each domain. These are discussed below and summarised with illustrative quotes and underlying mechanisms in Table 1.
Table 1
Summary table of themes, subthemes, illustrative quotes and underlying mechanisms
Subtheme | Illustrative Quote | Mechanism |
|---|
Meaning |
|---|
Advocacy across boundaries | “my automatic feeling was to very much be my SHO’s [resident doctors] advocate and I think one of the things that I reflected on was that the coordinator [nursing colleague] also was very stressed…” (P7) | A sense of advocacy across boundaries influenced by observing incivility within an interprofessional team in the simulation followed by individual and peer reflection. This appeared to lead to a shift in values away from ‘protection’ of own professional group or team, and towards advocating for all colleagues. |
Awareness | “highlighting how detrimental incivility…can be to all members of the, all people that are involved, even the people just witnessing it” (P10) | Greater awareness of the negative impacts of incivility through scenario observation and peer reflection on own and others’ experiences, standards and beliefs within the debriefing. |
Competence |
Mindful response | “I quite liked the way that the colleague doing the scenario, I suppose didn't immediately try and go in and just fix things. She probably thought about, take a pause…is there anything else going on that's making this more intense or more emotionally charged?” (P3) | Consideration of the benefits of a ‘mindful’ response through observing and reflecting on different approaches to managing incivility, both within the simulation and through discussing real-world experiences with peers. |
Self-regulation | “if I reflect on times I’ve ever been incivil to people, it’s often when you’re working within a really stressed or pressed system, or there’s something else going on” (P9) | Deepened understanding of the impact of incivility on self, the factors that may lead to own incivility and how these factors may be managed, through engaging with the simulation scenario and reflection with peers. |
Perspective taking | “I think we often forget that…everybody has their own competing agendas and we're not always very good at stopping and saying, ‘how’s your shift going now?’…and I think again with this scenario that's probably one thing to think about is understanding different points of view” (P3) | Greater recognition of the power of empathy and understanding others’ perspectives when managing incivility through engaging with the simulation scenario and reflection with peers. |
Self-Determination |
Identity Formation | I think how I see myself and view my role, has probably changed because it’s more of a leadership role, being the registrar… I’ve had to add to my armoury or whatever of not just being able to survive it for myself but trying to help other people work…through a difficult scenario or a situation (P7) | Development of a deeper understanding of the importance of human factors and behavioural skills when embodying a senior leadership role as the medical registrar, through experiencing the simulation scenario, debriefing with peers and individual reflection. This appeared to influence a perception of self as a leader and influencer within the system. |
Risk Assessment | “But I think definitely now, knowing the impact of it I would definitely be more assertive in saying that I don’t think this is helping, let’s stop” (P10) | Development of a more nuanced sense of risk assessment when managing incivility through reflecting on the benefits of challenging incivility balanced with the risks to self or professional relationships. |
Impact |
Socio-political support | “when there’s just quite an antagonistic culture on the ward…seeing your team members are behaving uncivilly to other staff members, that cascades because everyone feels that’s an acceptable way to behave” (P2) | The values, customs and beliefs of the team, department or organisation that influence incivility in the workplace. |
Participatory Culture | “it is helpful to know that you are working in an environment where you are respected enough, and you are valued enough, that people would understand or recognise if you had an issue with something…and you would be supported to follow through with escalating that” (P6) | The influence of sense of belonging, hierarchy and psychological safety on an individual’s perception of feeling valued and having a voice in an organisation |
Systems | “I think in terms of system change, very, very clear clinical pathways, referral criteria, communication pathways, I think, really does, when they are not in place creates a lot of stress, and with stress comes, sometimes, sadly, actions of incivility” (P9) | The influence of organisational systems and workplace resources on the experience of incivility in the workplace |
Table 1: Summary table of themes, subthemes, illustrative quotes and underlying mechanisms (see end of document)
Meaning
The theme of meaning encapsulated how individuals see the value of incivility as aligned to their own beliefs and standards. The subthemes comprised advocacy across boundaries and awareness.
Advocacy across boundaries referred to an expectation of a consistent standard of behaviour regardless of professional group or context. Observing and debriefing a scenario that centred around a doctor being rude to a nursing colleague appeared to prompt reflection regarding the importance of advocating for all colleagues regardless of profession or team. This included a shift in values away from “siding with where you feel familiar or where you feel your professional colleagues are” (P3) towards understanding “how to navigate these scenarios with fairness” (P3).
Awareness related to an individual reflecting on their own and uncovering others’ experience and values regarding incivility, through participation in SBE. This was facilitated by the opportunity to debrief with peers: “I also learnt a lot from just listening [to] the reflections of other colleagues” (P3). A deeper understanding of the detrimental impact of rudeness on individuals, teams, and patients appeared to enhance a sense of meaning regarding the importance of addressing incivility: “definitely something that I’m more aware of and would try to defuse at an earlier stage” (P10).
In summary, experiencing incivility-focused SBE appeared to increase the value participants place on maintaining workplace civility.
Competence
The theme of competence involved individuals reflecting on having the necessary skills to challenge incivility, or maintain their own civility, at work. Subthemes identified included mindful response, self-regulation and perspective taking.
