“Psychological Safety is a SHARED belief that no one will be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes​” – (Professor Amy Edmondson)

Physiological Safety and Restorative Just Cultures are inextricably linked in the workplace. Restorative just cultures realise that to err is human and to operate in a blame culture deals only with the person as the perpetrator, which closes down any learning of the contributing and causal factors that will remain in the system, so nothing is fixed. By creating psychologically safe environments, people are supported when things don’t go as expected or planned so feel safe to share their experiences, which is when the learning begins to happen.

Psychological Safety and Civility and Respect

In health care settings, types of negative behaviours such as incivility and disrespect, microaggressions and bullying and harassment have been shown to undermine levels of patient safety and are associated with decreased productivity, decreased team psychological safety, absenteeism, increased staff turnover employee and unfavourable patient outcomes. However, national reviews into patient safety such as A Promise to Learn - A Commitment to Act (Gov.UK 2013) and The NHS Patient Safety Strategy (2019) and the momentum to implement restorative just cultures (NHS Just Culture Guide, 2019) has seen a shift in this thinking, regarding many unfavourable outcomes as preventable and unacceptable and citing the need for psychologically safe teams that can work effectively together without a culture of fear and blame as critical to the prevention.

How is it Created?

The implementation of a restorative just culture places greater emphasis on psychological safety for continuous learning and improvement and includes solutions to address the well documented impact of legacy infrastructure and organisational design. By positioning culture, safety, improvement and organisational design as interdependencies truly enables us to optimise and upscale quality and improvement.

Psychological Safety is a multi-faceted concept and what this looks like in your organisation and what needs to change can only be discovered through the exploration of your own data, speaking your teams, triangulating this with your NHS Staff Survey, team level data, ER data and any others and then applying a gap analysis to see exactly where and the work needs to take place. The following shows some of the key themes that you may want to think about.

Open and Honest Dialogue

Psychological safety is continuously created through open and honest dialogue; creating a sense of inclusion and belonging in team based working plans, safety in speaking up and out, mutual respect, civility, cooperation and accountability through our leaders and teams. Through this approach we create a line of sight to RJC providing a golden thread through our people, systems and processes, providing a compassionate environment that supports ‘perfect care’ and high quality, safe services.

Voice Behaviour and Keeping Silent

Because of our traditions and cultures, keeping silent has often been a social expectation that we believe will maintain our interdependence in our social or workplace groups, harmony, conformance and as a way of avoiding conflict in the workplace. As such, we can be prone to withholding our voices rather than voice our concerns or ideas or report our own or other errors. In countries and organisations where the culture emphasizes collectivism, obedience, and respect for authority, people do not feel safe, or it is not the norm’ to make suggestions, ask questions, challenging authority or reporting something that may negatively influence patient care.

It’s not so much the speaking up part that employees have a fear of – it’s the potentially negative consequences and impacts that come from speaking up and reporting errors that people are fearful of, consequences which are quietly likely to happen in organisations where blame cultures exist. Restorative just cultures will map out and consider exactly what happens when someone speaks up, contributes, reports and error etc to see where the negative consequences occur and work out what needs to change so that people are supported but accountability is not avoided, and the learning takes place. Remember – what is happening in your organisation will be different to others, so mapping out your own processes and figuring out the gaps is the only way of doing this.

Language plays a huge part here as it subconsciously attaches stigma to certain words. Even from that sentence – the word error makes people not want to voice something that has happened, but what if the organisation change the word error to when things don’t go as planned or as expected, how much safer or willing would people feel to voice that “something hadn’t gone as expected” rather than “I’ve made an error”.

Inclusive and Compassionate Leadership

Inclusive leaders actively invite others to make contributions, voice their opinions, ask questions, and show appreciation for those contributions so that employees and teams feel that their voices are valued and heard. Leadership or team leadership and/or management behaviour can directly influence voice behaviour which in turn will affect the level to which people feel safe to voice anything. In health care organisation, by demonstrating inclusive leadership we can positively influence and increase level of psychological safety in the workplace which can decrease an employee’s fear of the potentially negative consequences of speaking up and error reporting.

Although there is a wealth of evidence on the outcomes of team psychological safety such as organisational learning and high performing teams (e.g., Edmondson, 1999; Guchair, Pasamehmetoglu & Dawson, 2014; Nembhard & Edmondson, 2011) a further important question we need to be able to answer in the work place is:

  • What Promotes feelings of Psychological Safety?
  • Which critical factors to be in place to help our teams to help themselves to feel psychologically safe?

Although we have mentioned some of these critical factors above, evidence tell us that when employees experience civil and respectful interactions in the workplace that encourage trust, understanding and rapport, this will contribute to their perceptions and experience of psychological safety. In other words, experienced civility and respect is a predictor of psychological safety. This becomes even more so when civility and respect are the ‘norms’ or the accepted way of doing things for everyone rather than experienced by some.

Moving psychological safety from concept to reality - Creating Psychologically Safe Teams in the Workplace

The following diagram shows the antecedents of psychological safety that has been drawn from the literature on team levels of psychological safety. This is by no means an exhaustive list and the levels to which these variables will exist and correlate will vary on the context in which they are applied. However it does give a wider understanding of what we needs to be in place if healthcare teams are to be in a position where psychologically safe environments are created and developed. Each of the concepts shown below will need to be reviewed and thought through as to how this would transpire in your organisation and teams, you can do this by applying the gap analysis and gathering the data in your organisation to show the level to which each on of these concepts exists and why – don’t forget the why as it usually tells you the solution. Click on the hyperlink for each one and it will take you to the article where you can read in more depth as to how this can be reviewed and mapped out further. Please note you will need organisational access for some of these articles.