11 minute read
Associate Editorial
from ACMS Bulletin November 2022
by TEAM
Psychological Safety in Health care
“Institutions are where the human heart either gets welcomed or thwarted or broken.” —Parker Palmer.1
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RosemaRy hanRahan, mD, mPh, PCC
During a recent webinar on psychological safety hosted by of the Center for Creative Leadership, the facilitator invited us to reflect on two situations from our past when we participated as a member of a professional team. We were asked to think about a time when we experienced a powerful connection between team members, and conversely, we were asked to recall a time when we experienced discouraging disconnection.2
For most of us, the latter scenario came to mind more easily. After all, as psychologist Rick Hanson, Senior Fellow of UC Berkeley’s Greater Good Science Center, and New York Times best-selling author reminds us, our brains are like Velcro for the bad and Teflon for the good.3
My reflection jettisoned me back 35 years to my first year and first day of internal medicine residency. Fresh with considerable knowledge, ample enthusiasm, and a fair amount of anxiety, I listened as our senior resident told us about “complication rounds.” These rounds, conducted three times a week, were a chance for ward teams, attending physicians, and faculty members to come together and discuss patient care situations with undesirable outcomes.
Complication rounds were meant to be opportunities to learn together without assigning blame or evoking shame so that we all would all become better physicians—first year and senior residents, fellows and attending physicians. We also received a free lunch.
Although these encounters occasionally went as forecasted, more often they morphed into a blame and shame scenario, at times ending with tears either in the conference room or after in solitude.
In the ensuing months, I first noticed that the residents stopped eating the free lunch, as did I--nothing could get past the lump in my throat and the knot in my stomach. Then I noticed, firstyear residents stopped volunteering cases for discussion. Finally, unless we absolutely had to be there, we stopped coming. Not only was it painful to be on the receiving end of the harsh scrutiny, it was also incredibly painful to watch others in the hot seat.
Reflecting back, with the clarity of time and experience, I now know that physical and psychological safety are essential for learning and personal fulfillment. I also acknowledge that what I needed then (and now) in times of distress, was the support of my colleagues, who I knew to be extraordinarily kind and compassionate.
I’d like to think that the incredible advances medicine has made in those 35 years since my residency include a more humane approach to human error. As a physician who has faced the personal and professional impacts of medical error, and as a professional coach who works with individuals in a variety of high-stress health care environments, I can attest that we are not there yet.
However, based on considerable experience and knowledge from other industries, we are beginning to recognize the critical need for psychological safety in health care for health care professionals. We are beginning to have the “Totally Honest, Totally Kind” (THTK) conversations we need to have so that we can consistently integrate psychological safety into our health care leadership discussions and team interactions.2
What is psychological safety?
Dr. Amy C. Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, is a widely recognized expert in psychological safety and the author of The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation and Growth.4
As defined by Dr. Edmondson, and elaborated on by the American Medical Association, “Psychological safety is a climate of trust and respect in which people are comfortable expressing and being themselves, and share the belief that teammates will not embarrass, reject, or punish a colleague for speaking up.”4,5,6
Speaking up may sound like asking for help or balanced feedback or saying I don’t know, or I made a mistake. At times, speaking up means feeling safe enough to share half-formed and messy ideas, or voicing problems without solutions in tow.
It also helpful to consider what psychological safety is not. It is not freedom from conflict or messy conversations. Nor is it seeking consensus. It is not a guarantee that others will agree or be persuaded by one’s ideas. Most definitely, psychological safety is not immunity from the consequences of mistakes, nor is it a safe haven for repeated poor performance. Psychological safety comes from a belief that while failure is not the desired outcome, it is an option that doesn’t require shaming an individual or ending a career.
This important topic has garnered attention in almost every industry. An often cited initiative is Google’s Project Aristotle of 2012. In their quest to build a perfect team, Google found that intelligence (IQ points) and resources (money) can’t compensate for what a team lacks in psychological safety. In fact, the company concluded that psychological safety was the single most important factor in explaining high performance.4,7
When psychological safety is high, people take more ownership and put forth more discretionary effort. Learning and problem-solving occur at greater velocity. When it’s low, people don’t move through the fear. Instead, they tend to shut down, self-censor, and focus their energy toward risk management, pain avoidance, and self-preservation.7
Some barriers to psychological safety rest at the individual level and are fundamental to our basic human need for safety. Both consciously and unconsciously, we all want to manage our image to look smart and capable to others.
In health care, culturally based and “institutionalized” barriers are common, including a culture that is drawn to tradition, undervalues dissent, highly values perfectionism and is highly litigious.
