What factors help and hinder efforts to address incivility in Australasian emergency departments? A modified Delphi study of FACEM perspectives

Workplace incivility is a global challenge for healthcare and a major leadership challenge facing emergency physicians. However, little is known about emergency physicians' understanding of the factors that help and hinder attempts to address incivility, or what emergency physicians believe are the priority factors to address. The present study makes a novel contribution to research in this area by examining the perceived enablers of, and barriers to, efforts to address incivility in Australian and Aotearoa New Zealand EDs.


Introduction
Workplace incivility, defined as a violation of norms in social interactions, shown as disregard of coworkers, causing conflict and stress, 1 is a global challenge for healthcare. In the specific context of emergency medicine, incivility is experienced during interactions with colleagues within the ED as well as interactions with other health services, departments and specialities. 2,3 This underscores the need to foster a workplace culture of respect, inclusion, and civility within hospitals and healthcare more generally.
The challenges of incivility documented in the international medical literature are germane to the Australian and Aotearoa New Zealand context. For example, as shown by Rixon and colleagues 4 in their study of the leadership challenges of Australasian directors of emergency medicine, managing challenging, uncivil colleagues was a common problem facing directors, regardless of their leadership experience or the geographical location of their hospitals. However, establishing that workplace incivility is a leadership challenge facing emergency physicians is a necessary but insufficient prelude to actually addressing incivility in Australasian EDs.
Incivility is a complex, emergent phenomenon that has many distal • Emergency physicians have a rich and nuanced understanding of workplace incivility. • Workplace culture was unanimously acknowledged as a major hindering factor to addressing incivility. • Emergency physicians relationships and networks across departments and specialties identified as a vital helping factor for addressing incivility. and proximate causes and a host of subtle (e.g. forgetting to include others) and overt manifestations (e.g. behaving disrespectfully when disagreeing with colleagues, name calling and public criticism). 5 The complexity of incivility also means that it is a phenomenon that is best addressed not through the top-down imposition of policies from management but rather the local, everyday practices of the people involved. 5 Thus, in order to foster civility and create a thriving inclusive and respectful environment in EDs, it is first necessary to understand how emergency physicians think about factors that help and hinder attempts to address incivility. Moreover, given the need to foster local, contextualised efforts to address incivilitythat is, leadership actions initiated by emergency physicians and trainees in the context of their own work experience, relationships, and environmentit is also necessary to understand the types of actions that emergency physicians would be prepared to enact.

Goals of this investigation
The aim of the present study was to explore FACEMs' beliefs about the factors that help and hinder efforts to address incivility in Australasian hospitals and EDs, with a view to identifying opportunities for FACEMs to initiate and lead efforts to foster civility in their hospitals.

Study design
The present study used an online modified Delphi method, situated within a broader action research framework. The use of action research within emergency medicine provides the opportunity to gain valuable insider insights and appreciate the beliefs and practices that animate institutions. 6 Such a research framework provides a strong alignment and congruence with the roles of the authors, who view study participants as having important knowledge and agency to contribute to research outcomes. While the Delphi approach is commonly known for its focus on striving for statistical consensus, the modified Delphi method used in the present study is geared to facilitate qualitative understanding among participants. Such an approach is particularly valuable in leadership development settings. 7 Furthermore, given that the purpose of the study was to identify FACEMs' beliefs about the factors that help and hinder attempts to address incivility in EDs, not to consolidate statistical agreement about these factors, we used the modified online Delphi method as an exploratory tool, which is an approach that provides leadership development opportunities for participants. 8 The study received ethics clearance from Swinburne University of Technology prior to commencement (SUHREC reference 20191353-1434).

Researcher reflexivity
AR and SW have a background in experiential approaches to leadership development, defined as techniques that are focussed on participant experience and sense-making. 9 CS brings a wealth of clinical and health systems leadership experience and has led civility-promotion initiatives. As leadership educators and coaches (AR and SW) and a clinicianmanager (CS), this focus on experiential research positions the researchers in a way that encourages participants to reflect on and make sense of their lived experiences, with a view to learning from this experience and enacting these learnings in the workplace.

