Education that empowers? A critical realist evaluation of a novel incivility-focused immersive simulation

Education that empowers? 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A critical realist evaluation of a novel incivility-focused immersive simulation Katherine Ralston, Valerie Rae, Ed Mellanby, Jane Hislop, Victoria Tallentire This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7426662/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Mar, 2026 Read the published version in Advances in Simulation → Version 1 posted 11 You are reading this latest preprint version Abstract Background When we experience incivility, or rudeness, our performance suffers, negatively impacting patient safety. Immersive simulation-based education (SBE) has been under-explored as an educational strategy that may empower individuals to challenge incivility. Psychological empowerment was conceptualised by Spreitzer as four cognitive domains (meaning, competence, self-determination, and impact) that influence motivation and an active orientation towards work. We aimed to explore the mechanisms underlying the influence of incivility-based immersive SBE on the experiences of medical registrars when facing workplace incivility. Methods We situated this study within a critical realist paradigm, a philosophical stance which aims to provide explanatory power to understanding the mechanisms that drive social reality. We conducted semi-structured interviews with 11 medical registrars at least four months after an incivility-based immersive simulation scenario. Interviews focused on participants’ experiences and reflections of workplace incivility, and the potential impact of their simulation experience. Data were analysed using template analysis, utilising Spreitzer’s theory of psychological empowerment as the guiding framework. Results Incivility-based SBE stimulated powerful reflection relating to the cognitive domains of psychological empowerment. Meaning encompassed a sense that civility was important, with subthemes of awareness and advocacy across boundaries. Competence referred to having the skills to manage incivility, with subthemes of mindful response, self-regulation and perspective taking. Self-determination related to having autonomy when experiencing incivility, with subthemes of identity formation and risk assessment. Impact was conceptualised as socio-structural mediators of transfer to practice, with subthemes of socio-political support, participatory culture, and systems. Conclusions We highlight the role of immersive SBE as a powerful tool to explore workplace incivility. SBE may influence behavioural change through provoking reflection related to psychological empowerment. We explore SBE as an influencer of the nuanced risk assessment that occurs when individuals face incivility. This framework of psychological empowerment has utility in designing effective SBE focused on relational aspects of work. Simulation empowerment civility Figures Figure 1 Figure 2 Figure 3 Background Workplace incivility is common and has a devastating impact on the effective working of healthcare teams ( 1 – 4 ). When we experience rudeness, our performance suffers, negatively impacting patient safety and staff wellbeing ( 4 – 6 ). Education has a role in addressing workplace incivility ( 7 ), with simulation-based education (SBE) increasingly recognised as a modality that can influence professional relationships and workplace culture ( 8 , 9 ). Immersive SBE, in particular, is an under-explored educational technique that could have utility in empowering individuals to manage workplace incivility. If we can better understand SBE as a tool for shaping these relational aspects of work, we may improve our ability to design SBE that leads to behavioural and cultural change. Incivility is rude or disrespectful behaviour that violates social norms for interaction in a given context, resulting in recipient distress ( 10 , 11 ). Incivility is driven by multiple factors, including personal stressors and a permissive workplace culture ( 12 , 13 ). When someone is rude, the performance of the entire team is impacted, threatening patient safety ( 5 , 6 , 14 ). Incivility also contributes to staff burnout and attrition ( 15 , 16 ). Civility has therefore become a hot topic in healthcare, driven by movements such as ‘Civility Saves Lives’ ( 11 ) and prioritised by healthcare organisations and regulatory bodies ( 17 , 18 ). Although we are increasingly aware that the ways in which healthcare professionals interact has a profound impact on patient care and staff wellbeing, our understanding of how we can positively influence such interactions remains limited. Organisational interventions to improve working environments ( 19 ) or graded intervention programmes ( 20 ) clearly have a role in addressing incivility. Concerning an individual’s ability to challenge workplace incivility, the evidence for educational interventions is mixed. The literature predominately concentrates on interventions at the level of knowledge or skill rehearsal in low immersion environments ( 21 ). Most educational interventions improve awareness of incivility, however evidence supporting subsequent behavioural change is limited ( 22 – 27 ). Immersive SBE, a technique where learners interact with an authentic guided creation of an experience followed by debriefing, has remained unexplored in the incivility literature ( 21 , 28 ). Given that immersive SBE allows the exploration of performance-based outcomes realistic to the complexity of working in healthcare, this technique may have utility in empowering individuals to challenge incivility in practice ( 21 , 28 ). If we can better understand the ‘black box’ of immersive SBE focused on the navigation of professional interactions, we are more likely to be effective in the design, delivery and evaluation of SBE exploring relational aspects of work. Conceptual Framework When conceptualising this study, we were intrigued by empowerment theory as described within the business and organisational development literature ( 29 , 30 ). Empowerment holds relevance when considering the ability of an individual to navigate professional relationships and manage workplace incivility ( 31 ). Psychological empowerment can be considered as a set of psychological states necessary for motivation and an active orientation towards one’s work ( 29 ). Spreitzer described and validated a theory of individual psychological empowerment in the workplace, shaped by four cognitive domains: meaning; competence; self-determination; and impact ( 29 ) (Fig. 1). Spreitzer also warned against an overly individualistic concept of empowerment and advocated for an ecological approach that integrates the wider socio-structural context of the workplace, such as access to resources and workplace culture ( 30 , 32 , 33 ). We utilised Spreitzer’s theory of psychological empowerment as a guiding conceptual framework for this study ( 29 , 33 ). Philosophical Orientation In order to understand the mechanisms behind the influence of SBE, this study was situated within a critical realist paradigm ( 34 ). Ontologically, critical realism considers that there is a reality that exists independent of our perception, which is driven by causal mechanisms ( 35 ). Although we can extend our understanding of that reality through observation, our understanding will remain subjective and imperfect ( 36 ). Epistemologically, critical realism aims to provide explanatory power in understanding the mechanisms that drive social reality ( 35 ). This is relevant to exploring complex interventions such as SBE, to uncover “what works for whom, under what circumstances, how and why?” ( 37 , 38 ). Critical realism engages with existing theory but acknowledges that theory is fallible and can be supported, modified or rejected through analysis to provide the best explanation of reality ( 39 ). Critical realism uncovers the causal mechanisms that lead to events through considering reality at three levels: the empirical, actual, and real ( 39 ). Empirical refers to events as we experience them. Actual refers to events occurring, whether we observe them or not. Real refers to the causal mechanisms influencing events. These concepts are detailed in Fig. 2 with an illustrative example. A critical realist lens allows us to iteratively build explanations for the outcomes of educational interventions, diving below the surface question of “does it work?” to examine “ why and in what ways does it work?” ( 37 ) Aim This study aimed to explore the mechanisms underlying the influence of incivility-focused immersive SBE on the experiences of medical registrars when facing workplace incivility. Methods Study Design The use of theory to inform study design resonates with the iterative explanation-building process underpinning critical realism ( 40 ). However, this is with the understanding that theories must be critically examined during the analysis ( 34 , 39 ), in this case we utilised and critiqued Spreitzer’s theory of psychological empowerment in the workplace ( 29 ). Context This study was conducted in NHS Lothian, within South-East Scotland. Following their primary medical qualification, doctors in Scotland undertake two years of foundation training before starting specialty training. Those pursuing a medical specialty complete stage one of internal medicine training (IMT), followed by stage two of IMT during which they are commonly known as ‘medical registrars’. This study focused on a one-day immersive simulation course to which all medical registrars within South-East Scotland were invited. An immersive simulation scenario focused on incivility was developed as part of this course, which involved the participant witnessing rudeness between members of the medical team (Additional File 1). Data collection and analysis Using a convenience sampling method, all participants (n = 21) who attended the course between 1st March 2023 and 8th December 2023 were invited by email to participate in this research. Those who responded and gave consent were invited to an online interview between three and 12 months after the course. This follow-up time was to allow participants a period of reflection following the course and time during which they may encounter workplace incivility. We developed a semi-structured interview schedule focused on exploring participants’ experiences of workplace incivility (Additional File 2). A critical realist approach aims to investigate participants’ reactions to the opportunities provided by the intervention to explore underlying mechanisms. Therefore, interview questions focused on how the session had influenced the participant’s views, understanding, or behaviours ( 37 ). An abbreviated version of the interview schedule was shared with participants ahead of the interview to allow time to consider their responses. To encourage free and honest conversation, interviews were conducted by VR, who had no prior relationship with the participants. Due to the diverse location of participants across South-East Scotland, interviews were conducted online and