Psychological safety in health care: simple, important, fragile

With the epidemic in health care of overwork, stress, and burnout, psychological safety is a crucial factor in achieving the highest levels of quality of care and quality of work environment. While simple in concept, psychological safety is also quite fragile and needs careful attention on a day-to-day and conversation-to-conversation basis to assure it.

Psychological safety means that people feel safe to speak up about concerns, new ideas, negative feelings, and disagreements. People can trust what they say will be understood and explored, not attacked, or discounted. Psychological safety is not a separate program. It is how we talk together to get work done. It is the way we define problems, create solutions, make decisions, and give and receive feedback.

Creating psychological safety is conceptually relatively simple. It requires inviting participation, including explicitly asking for and exploring different viewpoints as opposed to arguing back and forth. For example, a leader might say multiple times during a meeting: “No one has all the answers, including me. It is very easy to get off on the wrong track. We need to hear from all of you, especially when you disagree or have concerns.”

Psychological safety is very important as studies have shown it enables performance. Particularly with complex problems, the best results arise from collaborative learning, which requires openness and honesty. Also, inviting people to say what they really think facilitates intrinsic motivation, which enhances outcomes because it means approaching work out of genuine interest and commitment.

Despite the conceptual simplicity of psychological safety, it is quite fragile — it is difficult to develop and sustain. Our brains were hard-wired early in our evolution for quick reactions for survival. Even minor stresses in team interactions can activate this hard-wiring, causing anxiety and leaps to biased conclusions, often outside of awareness. This diminishes curiosity and openness, which are already hard to sustain in the midst of the usual, constant pressure for quick solutions. As a result, psychological safety must be assured conversation by conversation — we can’t assume that a safe state of affairs yesterday has continued to today.

Also, multiple studies have shown that it is inherently difficult in group situations for people to speak up with views contrary to others. For example, in health care, it is surprisingly common for experienced professionals not to speak up even when surgical patients are about to be harmed. This tendency to silence is magnified when work is fast-paced and by the presence of power differentials. Ultimately, even highly experienced professionals need repeated, explicit invitations and support to consistently speak up.

Perhaps the most difficult aspect of psychological safety is that it demands leaders who cultivate their own self-awareness, vulnerability, and humility: self-awareness because our minds can so easily be hijacked by the survival brain; vulnerability because we have to ask for and carefully listen to disagreements about things we really care about; and humility because we must admit when we are wrong and that we need advice and help.

All of these issues make psychological safety quite fragile. Developing and sustaining it is a matter of life-long commitment and practice.

Neil Baker is a physician and founder, Neil Baker Consulting and Coaching.

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