5 Ways to Promote Psychological Safety in Healthcare

Psychological safety in healthcare work environments is achieved when members of the care team feel safe speaking up and taking interpersonal risks. This meaning of the term was pioneered by Harvard researcher Amy Edmonson, and has been widely adopted in the industry because of how useful it is for understanding and improving healthcare team dynamics.

Research shows that fostering a culture in which nurses feel psychologically safe can encourage open communication and enhance teamwork. Nurses in this type of environment are more apt to learn and innovate. Nurses who feel safe about speaking up typically report more errors, which paves the way for fewer errors and better patient outcomes.

Here’s a closer look at this key to high-performing healthcare teams, and the critical components and what it looks like in practice. You’ll learn how to spot psychologically unsafe behaviors and attitudes, and what to do when you encounter these challenges. Our best practice will provide the five practical steps you can use to promote safety on your team.

What Is Psychological Safety in Healthcare?

Psychological safety can refer to a range of feelings related to wellbeing and the ability to express oneself in a group without fear of retribution. This term gained traction in healthcare leadership in the 1990s thanks to an increased focus on system failures (vs. individual incompetence) and Edmonson’s pivotal work on the characteristics of high-performing hospital teams.

The concept earned more attention with Google’s Project Aristotle, which involved a multi-year, scientific analysis of the company’s teamwork. Researchers involved in the project ultimately pinpointed psychological safety as the most important factor of the best teams within their organization. The teams with the highest performance metrics weren’t necessarily stacked with individual talent; rather, they were the ones where individuals felt welcome to express their ideas openly and be vulnerable with one another.

Benefits of Psychological Safety in Healthcare

A psychologically safe culture has many advantages over one that fosters blame and punishment. Here are some of the most significant benefits:

• Increased error reporting
• Improved team communication
• Better patient outcomes
• Higher nurse job satisfaction
• Higher nurse retention rates
• Decreased incivility on teams

Psychological Safety Examples

Here are two examples to show what this looks like in a clinical setting.

Inviting Input and Flattening Hierarchy

At a team huddle, a group of nurses discusses a patient fall that occurred the day before. A charge nurse with 20 years of experience turns to a new graduate nurse and asks with genuine interest: “You were his nurse a few days ago. Did you notice anything that helped his agitation and restlessness?”

Speaking Up and Taking Interpersonal Risks

During multidisciplinary rounds, a doctor says that a patient’s recent chest x-ray shows a “small pneumothorax.” A nurse speaks up: “What do you mean by small? Does the size of this pneumothorax change anything about the complications we should be watching for?” The doctor responds: “Those are great questions.” He describes the pneumothorax in more detail and the team works together to clearly define the signs and symptoms of a worsening condition for this patient.

The Key Components of Safe Teams

Here are the common factors that psychologically safe teams share:

• There’s a sense of trust on the team.
• There are appropriately colloquial and familiar relationships among staff.
• Individuals are willing to be vulnerable and voice concerns to the team.
• Most errors are viewed as team/system issues and opportunities for improvement.
• Clinicians prioritize the shared purpose of providing quality patient care.
• There’s a sense of equality among staff.
• Individuals show respect for diverse clinician perspectives.

Warning Signs That Clinicians Are Experiencing Issues with Psychological Safety

Nursing teamwork can break down in a variety of ways. Here are some red flags that may indicate your team is functioning without the necessary level of psychological safety:

• High nursing turnover rates
• Complaints about poor team dynamics
• Frequent communication breakdowns
• Expressions of dissatisfaction with the job
• Nurses display signs of burnout and fatigue
• Very few reported errors
• Hesitancy, fear, and shame around reporting mistakes
• Reports (formal or informal) of incivility and bullying on the team

Promoting Psychological Safety in Healthcare Organizations: 5 Best Practices

If you’ve noticed signs of unhealthy dynamics on your team, what can you do? Research into psychological safety gives us helpful information about how high-functioning teams work, providing a map to improvement and a goal to work toward. Below you’ll find best practices based on work around this theory.

1. Invite Healthcare Team Members to Voice Input

According to Edmonson’s work, it’s important for team members to engage with one another by asking questions. This includes higher-ups (like nurse managers and advanced practice nurses) seeking input from those who are technically below them on the hierarchy.

For example, a wound care nurse visiting the floor may invite input from a patient’s primary nurse by asking, “What do you think about how the wound is healing?” Not only should open-ended questions like this be asked, but also productively responded to. Create workflows that allow clinicians to engage in dialogue and adjust care plans accordingly. As a manager, you can model this by asking questions to staff, actively listening, and taking action in response to high-quality input.

2. Try Coaching to Help Nurses Correct Course

If you’re in a leadership position, you’ve probably noticed that addressing poor performance is challenging. Calling a nurse into your office to deliver negative feedback may lead the nurse to shut down or become defensive. Research into psychological safety supports the use of progressive discipline. This is when disciplinary actions occur on a continuum from least-serious to most-serious as a means of preventing mental harm.

With this approach, leaders intervene quickly when a performance issue is noticed, using the least-severe form of discipline available to them. A form of low-severity discipline is informal counseling, in which a manager has a discussion with an employee to try to understand the root of the performance issue and collaboratively come up with solutions.

3. Focus on Shared Purpose

Medical teams have an important advantage when it comes to teamwork. The ultimate objective is usually clear and incredibly motivating: Help the patient. It might not be as dramatic as saving the life of a coding patient on an operating table, but there is usually some element of helping others involved in the clinical workflow. Because psychological safety is a group phenomenon, it’s enhanced when the team acknowledges and focuses on their shared purpose.

4. Promote Familiarity on the Team

Psychologically safe teams display higher levels of behavioral integration than those that are unsafe, meaning that there’s a lot of information sharing and collaborative decision-making happening on a day-to-day basis. Promoting these exchanges could look like ensuring your nursing station has enough workspaces where clinicians can gather, or altering your rounding practices to encourage productive discussions. Consider strengthening shared governance initiatives at your facility, or giving staff the resources needed to start a committee.

5. Model High Standards and Vulnerability

Parents know that “do as I say, not as I do” isn’t a realistic approach. The best way to steer another person toward a behavior change is to be a role model. If you’re noticing unsafe and unsupportive behavior on your team, like incivility or bullying, you have a duty to intervene. However, it’s just as important that you model high standards by engaging with others respectfully and with integrity.

Edmonson’s work also highlights the importance of admitting fallibility. As a leader, owning a mistake is one way you can teach your team to do the same, so that solutions can be reached.

Learn More Ways to Improve Nursing Staff Satisfaction

Fostering psychological safety in healthcare settings is one way to prevent nursing staff burnout and turnover. Get more insights about facilitating a positive work environment in our healthcare leadership resources and guides.