Resilience, Dysfunctional Behavior, and Sensemaking: The Experiences of Emergency Medicine Physician Assistants Encountering Workplace Incivility by James P. McGinnis B.S. as Physician Associate, May 1995, The University of Oklahoma MPAS in Emergency Medicine, May 2002, The University of Nebraska A Dissertation submitted to The Faculty of The Graduate School of Education and Human Development of The George Washington University in partial fulfillment of the requirements for the degree of Doctor of Education May 16, 2021 Dissertation directed by Shaista E. Khilji Professor of Human and Organizational Learning and International Affairs The Graduate School of Education and Human Development of The George Washington University certifies that James Patrick McGinnis, II has passed the Final Examination for the degree of Doctor of Education as of December 7, 2020. This is the final and approved form of the dissertation. Resilience, Dysfunctional Behavior, and Sensemaking: The Experiences of Emergency Medicine Physician Assistants Encountering Workplace Incivility James P. McGinnis Dissertation Research Committee: Shaista E. Khilji, Professor of Human and Organizational Learning, Dissertation Director Ellen F. Goldman, Professor of Human and Organizational Learning, Committee Member Neal E. Chalofsky, Associate Professor Emeritus, Committee Member ii Dedication To the unheralded Spartans of emergency medicine, themselves committed to the art of healing, who willingly stand in the breech between sickness and health, between life and death, and ultimately between chaos and order. iii Acknowledgement No person stands as an island. Despite our cries of independence, rugged individualism, and self-sufficiency, none of us attain success wholly upon our singular efforts. We are intimately intertwined with those who surround us and the relationships that we encounter throughout our lived experiences. This is particularly true for the man who now offers these ensuing words of thanks, gratitude, and humility. Without the life I have lived, and the people who have been a part of it, the admittedly circuitous trajectory of my earthly journey would most assuredly have taken one or more far less desirable turns. Dr. Khilji, you are the chair of my dissertation committee, and as such, my dissertation advisor. There is no doubt that I would have failed to reach this point without your guidance, patience, and encouragement. You held me to an academic standard that, at times, I was not sure I could meet. More importantly, you demonstrated incredible patience as I muddled through this unfamiliar process. In so doing, you have broadened my horizons far beyond the boundaries of this research. Dr. Chalofsky, you are more than a member of my dissertation committee. You are the professor who led me to my first “eureka” moment in my doctoral studies and the one who first introduced me to the construct of incivility. It was not my intention to intrude upon your retirement years. Thank you for your dedication and commitment to this process and my journey. Dr. Goldman, you are another member of my dissertation committee who came to this process with equal parts rigor and encouragement. The clarity you provided, the guidance you offered, and the value you added to this process cannot be overstated. To say that I iv am grateful seems too little a commentary and fails to fully convey the value I place on the positive impact you have had on me and my work during this process. Dr. Honda and Dr. Crowley, your willingness to be a part of this final step in my journey is genuinely humbling. In the true spirit of academic camaraderie, you both freely and generously offered your assistance. I am grateful for the selflessness you displayed on my behalf. Tonya, my wife, and best friend came to this journey mid-stream. She had the incredible misfortune of marrying a man who was in the middle of his doctoral dissertation. Over the course of the last few years, she has endured lost weekends, delayed projects, shortened vacations, and endless responses of “just one more page”, or “just a few more revisions”. Your encouragement and support were invaluable in this and so many other endeavors. I am so glad you decided to “say me, yes!” How do I thank my mother, Joan? There simply are not enough pages available to properly communicate the depth of her influence in my life. A lifelong educator who built a career when women had few career options, she raised a family, sent a husband and two sons off to war, and endured a barrage of life’s disruptions that few can comprehend. Through it all she showed a grace and dignity that is all too rarely seen in our world. More importantly, she, along with my father, instilled in me an enduring faith in God. It is a faith that has sustained me through my darkest hours. Mom, you are my inspiration and my rock. My father, James V. McGinnis, did not live to see the culmination of my doctoral journey. However, I would not be here today without his influence. I inherited his perpetual inquisitiveness and his dogged determination. There is not a day that goes by that v I do not miss him. He had a saying, “A man’s going to do what a man wants to do”. It is a simple saying with a layered, and deep message and one that I repeated to myself frequently throughout this process. I miss you, Dad. Every, single, day. I miss you. My children, Shelby and Ian, and my stepson Sam have often wondered what it is I am doing and why, at my age, am I doing it. I wish I had easy answers for you. All I can offer you is the observation that long ago my parents instilled in me a love for learning. Some people see learning as an unpleasant but necessary step toward a career, or an arduous rite of passage to adulthood. Others embrace it as an enjoyable, integral, and necessary part of their very existence. For each of you, I hope my example will lead to a day when the latter overshadows the former in your own journey. To the men of the United States Army Special Forces, the “Green Berets”, with whom I served in the defense of this great nation of ours. Your names are too many to mention but know that your leadership, your mentoring, and your steadfast dedication to, and demand for, excellence in all that we do helped propel me to where I am today. To some it may be only a hat, but as President Kennedy noted, the Green Beret is more than that. It is “a symbol of excellence”. Earning it and earning the right to serve alongside you is one of the greatest achievements of my life. I am genuinely humbled to know that when I walked among you, I walked in the shadows of giants. Finally, to the participants in this research. Truly, without you this would never have happened. Thank you for sharing your stories with me in such an open and honest fashion. I heard you. Thank you for allowing me to share your experiences with others and give them just a small glimpse into the life of an emergency medicine PA. vi Abstract of Dissertation Resilience, Dysfunctional Behavior, and Sensemaking: The Experiences of Emergency Medicine Physician Assistants Encountering Workplace Incivility Existing literature examining workplace incivility in the healthcare setting does not address the experiences of emergency medicine physician assistants (EMPAs) as separate and unique from the experiences of other non-physician members of the emergency medicine healthcare team. The physician assistant profession is one of the fastest growing professions in the healthcare industry and many emergency departments are employing EMPAs to address issues of overcrowding. Within the healthcare setting, the emergency department is the area where employees most frequently encounter workplace incivility. Workplace incivility has been demonstrated to negatively impact employee well-being as well as organizational performance. Within healthcare, it is linked to employee burnout and decreased patient safety. Unfortunately, little is known about the lived work experience specific to EMPAs. A qualitative study was undertaken to examine their adaptive responses as a result of their experience with workplace incivility. Interviews with eleven participants provided the researcher with a rich understanding of how they made sense of their experiences and how they manifested their adaptive responses. Participants experienced WI as a threat to their sense of belonging. This threat was associated with experiences of emotional distress. Positive adaptations to this emotional distress included accessing their social capital and improving their clinical competence. Negative adaptations to this emotional distress included avoidance behaviors and engaging in acts of retribution. Participants vii exercised personal agency through direct confrontation with the source of their WI encounter and through organizational and career exit. Three conclusions resulted from this study. The first addresses the negative emotions experienced by EMPAs who encounter WI. The second reveals the role of social capital in the EMPAs development of resilience. The third highlights the risk of patient harm that results from their negative adaptive responses. These conclusions offer insight that directly addresses the culture of emergency medicine and the impact of that culture on the lived experiences of EMPAs, their well-being, and the safety of the patients they serve. viii Table of Contents Dedication ......................................................................................................................... iii Acknowledgments ...........................................................................................................