Selection of participants
Participants (n = 22; Table 1) were FACEMs who participated in the ACEM leadership development programme, 'Managing Challenging Colleagues'. These 22 participants were randomly selected from a much larger pool of FACEMs who had responded to a formal expression of interest from ACEM in this leadership development programme. Participants were invited to self-select into Delphi panels based on their self-described leadership experience; namely, new (<3 years), intermediate (3-5 years) and advanced (>5 years). Panel sizes were limited to a maximum of eight participants per panel to optimise participant engagement, which resulted in the formation of two 'new' panels.

Modified Delphi process
Panels were guided through a 4-week process of brainstorming the factors that help and hinder attempts to address incivility in EDs, narrowing down these factors, and then ranking them to identify the top three helping and hindering factors. Given the leadership development context, where high-quality dialogue and personal accountability are crucial, our modified Delphi was non-anonymous. Prior to embarking on the individual brainstorming, participants were instructed in the use of force-field analysis 10 as a leadership development tool. Forcefield analysis provides a framework to help people make sense of the forces that drive (helping forces) or block (hindering forces) movement towards a goal. In the context of incivility in EDs, this approach illuminates the factors variously facilitate and disrupt attempts to address incivility. Highlighting Delphi as a dialectical process allowed panellists to intentionally, and respectfully, explore disagreements and differences within their panels during the narrowing down and ranking processes, providing valuable leadership development learnings, while contributing to research fidelity. Finally, panels reviewed their final rankings to decide on which they would focus on as action items for creating change in their EDs.

Data analysis and rigour
Content analysis was used by the authors (AR and SW) to code and interpret participants' responses from the brainstorming phase. This enabled a common 'dictionary' to be created and used by and across the panels as they were guided through the steps of narrowing down and ranking. The team fostered rigour in several ways through the research process. First, the study and preparation of this manuscript have worked in with recommendations for reporting qualitative research. 11 Second, the team provided a clear decision trail regarding the appropriateness of the modified Delphi and its relevance for a study on incivility, helping to address trustworthiness more generally. 12 Finally, we apply Forero and colleagues' 13 four-dimension criteria to assess the rigour of our qualitative research in Table 2.

Helping and hindering factors
Participants identified a host of factors that help and hinder attempts to address incivility in EDs (Table 3). Content analysis revealed that these factors could be classified as either intrapersonal (i.e. within-person factors, such as personality or attitudes), interpersonal (e.g. history or quality of relationships between individuals), intragroup (e.g. quality of ED relationships, team climate, ED culture), intergroup (e.g. history or quality of relationships between ED and other specialties) and organisational or hospital-wide factors (e.g. the general workplace culture of a hospital). Overall, 26 helping factors and 33 hindering factors were identified. Notably, although the focus of the study was on incivility within EDs, a third of the factors identified related to intergroup and organisational factors.
In addition to identifying the range of factors that participants believe help and hinder attempts to address incivility in EDs, we wanted to understand what participants deemed the top three helping and hindering factors. The results of this ranking process are presented in Table 4. Notably, the key hindering factor identified by all panels was 'workplace culture', which is an organisational-level factor that describes general hospital culture rather than the culture of specific departments. The reasons provided for the identification of 'workplace culture' are exemplified the rationale provided by New 2 panel: 'There is a culture of acceptance of incivility to the point it becomes expected and to a degree accepted'. Moreover, most panels nominated another organisational-level factor, 'time pressure', as a significant hindering factor. The reasons provided for the identification of 'time pressure' are exemplified the rationale provided by New 1 panel: 'Lack of time reduces opportunities to develop strong relationships and a civil culture'. Notwithstanding cross-panel agreement about these two barriers,

Preferred helping factors to foster
The New 1 panel nominated 'ED culture of building relationships and networks'an intergroup factorbecause it was the 'most significant enabler to addressing incivility' and because 'ED is well positioned to model standards of conduct to the health system at large because we are positioned at the intersection of many departments'. Similarly, the New 2 panel selected 'leadership'an organisational factorbecause of link between leadership and role modelling, and the proposition that