scheduled according to participant availability. Interviews were audio-recorded, transcribed verbatim and analysed. Data were stored securely. We analysed the data using template analysis, a flexible deductive approach underpinned by theory- and researcher-driven analysis compatible with a critical realist stance ( 39 , 41 ). Analysis was completed in parallel with data collection. The research team were instructed to code excerpts that they felt related to experiences during and after the simulation intervention. KR analysed an initial data subset (n = 2), with ‘a priori’ codes based on Spreitzer’s theory of psychological empowerment in the workplace, as well as developing new and modified codes to form an initial coding template. These took the form of subthemes relating to each domain of psychological empowerment. Subsets of the data were then shared equally amongst the research team, with each transcript dual-coded by KR and another member of the team. Iterative modification and development of the coding template was driven by independent reflection, individual feedback, and collaborative discussion amongst the research team. This continued with data subsets until all transcripts were dual-coded and a final coding template had been agreed. The final template was reviewed independently by JH and subsequently discussed between JH, KR and VT to ensure the subthemes best reflected the mechanisms underlying SBE. Minor adjustments were made to subtheme descriptions prior to agreement by all authors. The final coding template was applied to the full data set by KR. Reflexivity There was purposeful diversity within the research team. KR is a medical registrar with medical education research experience, who developed the simulation course. VT is an acute medicine consultant with significant qualitative research and simulation experience. EM is an anaesthetist with experience in socio-cognitive skill training and research. VR is a paediatric doctor and medical education fellow. JH is a physiotherapist and academic in post-graduate medical education. VT and EM provided peer review of the incivility simulation scenario but were not involved in course delivery. The research team was purposely composed of those both involved (KR, VT, EM) and not involved (VR, JH) in the design of the educational intervention to encourage critical reflection. KR led the research team, keeping a reflective account on the research process and field notes within iterative versions of coding templates. Frequent meetings and email discussions between the research team throughout data collection and analysis encouraged collaboration, challenge, and reflection. Interpretation of findings is likely to have been influenced by previous work by the research team exploring workplace experiences of medical registrars ( 42 , 43 ). Results 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. Discussion In this study, we explore immersive SBE as a technique in overcoming the challenge of empowering healthcare professionals to manage workplace incivility. Utilising a critical realist lens, we found that incivility-focused SBE can stimulate powerful reflection encompassing the cognitive domains of psychological empowerment in the workplace. Through these reflections, it is possible that SBE influenced a subsequent sense of psychological empowerment when managing incivility in practice. There has been understandable hesitation in the use of immersive SBE to explore workplace relationships in areas such as incivility or microaggressions, with concerns including risk of participant or faculty distress and inadvertent development of unconscious bias ( 44 – 46 ). Here, we demonstrate the feasibility and impact of immersive SBE with an explicit and exclusive focus on workplace relationships, generating powerful peer reflection that could influence behavioural change in areas such as self-regulation and perspective-taking. We would caveat this with highlighting the importance of authentic but thoughtful scenario design and compassionate facilitation. For example, we designed our scenario around outcomes that went beyond simply challenging incivility to exploring why incivility occurred, with a focus on supporting colleagues and conflict resolution. We felt that exposing participants to direct rudeness risked psychological distress, therefore deliberately ensured participant exposure to incivility was in the role of a witness. We contained incivility within the participant’s own team to reduce the risk of stereotyping other professional groups. The use of SBE as a potentially powerful tool to shape professional relationships and culture is reflected in the literature, although these important outcomes can often be hidden within clinically focused scenarios ( 9 , 47 , 48 ). Translational simulation programmes in trauma and obstetric settings have been found to profoundly influence relational aspects of work, such as the concept of mutual respect ( 9 , 47 ). We encourage simulation educators to move forward to the deliberate and thoughtful incorporation of navigating professional relationships as a central focus within the objectives of simulation activities. Within the theme of self-determination, the subtheme of risk assessment held particular interest; shedding light on the inherent and complex tensions that exist when individuals must decide whether to challenge incivility. The barriers to challenging incivility cited in the literature are broadly reflected in our findings, including fear of escalation or reprisal, hierarchy, lack of staff continuity, silo working, and workplace culture ( 49 ). A novel finding within this study was a sense of responsibility towards others as a driver towards intervention when incivility occurs. This is distinct from previous sociological literature exploring incivility in the public sphere, where witnessing incivility commonly resulted in an ‘indifferent” response in comparison to direct incivility leading to an “intervention” response ( 50 ). This is likely mediated by several factors, such as a sense of duty to the wider team that appeared to be heightened through reflection within SBE on awareness, advocacy across boundaries and identity formation as a medical leader. Cortina et al ( 51 ) described a theory of biobehavioural responses to workplace incivility, with an approach or avoid response to incivility mediated by social affiliation between involved parties. This is reflected in our subtheme of participatory culture , with sense of social connection and belonging influencing the decision to challenge rudeness. Within this biobehavioural theory, affiliative actions could be directed towards the incivil party (relationship repair) or the social network (seeking support from others after experiencing incivility) ( 51 ). Our findings suggest this theory could be extended to include a sense of moral responsibility to others as an additional affiliative action that may mediate the response to incivility. We found that immersive SBE focused on relational aspects of work appeared to influence this sense of social connection and moral obligation, ‘shifting the scales’ on benefit versus risk assessment of intervention when incivility occurs (Fig. 3). In this study, we conceptualise a model for the mechanisms underlying SBE focused on professional relationships, utilising Spreitzer’s theory of psychological empowerment in the workplace with inclusion of socio-structural mediators of transfer to practice. Although evidence exists for SBE influencing domains related to psychological empowerment such as self-efficacy ( 52 – 55 ), this study is novel in the use of psychological empowerment theory as a conceptual framework to understand and evaluate SBE. We propose that this framework of psychological empowerment may have utility in the design, delivery, and evaluation of SBE related to professional behaviour and workplace relationships. For example, if a proposed outcome does not hold meaning to the participant, it is unlikely the educational activity will translate into behavioural change. We might then consider deliberate methods to introduce or consolidate a sense of meaning within the simulation activity, as explored in Table 2 . This would be an interesting avenue of future research. Table 2 Potential methods to introduce a sense of meaning within SBE objectives, using incivility as an example Stage of Simulation Activity Method to Introduce Meaning Pre-course Information sharing raising awareness of the impact of incivility in different accessible options: for example, sharing of “Civility Saves Lives” TED talk or infographic ( 11 ) Scenario design Highlighting the detrimental impact of incivility through designing and displaying a clear impact on individual performance, team working or interprofessional relationships utilising embedded faculty Debriefing Incorporating deliberate debrief discussion points, for example exploring participants experiences of incivility in the workplace, and the impact such experiences had on individuals and teams Post-course Sharing of consolidation materials in a different form to pre-course resources, for example a podcast Strengths and Limitations This study harnessed theory from business management and organisational development, utilising a critical realist lens to better understand the mechanisms underlying the influence of an incivility-based simulation on subsequent real-world experience. We acknowledge that in utilising psychological empowerment theory, we have chosen an individualistic lens for a topic that is inherently relational and influenced by socio-structural context. This may limit the applicability of our findings; however, we took steps to address this through consideration and incorporation of socio-structural factors within the analysis. We acknowledge that this study focused on the experiences of medical registrars within South-East Scotland and therefore may not be transferable to healthcare workers in different professional groups, contexts, and geographical locations. A valuable avenue for future research is exploration of the feasibility and impact of incivility-focused SBE within interprofessional teams. A further limitation is the reliance on participant recall within interviews regarding experiences of workplace incivility. Given the unpredictability of incivil encounters, an ethnographic approach was not practical, but participant diaries could have complemented our findings. Conclusions This critical realist study highlights the role of immersive SBE as a powerful tool for exploring professional interactions and relationships, which may influence behavioural change through stimulating reflection related to the cognitive domains of psychological empowerment. We explore SBE as an influencer of the nuanced risk assessment that individuals undertake when faced with incivility. We propose that this extended framework of psychological empowerment may have utility in designing and evaluating SBE which focuses on relational aspects of work, which we encourage simulation educators to prioritise going forward. Abbreviations IMT Internal Medicine Training SBE Simulation-Based Education Declarations Ethics approval and consent to participate This study received ethical approval from NHS Education for Scotland (NES/Res/46/22/Med). Participants gave informed written consent for data collection and the publication of anonymised results. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This research did not receive a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Authors' contributions KR led the conception and design of the study, data collection, data analysis and interpretation, and the drafting and revision of the manuscript. VR, EM and VT contributed to the conception and design of the study, data analysis and interpretation and the drafting and revision of this manuscript. JH contributed to the data analysis and interpretation and the drafting and revision of this manuscript. All authors approved the final manuscript for publication and have agreed to be accountable for all aspects of the work. Acknowledgements We would like to thank all the participants who were so generous in sharing their time, thoughts and experiences within the research interviews. References Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Leader. 2023(8):83-7. 10.1136/leader-2022-000717 Villafranca A, Fast I, Jacobsohn E. Disruptive behavior in the operating room: prevalence, consequences, prevention, and management. Current Opinion in Anesthesiology 2018;31(3):366-74. 10.1097/ACO.0000000000000592 Mammen BN, Lam L, Hills D. 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Taking simulation out of its “safe container”—exploring the bidirectional impacts of psychological safety and simulation in an emergency department. Advances in Simulation. 2022;7(1):5. 10.1186/s41077-022-00201-8 Brazil V, Purdy E, Alexander C, et al. Improving the relational aspects of trauma care through translational simulation. Advances in Simulation. 2019;4(1):10. 10.1186/s41077-019-0100-2 Andersson LM, Pearson CM. Tit for Tat? The Spiraling Effect of Incivility in the Workplace. Academy of Management Review. 1999;24(3):452-71. 10.5465/amr.1999.2202131 Civility Saves Lives [23/04/2025]. Available from: https://www.civilitysaveslives.com. Brennan PA, Oeppen RS. The role of human factors in improving patient safety. Trends in Urology & Men's Health. 2022;13(3):30-3. https://doi.org/10.1002/tre.858 Keller S, Yule S, Zagarese V, et al. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ Open. 2020;10(6). 10.1136/bmjopen-2019-035471 Daniel K, Kimberly B, Robert I, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety. 2019;28(9):750. 10.1136/bmjqs-2019-009598 Amick AE, Schrepel C, Bann M, et al. From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout. Academic Medicine. 2023;98(9):1076-82. 10.1097/ACM.0000000000005226 D'Ambra AM, Andrews DR. Incivility, retention and new graduate nurses: an integrated review of the literature. Journal of Nursing Management. 2014;22(6):735-42. https://doi.org/10.1111/jonm.12060 NHS England. Civility and Respect [23/04/2025]. Available from: https://www.england.nhs.uk/supporting-our-nhs-people/health-and-wellbeing-programmes/civility-and-respect/. General Medical Council, West M, Coia D. Caring for Doctors. Caring for Patients. 2019 [23/04/2025]. Available from: https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf. Osatuke K, Leiter M, Belton L, et al. Civility, Respect and Engagement at the Workplace (CREW): A national organization development program at the Department of Veterans Affairs. Journal of Management Policies and Practices. 2013;1(2):25-34. Dupras DM, Edson RS. The Vanderbilt Method for Resolving Unprofessional Behavior. Annals of Internal Medicine. 2008;149(10):775-6. Oliver N, Edgar S, Mellanby E, et al. The Scottish Simulation 'KSDP' Design Framework: a sense-making and ordered approach for building aligned simulation programmes. Advances in Simulation. 2024;9(1):52. 10.1186/s41077-024-00321-3 Clark CM, Kardong-Edgren S, Willhaus J. Pilot Study Using Cognitive Rehearsal, Simulation, and Biomarker Data to Address Workplace Incivility. Journal of Continuing Education in Nursing 2023;54(2):79-+. 10.3928/00220124-20230113-07 Rose KA, Jenkins SD, Astroth K, et al. Lessons Learned: Raising Awareness of Civility and Incivility Using Semi-Virtual Reality Simulation. Journal of Nursing Education 2020;59(8):461-4. 10.3928/01484834-20200723-08 Kile D, Eaton M, deValpine M, et al. The effectiveness of education and cognitive rehearsal in managing nurse-to-nurse incivility: A pilot study. Journal Of Nursing Management 2019;27(3):543-52. 10.1111/jonm.12709 Stagg SJ, Sheridan DJ, Jones RA, et al. Workplace bullying: The effectiveness of a workplace program. Workplace Health & Safety. 2013;61(8):333-8. Warrner J, Sommers K, Zappa M, et al. Decreasing workplace incivility. Nursing Management. 2016;47(1):22-30. Nikstaitis T, Simko LC. Incivility among intensive care nurses: The effects of an educational intervention. Dimensions of critical care nursing. 2014;33(5):293-301. Edgar S, Forrest K, McKimm J. Essential simulation in clinical education / edited by Kirsty Forrest, Judy McKimm, Simon Edgar. Chichester, West Sussex: John Wiley and Sons; 2013. Spreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. Academy of management Journal. 1995;38(5):1442-65. Spreitzer GM. Toward the integration of two perspectives: A review of social-structural and psychological empowerment at work. The Handbook of Organizational Behavior C Cooper et J Barling, dir Thousand Oaks, CA: Sage Publications. 2007. Shanta LL, Eliason ARM. Application of an empowerment model to improve civility in nursing education. Nurse Education in Practice. 2014;14(1):82-6. https://doi.org/10.1016/j.nepr.2013.06.009 Kanter RM. Men and women of the corporation. New York: Basic books; 1977. Spreitzer GM. Social structural characteristics of psychological empowerment. Academy of management journal. 1996;39(2):483-504. Bhaskar R. A realist theory of science: Routledge; 2013. Ellaway RH, Kehoe A, Illing J. Critical Realism and Realist Inquiry in Medical Education. Academic Medicine. 2020;95(7):984-8. 10.1097/acm.0000000000003232 Maxwell JA. A realist approach for qualitative research Thousand Oaks: SAGE Publications; 2012. Wong G, Greenhalgh T, Westhorp G, et al. Realist methods in medical education research: what are they and what can they contribute? Medical Education. 2012;46(1):89-96. https://doi.org/10.1111/j.1365-2923.2011.04045.x Kerins J, Ralston K, Stirling SA, et al. Training as imagined? A critical realist analysis of Scotland's internal medicine simulation programme. Adv Simul (Lond). 2024;9(1):27. 10.1186/s41077-024-00299-y Fletcher AJ. Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology. 2017;20(2):181-94. 10.1080/13645579.2016.1144401 Collier A. Critical realism: an introduction to Roy Bhaskar's philosophy. 1977. King N, Brooks JM. Template analysis for business and management students / Nigel King, Joanna M. Brooks. London: SAGE Publications Ltd; 2017. Ralston K, Smith SE, Kerins J, et al. Safety on the ground: using critical incident technique to explore the factors influencing medical registrars’ provision of safe care. BMJ Open Quality. 2024;13(1):e002641. 10.1136/bmjoq-2023-002641 Kerins J, Smith SE, Tallentire VR. "Ego massaging that helps": a framework analysis study of internal medicine trainees' interprofessional collaboration approaches. Medical Education Online. 2023;28(1):2243694. https://doi.org/10.1080/10872981.2023.2243694 Thom O’Neill, Merriman A, Robinson S. Beyond bystanding: a novel simulation methodology addressing interprofessional microaggressions. Journal of Healthcare Simulation. 2025(SRSIS 1). 10.54531/hgsr6094 Picketts L, Warren MD, Bohnert C. Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants. BMJ Simul Technol Enhanc Learn. 2021;7(6):590-9. 10.1136/bmjstel-2020-000853 Sauer PA, Thompson CE, Verzella MM. Empowering Nursing Students to Address Incivility. Clinical Simulation in Nursing. 2018;21:40-5. https://doi.org/10.1016/j.ecns.2018.06.004 Brazil V, McLean D, Lowe B, et al. A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH). BMC Health Services Research. 2022;22(1):1108. 10.1186/s12913-022-08463-8 Brydges R, Nemoy L, Ng S, et al. Getting everyone to the table: exploring everyday and everynight work to consider ‘latent social threats’ through interprofessional tabletop simulation. Advances in Simulation. 2021;6(1):39. 10.1186/s41077-021-00191-z Rixon A, Skinner C, Wilson S. What factors help and hinder efforts to address incivility in Australasian emergency departments? A modified Delphi study of FACEM perspectives. Emergency Medicine Australasia. 2023;35(3):420-6. https://doi.org/10.1111/1742-6723.14132 Phillips T, Smith P. Emotional and behavioural responses to everyday incivility:Challenging the fear/avoidance paradigm. Journal of Sociology. 2004;40(4):378-99. 10.1177/1440783304048382 Cortina LM, Sandy Hershcovis M, Clancy KBH. The Embodiment of Insult: A Theory of Biobehavioral Response to Workplace Incivility. Journal of Management. 2021;48(3):738-63. 10.1177/0149206321989798 Watters C, Reedy G, Ross A, et al. Does interprofessional simulation increase self-efficacy: a comparative study. BMJ Open. 2015;5(1):e005472. 10.1136/bmjopen-2014-005472 Franklin AE, Lee CS. Effectiveness of simulation for improvement in self-efficacy among novice nurses: a meta-analysis. J Nurs Educ. 2014;53(11):607-14. 10.3928/01484834-20141023-03 Kameg K, Howard VM, Clochesy J, et al. The impact of high fidelity human simulation on self-efficacy of communication skills. Issues Ment Health Nurs. 2010;31(5):315-23. 10.3109/01612840903420331 Hung C-C, Kao H-F, Liu H-C, et al. Effects of simulation-based learning on nursing students' perceived competence, self-efficacy, and learning satisfaction: A repeat measurement method. Nurse Education Today. 2020;97:104725. 10.1016/j.nedt.2020.104725 Additional Declarations No competing interests reported. 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Ralston","email":"data:image/png;base64,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","orcid":"","institution":"Medical Education Directorate, NHS Lothian","correspondingAuthor":true,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Ralston","suffix":""},{"id":510811516,"identity":"a5a8e361-e24c-4eaf-8fe5-32dc6f618eac","order_by":1,"name":"Valerie Rae","email":"","orcid":"","institution":"Medical Education Directorate, NHS Lothian","correspondingAuthor":false,"prefix":"","firstName":"Valerie","middleName":"","lastName":"Rae","suffix":""},{"id":510811517,"identity":"58e22798-ca02-42f5-bc40-270cbcbbcb5f","order_by":2,"name":"Ed Mellanby","email":"","orcid":"","institution":"Medical Education Directorate, NHS Lothian","correspondingAuthor":false,"prefix":"","firstName":"Ed","middleName":"","lastName":"Mellanby","suffix":""},{"id":510811518,"identity":"557f597c-c841-4227-8f20-0d3aea3f2a1b","order_by":3,"name":"Jane Hislop","email":"","orcid":"","institution":"University of Edinburgh","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Hislop","suffix":""},{"id":510811519,"identity":"0a8bcd93-82df-4b00-bc29-1f774a1577cb","order_by":4,"name":"Victoria Tallentire","email":"","orcid":"","institution":"Medical Education Directorate, NHS Lothian","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"Tallentire","suffix":""}],"badges":[],"createdAt":"2025-08-21 13:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7426662/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7426662/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s41077-026-00413-2","type":"published","date":"2026-03-19T15:59:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90909812,"identity":"4bb6542d-f0e0-448c-a0f5-246bb6c5c2d2","added_by":"auto","created_at":"2025-09-09 13:32:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":171712,"visible":true,"origin":"","legend":"\u003cp\u003eThe four cognitions of individual psychological empowerment in the workplace described and validated by Spreitzer, as they relate to incivility (29).