Mindful response related to participants’ reflections on the effectiveness of taking a more balanced approach when challenging incivility. Several participants commented on a change in mindset following SBE from “[being] a bit gung-ho” (P1) towards a “pause and reflect” (P3) or “more measured approach” (P1). The ability to step back, gather information and “show both sides of the story” (P5) to “encourage others to recognise the impacts of their actions” (P5) were identified as important skills in managing incivility.
Self-regulation related to participants reflecting on the impact of incivility on themselves, as well as identifying and managing factors that may lead to their own rudeness. Medical error was identified as one negative consequence of experiencing incivility: “I was quite distracted…I ended up…requesting scans on the wrong patient” (P2). Participants reflected on how they may regulate their own risk of incivility:
“It’s made me reflect a bit more on myself…when you’re busy and how you communicate to people, that you can be a bit more aware yourself, of what you say to people” (P2)
Perspective taking referred to reflections on the importance of empathy and consideration of the wider context when managing rudeness. This included giving “people the benefit of the doubt… if someone’s being rude… actually, are they okay?” (P1) and “exploring the underlying issues that might make a person act or behave out of character” (P6). Participants consistently identified that the ability to explore the perspectives of each party was essential to the effective management of incivility.
In summary, experiencing incivility-focused SBE appeared to influence skills in managing incivility through the development of effective response strategies and improved self-regulation.
Self-Determination
Self-determination comprised a sense of control or autonomy in initiating or regulating actions. Subthemes included identity formation and risk assessment.
Identity formation involved embodying a more senior leadership role as the medical registrar through developing a greater understanding of the importance of behavioural skills within this role. Participants expressed that they rarely have the opportunity to debrief with peers, a process which was considered “validating and helpful to know that other people were having similar challenges” (P2). This led to reflection on experiencing a sense of professional growth through SBE:
“I just came away with slightly broader shoulders…you just felt more of a mature doctor” (P4)
Risk assessment encompassed a sense that the benefits of addressing incivility are balanced with inherent risk. Participants reflected on fears regarding “escalating a situation” (P3), a sense of futility or a risk of damaging relationships. Participants also considered risk to self, whether emotional or related to career progression: “you don't want to create bad relationships…don't want to impact your ability to get good training” (P5). There was interaction between risk assessment and the subthemes of socio-political support and participatory culture, further discussed within the impact theme.
A sense of competence in managing incivility appeared to ameliorate these risks: “I am probably more comfortable to escalate it a little bit” (P6). Tension was evident between these risks and a sense of duty in addressing incivility for the benefit of others: “as you get more senior, you do just feel that you have that responsibility” (P5). This sense of responsibility appeared to be influenced by subthemes of awareness, advocacy across boundaries and identity formation:
“I’m much more aware of the wider impact of it [incivility]…having that knowledge gives me more confidence to intervene” (P10)
In summary, engaging with incivility-focused SBE with peers appeared to contribute to professional identity development within the medical registrar role, with subsequent influence on the complex risk assessment that occurs when considering whether to challenge incivility.
Impact
Impact refers to the degree to which an individual can influence incivility in their workplace. We found that SBE had limited influence in this area, therefore widened the conceptualisation of ‘impact’ to include the socio-structural mediators (factors that can facilitate or hinder) of transfer from SBE to practice. Through this, we could better understand the mechanisms behind why SBE may be successful or unsuccessful in influencing behaviour. Subthemes identified were socio-political support, participatory culture and systems.
Socio-political support comprised the values, customs and beliefs of the team, department or organisation regarding incivility. Role-modelling was reflected as an important factor in setting cultural norms: “seeing the med reg and seeing them being not very nice on the phone…I could have been at risk of being that type of med reg because that's…what I thought the med reg was” (P11). A sense of socio-political support also appeared to influence risk assessment, for example inertia in challenging incivility: “perhaps it’s known in the department that this is how someone behaves and clearly people have been aware of it…saying something’s not really going to change anything” (P2). However, participants repeatedly expressed that education regarding incivility, including within SBE, bolstered a sense of socio-political support for civility at work.
Participatory culture referred to a sense of feeling valued and having a voice within a team or organisation, which also influenced a sense of risk assessment when challenging incivility. This was affected by a sense of belonging, with rotational jobs and lack of continuity perpetuating a feeling of vulnerability: “a transient entity who doesn’t really belong” (P2). Hierarchy was reflected as “a big part of the challenge” (P5) to speaking up, however relationship-building influenced a sense of voice: “if the department is making some sort of effort to see you as an individual…I am no longer really just a number” (P6). A sense of psychological safety, or feeling able to speak up without fear of consequence, was described as important: “teams like that where everyone feels really empowered…you wouldn’t mind saying, oh, that made me feel a bit uncomfortable” (P2)
The subtheme of systems acknowledges the fact that incivility is often perpetuated by poorly designed or under-resourced systems:
“should we be focusing instead on the systems that create an environment in which incivility bubbles and brews…if I think about times I’ve been incivil, it’s because I’ve been so busy and stressed, and so if you cut half my workload out, it probably wouldn’t have happened?” (P9)
In summary, these socio-structural mediators of transfer to practice influenced the ability of participants to impact workplace civility. However, experiencing an incivility-based SBE increased the perception of socio-political support for civility amongst participants.