Discussion
The present study of FACEMs' beliefs about factors that help and hinder attempts to address incivility in EDs suggests that emergency physicians have a rich and nuanced understanding of workplace incivility. Moreover, the identification of helping and hindering factors at the intrapersonal, interpersonal, intragroup, intergroup and organisationlevel suggests that emergency physicians view workplace incivility as a complex phenomenon that has several underlying and interlocking causes, with no simple solutions. This perceived complexity is further suggested by the differences in opinion observed between the panels about the factors that help and hinder attempts to address incivility in EDs. Intrapersonal refers to factors within the person, such as their personality, attitudes, beliefs and desires; interpersonal refers to factors between people (e.g. their history with each other, perceptions of others, social actions); intragroup refers to factors within a group, in this case the ED (e.g. quality of relationships among group members, group culture and climate); intergroup refers to factors between groups, such as between ED and other specialties; and organisation refers to hospitallevel factors (e.g. organisation culture, institutional leadership, policies, etc.).
Notwithstanding the differences of opinion about these factors, there were two notable areas of convergence. First, the general workplace culture of hospitals, which was broadly characterised as a culture of acceptance of incivility, was unanimously acknowledged as a major hindering factor. This underscores the vital importance of addressing workplace culture, which emerges from complex interactions between workplace practices, norms and conditions, in any initiative to address workplace incivility. Second, emergency physicians' relationships and networks across departments and specialties were acknowledged as a vital helping factor. The identification of 'relationships and networks' by the new, intermediate and advanced panels alike, reveals keen insight into the ways in which poor relationships between individuals and groups clears the way for the violation of norms in social interactions and the development of workplace cultures in which incivility is normalised. Thus, improving the quality of interactions and relationships with colleagues within the ED across the hospital is a practical, everyday way that emergency physicians can foster workplace civility.
Consistent with Klingberg and colleagues, 3 who found that most sources of incivility experienced by emergency physicians originated outside the ED, many of the problematic factors identified in the present study were intergroup and organisational factors (e.g. tribalism, competing priorities, workplace culture). Nevertheless, fully two-thirds of the hindering (e.g. culture and gender differences, ED culture, constant changing of team make-up) and helping factors (e.g. supportive colleagues, shared goals, clinical teamwork in EDs) identified were located within the ED, indicating that many of the roots of, and solutions to, are located in the ED.
The factors nominated by the panels as those they would address as a priority were illuminating, and broadly reflective of a host of recommendations made in ACEM's Discrimination, Bullying and Sexual Harassment Action Plan. 14 Notably, the pattern of results suggested that types of barriers and enablers chosen by panels were partly a function of their leadership experience. To illustrate, the preferred hindering (bias and discrimination, tribalism and siloworking) and helping factors (ED culture of building relationships and networks, leadership) of the New panels were weighted more to interpersonal and intergroup factors than organisational factors. By contrast, the preferred hindering (workplace culture) and helping factors (professionalism, reciprocity and 'back scratching') of the Advanced and Intermediate panels were weighted more to organisational and intergroup factors. Although the data does not permit strong inferences, this pattern of results is consistent with the notion that, as leadership experience and sphere of influence grows, so too does the organisational complexity of the interventions emergency physicians are prepared to initiate.
Finally, the success of the modified Delphi method used in this paper offers an example of a constructive approach that teams in healthcare settings can use to decide upon local, ground-up approaches to address incivility, and other similar complex problems. Emergency physicians may consider the use of such methods when initiating and designing interventions in their EDs and hospitals to foster participation and buy-in from colleagues.

Conclusion
Workplace incivility and the entrenchment of cultures of incivility are complex problems that are experienced acutely by FACEMs and ED staff. The findings of our study provide new insight into many options FACEMs have to address incivility in EDs, opening up new avenues of and opportunities for formal and informal leadership in the ED.

Limitations
There are several limitations to the present study creating possible bias. Our convenience sampling method, which targeted FACEMs who were enrolled in a leadership development programme, may have led to response bias in the factors identified. Moreover, our use of a free-response format encouraged answers that were salient to participants rather than comprehensive (e.g. identifying all possible helping and hindering factors). A final limitation relates to the fact that participant ethnicity was not measured in the present study. In the context of the topic of incivility, and the potential role of ethnic differences in perceptions and the experience of incivility, this is a factor that deserves consideration in future research.