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7426662/v1/9f5b86e4b4a3a554bcef81de.png"},{"id":90912280,"identity":"0289ca00-ab66-4fe5-9e53-3ca92576a0dc","added_by":"auto","created_at":"2025-09-09 13:48:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":287465,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrative example of levels of reality in critical realism\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7426662/v1/de20ae3c0b13571c38855ccc.png"},{"id":90911240,"identity":"bfc04684-67ae-4b69-bb10-451c202a079f","added_by":"auto","created_at":"2025-09-09 13:40:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":155384,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the interactions between the factors influencing risk assessment when deciding on response to incivility.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7426662/v1/746314e36961353862769a68.png"},{"id":105223433,"identity":"86f8a162-e25d-4efb-9e39-fb3291e1ebcd","added_by":"auto","created_at":"2026-03-23 16:06:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1288807,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7426662/v1/66b04461-9d32-4a8f-9db8-c5ceede60f82.pdf"},{"id":90909799,"identity":"88a5e41a-b3cf-480a-bd67-639190d4a354","added_by":"auto","created_at":"2025-09-09 13:32:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":24368,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7426662/v1/f7ce1f342f4fac185181fdd5.docx"},{"id":90909811,"identity":"35cfb77f-45ed-4bc9-b35d-02050eb81a2d","added_by":"auto","created_at":"2025-09-09 13:32:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19786,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7426662/v1/9e84039d913428ba8c38dd43.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Education that empowers? A critical realist evaluation of a novel incivility-focused immersive simulation","fulltext":[{"header":"Background","content":"\u003cp\u003eWorkplace incivility is common and has a devastating impact on the effective working of healthcare teams (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). When we experience rudeness, our performance suffers, negatively impacting patient safety and staff wellbeing (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Education has a role in addressing workplace incivility (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), with simulation-based education (SBE) increasingly recognised as a modality that can influence professional relationships and workplace culture (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Immersive SBE, in particular, is an under-explored educational technique that could have utility in empowering individuals to manage workplace incivility. If we can better understand SBE as a tool for shaping these relational aspects of work, we may improve our ability to design SBE that leads to behavioural and cultural change.\u003c/p\u003e\u003cp\u003eIncivility is rude or disrespectful behaviour that violates social norms for interaction in a given context, resulting in recipient distress (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Incivility is driven by multiple factors, including personal stressors and a permissive workplace culture (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). When someone is rude, the performance of the entire team is impacted, threatening patient safety (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Incivility also contributes to staff burnout and attrition (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Civility has therefore become a hot topic in healthcare, driven by movements such as \u0026lsquo;Civility Saves Lives\u0026rsquo; (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and prioritised by healthcare organisations and regulatory bodies (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough we are increasingly aware that the ways in which healthcare professionals interact has a profound impact on patient care and staff wellbeing, our understanding of how we can positively influence such interactions remains limited. Organisational interventions to improve working environments (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) or graded intervention programmes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) clearly have a role in addressing incivility. Concerning an \u003cem\u003eindividual\u0026rsquo;s\u003c/em\u003e ability to challenge workplace incivility, the evidence for educational interventions is mixed. The literature predominately concentrates on interventions at the level of knowledge or skill rehearsal in low immersion environments (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Most educational interventions improve awareness of incivility, however evidence supporting subsequent behavioural change is limited (\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Immersive SBE, a technique where learners interact with an authentic guided creation of an experience followed by debriefing, has remained unexplored in the incivility literature (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Given that immersive SBE allows the exploration of performance-based outcomes realistic to the complexity of working in healthcare, this technique may have utility in empowering individuals to challenge incivility in practice (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). If we can better understand the \u0026lsquo;black box\u0026rsquo; of immersive SBE focused on the navigation of professional interactions, we are more likely to be effective in the design, delivery and evaluation of SBE exploring relational aspects of work.\u003c/p\u003e\n\u003ch3\u003eConceptual Framework\u003c/h3\u003e\n\u003cp\u003eWhen conceptualising this study, we were intrigued by empowerment theory as described within the business and organisational development literature (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Empowerment holds relevance when considering the ability of an individual to navigate professional relationships and manage workplace incivility (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Psychological empowerment can be considered as a set of psychological states necessary for motivation and an active orientation towards one\u0026rsquo;s work (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Spreitzer described and validated a theory of individual psychological empowerment in the workplace, shaped by four cognitive domains: meaning; competence; self-determination; and impact (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) (Fig.\u0026nbsp;1). Spreitzer also warned against an overly individualistic concept of empowerment and advocated for an ecological approach that integrates the wider socio-structural context of the workplace, such as access to resources and workplace culture (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). We utilised Spreitzer\u0026rsquo;s theory of psychological empowerment as a guiding conceptual framework for this study (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePhilosophical Orientation\u003c/h2\u003e\u003cp\u003eIn order to understand the mechanisms behind the influence of SBE, this study was situated within a critical realist paradigm (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Ontologically, critical realism considers that there is a reality that exists independent of our perception, which is driven by causal mechanisms (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Although we can extend our understanding of that reality through observation, our understanding will remain subjective and imperfect (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Epistemologically, critical realism aims to provide explanatory power in understanding the mechanisms that drive social reality (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This is relevant to exploring complex interventions such as SBE, to uncover \u0026ldquo;what works for whom, under what circumstances, how and why?\u0026rdquo; (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Critical realism engages with existing theory but acknowledges that theory is fallible and can be supported, modified or rejected through analysis to provide the best explanation of reality (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCritical realism uncovers the causal mechanisms that lead to events through considering reality at three levels: the empirical, actual, and real (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Empirical refers to events as we experience them. Actual refers to events occurring, whether we observe them or not. Real refers to the causal mechanisms influencing events. These concepts are detailed in Fig.\u0026nbsp;2 with an illustrative example. A critical realist lens allows us to iteratively build explanations for the outcomes of educational interventions, diving below the surface question of \u0026ldquo;does it work?\u0026rdquo; to examine \u0026ldquo;\u003cem\u003ewhy\u003c/em\u003e and \u003cem\u003ein what ways\u003c/em\u003e does it work?\u0026rdquo; (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAim\u003c/h3\u003e\n\u003cp\u003eThis study aimed to explore the mechanisms underlying the influence of incivility-focused immersive SBE on the experiences of medical registrars when facing workplace incivility.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThe use of theory to inform study design resonates with the iterative explanation-building process underpinning critical realism (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). However, this is with the understanding that theories must be critically examined during the analysis (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), in this case we utilised and critiqued Spreitzer\u0026rsquo;s theory of psychological empowerment in the workplace (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eContext\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in NHS Lothian, within South-East Scotland. Following their primary medical qualification, doctors in Scotland undertake two years of foundation training before starting specialty training. Those pursuing a medical specialty complete stage one of internal medicine training (IMT), followed by stage two of IMT during which they are commonly known as \u0026lsquo;medical registrars\u0026rsquo;.