Introduction:

Workplace incivility is a pervasive issue in healthcare, negatively impacting staff well-being, teamworking, cognitive load and patient safety [1]. Traditional training may not capture specific human factor or patient safety elements related to incivility. This project aims to evaluate the effectiveness of an innovative, multidisciplinary simulation-based intervention designed to increase awareness of incivility and its impact on patient safety within the NICU.

Methods:

A prospective design was used in preparing and planning the scenario [2,3]. The simulation ran during a structured teaching session, with participants of various nursing and medical grades from the NICU. In total there were 4 participants with 3 confederates in the simulation and 21 observers. A learning conversation was guided by 4 experienced debriefers, 1 of whom was a confederate.

The multidisciplinary team participated in a high-fidelity simulation depicting a patient handover with an array of embedded uncivil behaviours enacted by and towards pre-briefed confederates. Participants were briefed to receive handover but not briefed around the central theme of incivility. Their experience and response to witnessing incivility was the central driver for the learning conversation. Psychological safety was considered through confederate training and structured debriefing immediately post-simulation.

Feedback was collected via direct observation during the simulation, analysis of debriefing, and anonymous post-simulation surveys assessing realism, learning and perceived changes in awareness and preparedness.

Results:

Observation confirmed realistic enactment of incivility and notable bystander passivity among participants. Post-event analysis demonstrated increased participant recognition of incivility, understanding of its link to communication breakdown and cognitive load, and crucially, a connection drawn between the simulated incivility and a patient safety. Survey data indicated high perceived realism and educational value, particularly for the debriefing. Participants reported significantly increased awareness of incivility and its impacts, alongside increased (though less pronounced) preparedness to address it.

Discussion:

The simulation effectively increased awareness of incivility and vividly demonstrated its potential patient safety consequences within a realistic NICU context. The link was made to potential patient care errors and impact on cognitive load, underscoring mechanisms by which incivility impacts care. Observed bystander passivity highlights potential cultural challenges requiring further attention, but the inherent difficulty associated with challenging incivility. The findings support immersive simulation as an effective educational strategy for this sensitive topic but emphasise the absolute necessity of psychological safety for participants and observers throughout design and implementation. This intervention provides a valuable model adaptable to other healthcare settings seeking to foster civility and improve safety.

Ethics Statement:

As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable.

References

1. Van Heugten K, Casler K, Sharplin E. The prevalence of incivility in hospitals and the effects of incivility on patient safety culture and outcomes: A systematic review and meta-analysis. J Adv Nurs. 2024 Mar 22. doi: 10.1111/jan.16111. Epub ahead of print. PMID: 38515008.

2. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339–49. doi: 10.1097/SIH.0000000000000051. PMID: 25119147.

3. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011 Sep 7;306(9):978–88. doi: 10.1001/jama.2011.1234. PMID: 21900138.