When I transitioned into a new role as a training faculty member at an academic medical center a few years ago, it didn’t take long to realize that the program had a problem with psychological safety. There wasn’t much.
As I got to know the trainees and heard specific feedback, I began to understand why. The trainees felt criticized and unsupported by the training faculty. And every time there was a faculty meeting, rumors circulated about trainees’ poor performance, which led them to worry about being failed out of the program. As I developed relationships with the training faculty, it became clear that staff members felt as unsafe as the trainees.
Everyone was impacted by cultural habits that promoted indirect communication, over-emphasized “growth areas,” and limited power sharing between those without titles.
After observing for several months, I decided to act and provide direct feedback to the training director and the department chief. I shared my concerns about the program’s cultural practices. I recommended various changes to promote psychological safety and a learning environment where trainees could be sufficiently supported to learn, grow, and spread their wings as developing medical professionals.
My feedback was met with resistance. Leadership was taken aback by my concerns and unwilling to consider my recommendations. I was initially told that I was dead wrong, “that’s not happening.” So, nothing changed. Nothing changed until a complaint was filed, and the program’s governing body initiated an investigation. The external scrutiny and feedback motivated the program’s leadership to let go of the most problematic cultural practices, such as discussing trainees’ foibles in all staff meetings without providing behaviorally specific feedback to trainees first.
I don’t know if hearts and minds were changed, but the implementation of these modest changes improved psychological safety. Over time trainees reported feeling more supported, and faculty meetings took on a more civil tone with less opportunity for backbiting or criticism of the least powerful. Everyone felt safer. Changing the program’s training policies and communication practices profoundly impacted psychological safety for trainees and faculty in the training environment.
Leaders in health care environments often fail to recognize their role in creating psychological safety and consider building it as something that can be accomplished by giving a presentation on high-reliability principles at their quarterly staff meetings.
A failure to create psychological safety for the least powerful in the system is a failure of leadership. A lack of psychological safety for employees increases physical safety risks for patients.
Leaders have the power to shape expectations and create psychologically safer environments in health care. Leaders are responsible for setting the tone for respectful and safe communication practices. But the work to create psychological safety must start within. Health care systems need courageous leaders willing to self-reflect and acknowledge the unintended impacts (and harms) their workplace policies and communication practices have on our employees, health professions trainees, and patients.
We have made creating psychological safety overly complicated.
To create lasting psychological safety in health care systems, senior and executive leaders need to do three things: elevate historically lower power and diverse employees to the decision-making table, give extra weight to the needs and perspectives of these employees, and respond with systemic policy changes that address these employees’ needs in courageous ways.
When we create a safer and more supportive environment for our lowest-power employees, we create an environment where all employees thrive. And we create a safer environment for patient care. Everyone wins, and we create a resilient system that is a pleasure for health care leaders and our diverse employees to work in.
We all deserve to work in an environment where every person in our health care system, from the housekeeping and maintenance employees to the CEO, feels valued, honored, and safe. Let’s get to work.
Nicola F. De Paul is a clinical psychologist and a health systems leadership consultant.