\u003c/p\u003e\u003cp\u003eThis study focused on a one-day immersive simulation course to which all medical registrars within South-East Scotland were invited. An immersive simulation scenario focused on incivility was developed as part of this course, which involved the participant witnessing rudeness between members of the medical team (Additional File 1).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData collection and analysis\u003c/h2\u003e\u003cp\u003eUsing a convenience sampling method, all participants (n\u0026thinsp;=\u0026thinsp;21) who attended the course between 1st March 2023 and 8th December 2023 were invited by email to participate in this research. Those who responded and gave consent were invited to an online interview between three and 12 months after the course. This follow-up time was to allow participants a period of reflection following the course and time during which they may encounter workplace incivility.\u003c/p\u003e\u003cp\u003eWe developed a semi-structured interview schedule focused on exploring participants\u0026rsquo; experiences of workplace incivility (Additional File 2). A critical realist approach aims to investigate participants\u0026rsquo; reactions to the opportunities provided by the intervention to explore underlying mechanisms. Therefore, interview questions focused on how the session had influenced the participant\u0026rsquo;s views, understanding, or behaviours (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). An abbreviated version of the interview schedule was shared with participants ahead of the interview to allow time to consider their responses. To encourage free and honest conversation, interviews were conducted by VR, who had no prior relationship with the participants. Due to the diverse location of participants across South-East Scotland, interviews were conducted online and scheduled according to participant availability. Interviews were audio-recorded, transcribed verbatim and analysed. Data were stored securely.\u003c/p\u003e\u003cp\u003eWe analysed the data using template analysis, a flexible deductive approach underpinned by theory- and researcher-driven analysis compatible with a critical realist stance (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Analysis was completed in parallel with data collection. The research team were instructed to code excerpts that they felt related to experiences during and after the simulation intervention. KR analysed an initial data subset (n\u0026thinsp;=\u0026thinsp;2), with \u0026lsquo;a priori\u0026rsquo; codes based on Spreitzer\u0026rsquo;s theory of psychological empowerment in the workplace, as well as developing new and modified codes to form an initial coding template. These took the form of subthemes relating to each domain of psychological empowerment. Subsets of the data were then shared equally amongst the research team, with each transcript dual-coded by KR and another member of the team. Iterative modification and development of the coding template was driven by independent reflection, individual feedback, and collaborative discussion amongst the research team. This continued with data subsets until all transcripts were dual-coded and a final coding template had been agreed. The final template was reviewed independently by JH and subsequently discussed between JH, KR and VT to ensure the subthemes best reflected the mechanisms underlying SBE. Minor adjustments were made to subtheme descriptions prior to agreement by all authors. The final coding template was applied to the full data set by KR.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eThere was purposeful diversity within the research team. KR is a medical registrar with medical education research experience, who developed the simulation course. VT is an acute medicine consultant with significant qualitative research and simulation experience. EM is an anaesthetist with experience in socio-cognitive skill training and research. VR is a paediatric doctor and medical education fellow. JH is a physiotherapist and academic in post-graduate medical education. VT and EM provided peer review of the incivility simulation scenario but were not involved in course delivery. The research team was purposely composed of those both involved (KR, VT, EM) and not involved (VR, JH) in the design of the educational intervention to encourage critical reflection. KR led the research team, keeping a reflective account on the research process and field notes within iterative versions of coding templates. Frequent meetings and email discussions between the research team throughout data collection and analysis encouraged collaboration, challenge, and reflection. Interpretation of findings is likely to have been influenced by previous work by the research team exploring workplace experiences of medical registrars (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 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\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary table of themes, subthemes, illustrative quotes and underlying mechanisms\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIllustrative Quote\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMechanism\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMeaning\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdvocacy across boundaries\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;my automatic feeling was to very much be my SHO\u0026rsquo;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\u0026hellip;\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA 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 \u0026lsquo;protection\u0026rsquo; of own professional group or team, and towards advocating for all colleagues.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAwareness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;highlighting how detrimental incivility\u0026hellip;can be to all members of the, all people that are involved, even the people just witnessing it\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGreater awareness of the negative impacts of incivility through scenario observation and peer reflection on own and others\u0026rsquo; experiences, standards and beliefs within the debriefing.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCompetence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMindful response\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;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\u0026hellip;is there anything else going on that's making this more intense or more emotionally charged?\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConsideration of the benefits of a \u0026lsquo;mindful\u0026rsquo; response through observing and reflecting on different approaches to managing incivility, both within the simulation and through discussing real-world experiences with peers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-regulation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;if I reflect on times I\u0026rsquo;ve ever been incivil to people, it\u0026rsquo;s often when you\u0026rsquo;re working within a really stressed or pressed system, or there\u0026rsquo;s something else going on\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDeepened 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.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerspective taking\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think we often forget that\u0026hellip;everybody has their own competing agendas and we're not always very good at stopping and saying, \u0026lsquo;how\u0026rsquo;s your shift going now?\u0026rsquo;\u0026hellip;and I think again with this scenario that's probably one thing to think about is understanding different points of view\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGreater recognition of the power of empathy and understanding others\u0026rsquo; perspectives when managing incivility through engaging with the simulation scenario and reflection with peers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-Determination\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIdentity Formation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eI think how I see myself and view my role, has probably changed because it\u0026rsquo;s more of a leadership role, being the registrar\u0026hellip; I\u0026rsquo;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\u0026hellip;through a difficult scenario or a situation (P7)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDevelopment 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.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRisk Assessment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But I think definitely now, knowing the impact of it I would definitely be more assertive in saying that I don\u0026rsquo;t think this is helping, let\u0026rsquo;s stop\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDevelopment 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.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImpact\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocio-political support\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;when there\u0026rsquo;s just quite an antagonistic culture on the ward\u0026hellip;seeing your team members are behaving uncivilly to other staff members, that cascades because everyone feels that\u0026rsquo;s an acceptable way to behave\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe values, customs and beliefs of the team, department or organisation that influence incivility in the workplace.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipatory Culture\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;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\u0026hellip;and you would be supported to follow through with escalating that\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe influence of sense of belonging, hierarchy and psychological safety on an individual\u0026rsquo;s perception of feeling valued and having a voice in an organisation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSystems\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;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\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe influence of organisational systems and workplace resources on the experience of incivility in the workplace\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Summary table of themes, subthemes, illustrative quotes and underlying mechanisms (see end of document)\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMeaning\u003c/h2\u003e\u003cp\u003eThe theme of meaning encapsulated how individuals see the value of incivility as aligned to their own beliefs and standards. The subthemes comprised \u003cem\u003eadvocacy across boundaries\u003c/em\u003e and \u003cem\u003eawareness.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAdvocacy across boundaries\u003c/em\u003e 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 \u0026ldquo;\u003cem\u003esiding with where you feel familiar or where you feel your professional colleagues are\u0026rdquo; (P3)\u003c/em\u003e towards understanding \u0026ldquo;\u003cem\u003ehow to navigate these scenarios with fairness\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAwareness\u003c/em\u003e related to an individual reflecting on their own and uncovering others\u0026rsquo; experience and values regarding incivility, through participation in SBE. This was facilitated by the opportunity to debrief with peers: \u0026ldquo;\u003cem\u003eI also learnt a lot from just listening [to] the reflections of other colleagues\u0026rdquo; (P3).\u003c/em\u003e 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: \u003cem\u003e\u0026ldquo;definitely something that I\u0026rsquo;m more aware of and would try to defuse at an earlier stage\u0026rdquo; (P10).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e In summary, experiencing incivility-focused SBE appeared to increase the value participants place on maintaining workplace civility.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eCompetence\u003c/h2\u003e\u003cp\u003eThe theme of competence involved individuals reflecting on having the necessary skills to challenge incivility, or maintain their own civility, at work. Subthemes identified included \u003cem\u003emindful response, self-regulation\u003c/em\u003e and \u003cem\u003eperspective taking\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMindful response\u003c/em\u003e related to participants\u0026rsquo; reflections on the effectiveness of taking a more balanced approach when challenging incivility. Several participants commented on a change in mindset following SBE from \u003cem\u003e\u0026ldquo;[being] a bit gung-ho\u0026rdquo; (P1)\u003c/em\u003e towards a \u003cem\u003e\u0026ldquo;pause and reflect\u0026rdquo; (P3)\u003c/em\u003e or \u0026ldquo;\u003cem\u003emore measured approach\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P1).\u003c/em\u003e The ability to step back, gather information and \u0026ldquo;\u003cem\u003eshow both sides of the story\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P5)\u003c/em\u003e to \u0026ldquo;\u003cem\u003eencourage others to recognise the impacts of their actions\u0026rdquo; (P5)\u003c/em\u003e were identified as important skills in managing incivility.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSelf-regulation\u003c/em\u003e 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: \u0026ldquo;\u003cem\u003eI was quite distracted\u0026hellip;I ended up\u0026hellip;requesting scans on the wrong patient\u0026rdquo; (P2).\u003c/em\u003e Participants reflected on how they may regulate their own risk of incivility:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s made me reflect a bit more on myself\u0026hellip;when you\u0026rsquo;re busy and how you communicate to people, that you can be a bit more aware yourself, of what you say to people\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePerspective taking\u003c/em\u003e referred to reflections on the importance of empathy and consideration of the wider context when managing rudeness. This included giving \u0026ldquo;\u003cem\u003epeople the benefit of the doubt\u0026hellip; if someone\u0026rsquo;s being rude\u0026hellip; actually, are they okay?\u0026rdquo; (P1)\u003c/em\u003e and \u0026ldquo;\u003cem\u003eexploring the underlying issues that might make a person act or behave out of character\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P6).\u003c/em\u003e Participants consistently identified that the ability to explore the perspectives of each party was essential to the effective management of incivility.\u003c/p\u003e\u003cp\u003eIn summary, experiencing incivility-focused SBE appeared to influence skills in managing incivility through the development of effective response strategies and improved self-regulation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSelf-Determination\u003c/h2\u003e\u003cp\u003eSelf-determination comprised a sense of control or autonomy in initiating or regulating actions. Subthemes included \u003cem\u003eidentity formation\u003c/em\u003e and \u003cem\u003erisk assessment.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIdentity formation\u003c/em\u003e 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 \u0026ldquo;\u003cem\u003evalidating and helpful to know that other people were having similar challenges\u0026rdquo; (P2)\u003c/em\u003e. This led to reflection on experiencing a sense of professional growth through SBE:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI just came away with slightly broader shoulders\u0026hellip;you just felt more of a mature doctor\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eRisk assessment\u003c/em\u003e encompassed a sense that the benefits of addressing incivility are balanced with inherent risk. Participants reflected on fears regarding \u0026ldquo;\u003cem\u003eescalating a situation\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P3)\u003c/em\u003e, a sense of futility or a risk of damaging relationships. Participants also considered risk to self, whether emotional or related to career progression: \u0026ldquo;\u003cem\u003eyou don't want to create bad relationships\u0026hellip;don't want to impact your ability to get good training\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P5).\u003c/em\u003e There was interaction between risk assessment and the subthemes of socio-political support and participatory culture, further discussed within the impact theme.\u003c/p\u003e\u003cp\u003eA sense of \u003cem\u003ecompetence\u003c/em\u003e in managing incivility appeared to ameliorate these risks: \u003cem\u003e\u0026ldquo;I am probably more comfortable to escalate it a little bit\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P6).\u003c/em\u003e Tension was evident between these risks and a sense of duty in addressing incivility for the benefit of others: \u003cem\u003e\u0026ldquo;as you get more senior, you do just feel that you have that responsibility\u0026rdquo; (P5).\u003c/em\u003e This sense of responsibility appeared to be influenced by subthemes of \u003cem\u003eawareness\u003c/em\u003e, \u003cem\u003eadvocacy across boundaries\u003c/em\u003e and \u003cem\u003eidentity formation\u003c/em\u003e:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m much more aware of the wider impact of it [incivility]\u0026hellip;having that knowledge gives me more confidence to intervene\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn 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.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eImpact\u003c/h2\u003e\u003cp\u003eImpact 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 \u0026lsquo;impact\u0026rsquo; 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 \u003cem\u003ewhy\u003c/em\u003e SBE may be successful or unsuccessful in influencing behaviour. Subthemes identified were \u003cem\u003esocio-political support, participatory culture\u003c/em\u003e and \u003cem\u003esystems.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSocio-political support\u003c/em\u003e 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: \u003cem\u003e\u0026ldquo;seeing the med reg and seeing them being not very nice on the phone\u0026hellip;I could have been at risk of being that type of med reg because that's\u0026hellip;what I thought the med reg was\u0026rdquo; (P11).\u003c/em\u003e A sense of \u003cem\u003esocio-political support\u003c/em\u003e also appeared to influence \u003cem\u003erisk assessment\u003c/em\u003e, for example inertia in challenging incivility: \u0026ldquo;\u003cem\u003eperhaps it\u0026rsquo;s known in the department that this is how someone behaves and clearly people have been aware of it\u0026hellip;saying something\u0026rsquo;s not really going to change anything\u0026rdquo; (P2).\u003c/em\u003e However, participants repeatedly expressed that education regarding incivility, including within SBE, bolstered a sense of socio-political support for civility at work.\u003c/p\u003e\u003cp\u003e\u003cem\u003eParticipatory culture\u003c/em\u003e referred to a sense of feeling valued and having a voice within a team or organisation, which also influenced a sense of \u003cem\u003erisk assessment\u003c/em\u003e when challenging incivility. This was affected by a sense of belonging, with rotational jobs and lack of continuity perpetuating a feeling of vulnerability: \u0026ldquo;\u003cem\u003ea transient entity who doesn\u0026rsquo;t really belong\u0026rdquo; (P2).\u003c/em\u003e Hierarchy was reflected as \u0026ldquo;\u003cem\u003ea big part of the challenge\u003c/em\u003e\u0026rdquo; \u003cem\u003e(P5)\u003c/em\u003e to speaking up, however relationship-building influenced a sense of voice: \u0026ldquo;\u003cem\u003eif the department is making some sort of effort to see you as an individual\u0026hellip;I am no longer really just a number\u0026rdquo; (P6).\u003c/em\u003e A sense of psychological safety, or feeling able to speak up without fear of consequence, was described as important: \u003cem\u003e\u0026ldquo;teams like that where everyone feels really empowered\u0026hellip;you wouldn\u0026rsquo;t mind saying, oh, that made me feel a bit uncomfortable\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe subtheme of \u003cem\u003esystems\u003c/em\u003e acknowledges the fact that incivility is often perpetuated by poorly designed or under-resourced systems:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;should we be focusing instead on the systems that create an environment in which incivility bubbles and brews\u0026hellip;if I think about times I\u0026rsquo;ve been incivil, it\u0026rsquo;s because I\u0026rsquo;ve been so busy and stressed, and so if you cut half my workload out, it probably wouldn\u0026rsquo;t have happened?\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e 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.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we explore immersive SBE as a technique in overcoming the challenge of empowering healthcare professionals to manage workplace incivility. Utilising a critical realist lens, we found that incivility-focused SBE can stimulate powerful reflection encompassing the cognitive domains of psychological empowerment in the workplace. Through these reflections, it is possible that SBE influenced a subsequent sense of psychological empowerment when managing incivility in practice.\u003c/p\u003e\u003cp\u003eThere has been understandable hesitation in the use of immersive SBE to explore workplace relationships in areas such as incivility or microaggressions, with concerns including risk of participant or faculty distress and inadvertent development of unconscious bias (\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Here, we demonstrate the feasibility and impact of immersive SBE with an \u003cem\u003eexplicit and exclusive\u003c/em\u003e focus on workplace relationships, generating powerful peer reflection that could influence behavioural change in areas such as self-regulation and perspective-taking. We would caveat this with highlighting the importance of authentic but thoughtful scenario design and compassionate facilitation. For example, we designed our scenario around outcomes that went beyond simply challenging incivility to exploring why incivility occurred, with a focus on supporting colleagues and conflict resolution. We felt that exposing participants to direct rudeness risked psychological distress, therefore deliberately ensured participant exposure to incivility was in the role of a witness. We contained incivility within the participant\u0026rsquo;s own team to reduce the risk of stereotyping other professional groups. The use of SBE as a potentially powerful tool to shape professional relationships and culture is reflected in the literature, although these important outcomes can often be hidden within clinically focused scenarios (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Translational simulation programmes in trauma and obstetric settings have been found to profoundly influence relational aspects of work, such as the concept of mutual respect (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). We encourage simulation educators to move forward to the deliberate and thoughtful incorporation of navigating professional relationships as a \u003cem\u003ecentral focus\u003c/em\u003e within the objectives of simulation activities.\u003c/p\u003e\u003cp\u003eWithin the theme of self-determination, the subtheme of \u003cem\u003erisk assessment\u003c/em\u003e held particular interest; shedding light on the inherent and complex tensions that exist when individuals must decide whether to challenge incivility. The barriers to challenging incivility cited in the literature are broadly reflected in our findings, including fear of escalation or reprisal, hierarchy, lack of staff continuity, silo working, and workplace culture (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). A novel finding within this study was a sense of responsibility towards others as a driver towards intervention when incivility occurs. This is distinct from previous sociological literature exploring incivility in the public sphere, where witnessing incivility commonly resulted in an \u0026lsquo;indifferent\u0026rdquo; response in comparison to direct incivility leading to an \u0026ldquo;intervention\u0026rdquo; response (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). This is likely mediated by several factors, such as a sense of duty to the wider team that appeared to be heightened through reflection within SBE on \u003cem\u003eawareness, advocacy across boundaries\u003c/em\u003e and \u003cem\u003eidentity formation\u003c/em\u003e as a medical leader.\u003c/p\u003e\u003cp\u003eCortina \u003cem\u003eet al\u003c/em\u003e (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) described a theory of biobehavioural responses to workplace incivility, with an approach or avoid response to incivility mediated by social affiliation between involved parties. This is reflected in our subtheme of \u003cem\u003eparticipatory culture\u003c/em\u003e, with sense of social connection and belonging influencing the decision to challenge rudeness. Within this biobehavioural theory, affiliative actions could be directed towards the incivil party (relationship repair) or the social network (seeking support from others after experiencing incivility) (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Our findings suggest this theory could be extended to include a sense of \u003cem\u003emoral responsibility to others\u003c/em\u003e as an additional affiliative action that may mediate the response to incivility. We found that immersive SBE focused on relational aspects of work appeared to influence this sense of social connection and moral obligation, \u0026lsquo;shifting the scales\u0026rsquo; on benefit versus risk assessment of intervention when incivility occurs (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eIn this study, we conceptualise a model for the mechanisms underlying SBE focused on professional relationships, utilising Spreitzer\u0026rsquo;s theory of psychological empowerment in the workplace with inclusion of socio-structural mediators of transfer to practice. Although evidence exists for SBE influencing domains related to psychological empowerment such as self-efficacy (\u003cspan additionalcitationids=\"CR53 CR54\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), this study is novel in the use of psychological empowerment theory as a conceptual framework to understand and evaluate SBE. We propose that this framework of psychological empowerment may have utility in the design, delivery, and evaluation of SBE related to professional behaviour and workplace relationships. For example, if a proposed outcome does not hold meaning to the participant, it is unlikely the educational activity will translate into behavioural change. We might then consider deliberate methods to introduce or consolidate a sense of meaning within the simulation activity, as explored in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. This would be an interesting avenue of future research.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePotential methods to introduce a sense of meaning within SBE objectives, using incivility as an example\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStage of Simulation Activity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethod to Introduce Meaning\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInformation sharing raising awareness of the impact of incivility in different accessible options: for example, sharing of \u0026ldquo;Civility Saves Lives\u0026rdquo; TED talk or infographic (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScenario design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHighlighting the detrimental impact of incivility through designing and displaying a clear impact on individual performance, team working or interprofessional relationships utilising embedded faculty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDebriefing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncorporating deliberate debrief discussion points, for example exploring participants experiences of incivility in the workplace, and the impact such experiences had on individuals and teams\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSharing of consolidation materials in a different form to pre-course resources, for example a podcast\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study harnessed theory from business management and organisational development, utilising a critical realist lens to better understand the mechanisms underlying the influence of an incivility-based simulation on subsequent real-world experience. We acknowledge that in utilising psychological empowerment theory, we have chosen an individualistic lens for a topic that is inherently relational and influenced by socio-structural context. This may limit the applicability of our findings; however, we took steps to address this through consideration and incorporation of socio-structural factors within the analysis. We acknowledge that this study focused on the experiences of medical registrars within South-East Scotland and therefore may not be transferable to healthcare workers in different professional groups, contexts, and geographical locations. A valuable avenue for future research is exploration of the feasibility and impact of incivility-focused SBE within interprofessional teams. A further limitation is the reliance on participant recall within interviews regarding experiences of workplace incivility. Given the unpredictability of incivil encounters, an ethnographic approach was not practical, but participant diaries could have complemented our findings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis critical realist study highlights the role of immersive SBE as a powerful tool for exploring professional interactions and relationships, which may influence behavioural change through stimulating reflection related to the cognitive domains of psychological empowerment. We explore SBE as an influencer of the nuanced risk assessment that individuals undertake when faced with incivility. We propose that this extended framework of psychological empowerment may have utility in designing and evaluating SBE which focuses on relational aspects of work, which we encourage simulation educators to prioritise going forward.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIMT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternal Medicine Training\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSBE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSimulation-Based Education\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from NHS Education for Scotland (NES/Res/46/22/Med).\u0026nbsp;Participants gave informed written consent for data collection and the publication of anonymised results. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKR led the conception and design of the study, data collection, data analysis and interpretation, and the drafting and revision of the manuscript. VR, EM and VT contributed to the conception and design of the study, data analysis and interpretation and the drafting and revision of this manuscript. JH contributed to the data analysis and interpretation and the drafting and revision of this manuscript. All authors approved the final manuscript for publication and have agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants who were so generous in sharing their time, thoughts and experiences within the research interviews.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGuppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Leader. 2023(8):83-7. 10.1136/leader-2022-000717\u003c/li\u003e\n\u003cli\u003eVillafranca A, Fast I, Jacobsohn E. 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The Spiraling Effect of Incivility in the Workplace. Academy of Management Review. 1999;24(3):452-71. 10.5465/amr.1999.2202131\u003c/li\u003e\n\u003cli\u003eCivility Saves Lives [23/04/2025]. Available from: https://www.civilitysaveslives.com. \u003c/li\u003e\n\u003cli\u003eBrennan PA, Oeppen RS. The role of human factors in improving patient safety. Trends in Urology \u0026amp; Men\u0026apos;s Health. 2022;13(3):30-3. https://doi.org/10.1002/tre.858\u003c/li\u003e\n\u003cli\u003eKeller S, Yule S, Zagarese V, et al. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ Open. 2020;10(6). 10.1136/bmjopen-2019-035471\u003c/li\u003e\n\u003cli\u003eDaniel K, Kimberly B, Robert I, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality \u0026amp; Safety. 2019;28(9):750. 10.1136/bmjqs-2019-009598\u003c/li\u003e\n\u003cli\u003eAmick AE, Schrepel C, Bann M, et al. 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Lessons Learned: Raising Awareness of Civility and Incivility Using Semi-Virtual Reality Simulation. Journal of Nursing Education 2020;59(8):461-4. 10.3928/01484834-20200723-08\u003c/li\u003e\n\u003cli\u003eKile D, Eaton M, deValpine M, et al. The effectiveness of education and cognitive rehearsal in managing nurse-to-nurse incivility: A pilot study. Journal Of Nursing Management 2019;27(3):543-52. 10.1111/jonm.12709\u003c/li\u003e\n\u003cli\u003eStagg SJ, Sheridan DJ, Jones RA, et al. Workplace bullying: The effectiveness of a workplace program. Workplace Health \u0026amp; Safety. 2013;61(8):333-8. \u003c/li\u003e\n\u003cli\u003eWarrner J, Sommers K, Zappa M, et al. Decreasing workplace incivility. Nursing Management. 2016;47(1):22-30. \u003c/li\u003e\n\u003cli\u003eNikstaitis T, Simko LC. Incivility among intensive care nurses: The effects of an educational intervention. Dimensions of critical care nursing. 2014;33(5):293-301. \u003c/li\u003e\n\u003cli\u003eEdgar S, Forrest K, McKimm J. Essential simulation in clinical education / edited by Kirsty Forrest, Judy McKimm, Simon Edgar. Chichester, West Sussex: John Wiley and Sons; 2013. \u003c/li\u003e\n\u003cli\u003eSpreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. Academy of management Journal. 1995;38(5):1442-65. \u003c/li\u003e\n\u003cli\u003eSpreitzer GM. Toward the integration of two perspectives: A review of social-structural and psychological empowerment at work. The Handbook of Organizational Behavior C Cooper et J Barling, dir Thousand Oaks, CA: Sage Publications. 2007. \u003c/li\u003e\n\u003cli\u003eShanta LL, Eliason ARM. Application of an empowerment model to improve civility in nursing education. Nurse Education in Practice. 2014;14(1):82-6. https://doi.org/10.1016/j.nepr.2013.06.009\u003c/li\u003e\n\u003cli\u003eKanter RM. Men and women of the corporation. New York: Basic books; 1977. \u003c/li\u003e\n\u003cli\u003eSpreitzer GM. Social structural characteristics of psychological empowerment. Academy of management journal. 1996;39(2):483-504. \u003c/li\u003e\n\u003cli\u003eBhaskar R. A realist theory of science: Routledge; 2013. \u003c/li\u003e\n\u003cli\u003eEllaway RH, Kehoe A, Illing J. Critical Realism and Realist Inquiry in Medical Education. Academic Medicine. 2020;95(7):984-8. 10.1097/acm.0000000000003232\u003c/li\u003e\n\u003cli\u003eMaxwell JA. A realist approach for qualitative research Thousand Oaks: SAGE Publications; 2012. \u003c/li\u003e\n\u003cli\u003eWong G, Greenhalgh T, Westhorp G, et al. Realist methods in medical education research: what are they and what can they contribute? Medical Education. 2012;46(1):89-96. https://doi.org/10.1111/j.1365-2923.2011.04045.x\u003c/li\u003e\n\u003cli\u003eKerins J, Ralston K, Stirling SA, et al. Training as imagined? A critical realist analysis of Scotland\u0026apos;s internal medicine simulation programme. Adv Simul (Lond). 2024;9(1):27. 10.1186/s41077-024-00299-y\u003c/li\u003e\n\u003cli\u003eFletcher AJ. Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology. 2017;20(2):181-94. 10.1080/13645579.2016.1144401\u003c/li\u003e\n\u003cli\u003eCollier A. Critical realism: an introduction to Roy Bhaskar\u0026apos;s philosophy. 1977. \u003c/li\u003e\n\u003cli\u003eKing N, Brooks JM. Template analysis for business and management students / Nigel King, Joanna M. Brooks. London: SAGE Publications Ltd; 2017. \u003c/li\u003e\n\u003cli\u003eRalston K, Smith SE, Kerins J, et al. Safety on the ground: using critical incident technique to explore the factors influencing medical registrars\u0026rsquo; provision of safe care. BMJ Open Quality. 2024;13(1):e002641. 10.1136/bmjoq-2023-002641\u003c/li\u003e\n\u003cli\u003eKerins J, Smith SE, Tallentire VR. \u0026quot;Ego massaging that helps\u0026quot;: a framework analysis study of internal medicine trainees\u0026apos; interprofessional collaboration approaches. Medical Education Online. 2023;28(1):2243694. https://doi.org/10.1080/10872981.2023.2243694\u003c/li\u003e\n\u003cli\u003eThom O\u0026rsquo;Neill, Merriman A, Robinson S. Beyond bystanding: a novel simulation methodology addressing interprofessional microaggressions. Journal of Healthcare Simulation. 2025(SRSIS 1). 10.54531/hgsr6094\u003c/li\u003e\n\u003cli\u003ePicketts L, Warren MD, Bohnert C. Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants. BMJ Simul Technol Enhanc Learn. 2021;7(6):590-9. 10.1136/bmjstel-2020-000853\u003c/li\u003e\n\u003cli\u003eSauer PA, Thompson CE, Verzella MM. Empowering Nursing Students to Address Incivility. Clinical Simulation in Nursing. 2018;21:40-5. https://doi.org/10.1016/j.ecns.2018.06.004\u003c/li\u003e\n\u003cli\u003eBrazil V, McLean D, Lowe B, et al. A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH). BMC Health Services Research. 2022;22(1):1108. 10.1186/s12913-022-08463-8\u003c/li\u003e\n\u003cli\u003eBrydges R, Nemoy L, Ng S, et al. Getting everyone to the table: exploring everyday and everynight work to consider \u0026lsquo;latent social threats\u0026rsquo; through interprofessional tabletop simulation. Advances in Simulation. 2021;6(1):39. 10.1186/s41077-021-00191-z\u003c/li\u003e\n\u003cli\u003eRixon A, Skinner C, Wilson S. What factors help and hinder efforts to address incivility in Australasian emergency departments? A modified Delphi study of FACEM perspectives. Emergency Medicine Australasia. 2023;35(3):420-6. https://doi.org/10.1111/1742-6723.14132\u003c/li\u003e\n\u003cli\u003ePhillips T, Smith P. Emotional and behavioural responses to everyday incivility:Challenging the fear/avoidance paradigm. Journal of Sociology. 2004;40(4):378-99. 10.1177/1440783304048382\u003c/li\u003e\n\u003cli\u003eCortina LM, Sandy Hershcovis M, Clancy KBH. The Embodiment of Insult: A Theory of Biobehavioral Response to Workplace Incivility. Journal of Management. 2021;48(3):738-63. 10.1177/0149206321989798\u003c/li\u003e\n\u003cli\u003eWatters C, Reedy G, Ross A, et al. Does interprofessional simulation increase self-efficacy: a comparative study. BMJ Open. 2015;5(1):e005472. 10.1136/bmjopen-2014-005472\u003c/li\u003e\n\u003cli\u003eFranklin AE, Lee CS. Effectiveness of simulation for improvement in self-efficacy among novice nurses: a meta-analysis. J Nurs Educ. 2014;53(11):607-14. 10.3928/01484834-20141023-03\u003c/li\u003e\n\u003cli\u003eKameg K, Howard VM, Clochesy J, et al. The impact of high fidelity human simulation on self-efficacy of communication skills. Issues Ment Health Nurs. 2010;31(5):315-23. 10.3109/01612840903420331\u003c/li\u003e\n\u003cli\u003eHung C-C, Kao H-F, Liu H-C, et al. Effects of simulation-based learning on nursing students\u0026apos; perceived competence, self-efficacy, and learning satisfaction: A repeat measurement method. Nurse Education Today. 2020;97:104725. 10.1016/j.nedt.2020.104725\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Simulation, empowerment, civility ","lastPublishedDoi":"10.21203/rs.3.rs-7426662/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7426662/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhen we experience incivility, or rudeness, our performance suffers, negatively impacting patient safety. Immersive simulation-based education (SBE) has been under-explored as an educational strategy that may empower individuals to challenge incivility. Psychological empowerment was conceptualised by Spreitzer as four cognitive domains (meaning, competence, self-determination, and impact) that influence motivation and an active orientation towards work. We aimed to explore the mechanisms underlying the influence of incivility-based immersive SBE on the experiences of medical registrars when facing workplace incivility.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe situated this study within a critical realist paradigm, a philosophical stance which aims to provide explanatory power to understanding the mechanisms that drive social reality. We conducted semi-structured interviews with 11 medical registrars at least four months after an incivility-based immersive simulation scenario. Interviews focused on participants\u0026rsquo; experiences and reflections of workplace incivility, and the potential impact of their simulation experience. Data were analysed using template analysis, utilising Spreitzer\u0026rsquo;s theory of psychological empowerment as the guiding framework.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIncivility-based SBE stimulated powerful reflection relating to the cognitive domains of psychological empowerment. Meaning encompassed a sense that civility was important, with subthemes of awareness and advocacy across boundaries. Competence referred to having the skills to manage incivility, with subthemes of mindful response, self-regulation and perspective taking. Self-determination related to having autonomy when experiencing incivility, with subthemes of identity formation and risk assessment. Impact was conceptualised as socio-structural mediators of transfer to practice, with subthemes of socio-political support, participatory culture, and systems.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe highlight the role of immersive SBE as a powerful tool to explore workplace incivility. SBE may influence behavioural change through provoking reflection related to psychological empowerment. We explore SBE as an influencer of the nuanced risk assessment that occurs when individuals face incivility. This framework of psychological empowerment has utility in designing effective SBE focused on relational aspects of work.\u003c/p\u003e","manuscriptTitle":"Education that empowers? A critical realist evaluation of a novel incivility-focused immersive simulation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 13:32:09","doi":"10.21203/rs.3.rs-7426662/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-21T11:42:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-09T20:27:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-04T14:38:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-20T10:22:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258440486536664038942157286455467799811","date":"2025-09-11T19:43:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308900797825434821524802358426059735636","date":"2025-09-05T13:07:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144433205265543773501113056529267438131","date":"2025-09-05T10:47:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-03T09:55:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-22T08:41:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T08:41:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Simulation","date":"2025-08-21T13:21:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efc7a733-05cc-4131-9e1c-5de3cf30c2e5","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:02:58+00:00","versionOfRecord":{"articleIdentity":"rs-7426662","link":"https://doi.org/10.1186/s41077-026-00413-2","journal":{"identity":"advances-in-simulation","isVorOnly":false,"title":"Advances in Simulation"},"publishedOn":"2026-03-19 15:59:18","publishedOnDateReadable":"March 19th, 2026"},"versionCreatedAt":"2025-09-09 13:32:09","video":"","vorDoi":"10.1186/s41077-026-00413-2","vorDoiUrl":"https://doi.org/10.1186/s41077-026-00413-2","workflowStages":[]},"version":"v1","identity":"rs-7426662","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7426662","identity":"rs-7426662","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}