Clearly, psychological safety is complex and difficult to establish. It is also fragile and easily lost. Psychological safety is influenced by individual-level factors, organizational climate, and leadership. However, it primarily lives and breathes as a team-level phenomenon.8
High-quality health care delivery is innately iterative and highly dependent on interprofessional teams. These teams must work together in complex, highly technical, and rapidly changing environments. Stakes are high, and uncertainty and ambiguity rumble with facts and data on a frequent basis. Yet a hierarchy of authority and power exists, and some would argue it is necessary at times. Grit and even ego are amazing qualities that often manifest as strengths; however, when overutilized, these strengths can become derailers, fostering a fixed rather than growth mindset. A growth mindset embraces challenge as opportunities to learn and innovate. Psychology safety can help individuals and teams shift from fixed to growth mindsets.5
In health care, we are fortunate to have many of the brightest minds, kindest hearts, and most expert hands in the world. The culture of an organization, and the day-to-day teams are the “institutions” that can welcome, thwart, or break hearts and minds.
In her work with health care teams, Dr. Edmondson found that when psychological safety was present, mistakes were reported more often, but earlier. Silence leads to harm that could have been prevented. When employees don’t have the freedom to speak up, organization’s lose mindshare and early awareness of risks.4
Burnout is at the forefront of many conversations today. As forces join to support health care workers in staying well, we know that peer support is an important intervention in preventing burnout and other manifestations of clinician distress. Psychological safety is foundational in establishing peer support programs.5
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The topic of psychological safety frequently comes up in both team and leadership coaching. If psychological safety lives and breathes at the team level, what is the role of the leader in establishing psychological safety? Edmondson offers one tip for creating psychological safety: it starts with the leader.4
Fostering psychological safety necessitates the awareness and dismantling of barriers and establishment of new norms within teams and organizations. The leader’s most important role—above that of creating a vision and setting strategy— is to cultivate an environment of trust and respect. A leader also serves as the link between individuals, teams, and other influencers and decision makers.7
Psychological safety is not binary, something teams either have or don’t. Though, to some extent, it can be measured. A number of short Likert scale-type surveys are available to assess psychological safety within teams. Most are adapted from a seven-question survey developed by Edmondson. The survey questions examine individual safety, team respect, and team learning.4,9
Shifting the culture of blame and shame that still exists in many health care environments and tapping into the wisdom and gifts of highly skilled and caring teams will take time-and tolerance for discomfort and imperfection.
Nevertheless, small, consistent steps in the right direction will get us far. I find it helpful for myself and with coaching clients to approach desired change from the inside out, sometimes described as “being and doing.” I offer a few suggestions in this direction: 1. Become aware of your own mindset and behaviors: Be aware of your derailers. These can be difficult to sort out alone. Consider asking for assistance from a trusted colleague or professional coach. Assessments such as the Hogan Development
Survey can be helpful.10 2. Model the behavior you want to see from others: Actively listen to what is being said and not said.
Invite dissent by asking openended questions: “What are we missing here?” or “What’s another viewpoint?” Acknowledge and thank people when they speak up. Stay curious and engage in co-discovery as a team when complex problems arise or mistakes occur. Be THTK without excusing repeated poor performance. 3. Be willing to show vulnerability:
Admit you don’t know the answer, that you need help and/or that you have made a mistake. 4. Make it easy to ask for help and offer input: Not everyone will speak out in a large group, especially introverts who may need time to process.
Create different forums for input-reach out by email or schedule one-on-one meetings. Establish norms that encourage the sharing of imperfectly formed ideas, as well as problems (especially complex ones) that may not yet have solutions. 5. Pay attention and be intentional about how mistakes are handled:
When a mistake is made, especially when significant harm occurs, we are at our most vulnerable. We must always keep our patients at the center of our caring and focus. Yet, we can also support each other and avoid blame and shame. In doing so, we can learn and thrive with hearts and minds that are welcomed and opened.
We are rapidly, albeit unevenly, gaining awareness about what psychological safety is and is not. We are beginning to realize what it means to integrate the mindset and behaviors necessary for psychological safety into a profession that thrives with talented and compassionate individuals and high-functioning teams.
I encourage us to reflect on what it looks like, and means to be a powerfully connected team and ask ourselves--what will I stop, start, or continue to do to foster psychological safety?
References
1. Intrator, S. E., ed. (2005). Living the questions: Essays inspired by the work and life of Parker J. Palmer.
Jossey–Bass. 2. Altman, D. (2022). How leaders & leadership collectives can increase psychological safety. https://www. ccl.org/webinars/how-leaders-andleadership-collectives-can-increasepsychological-safety-at-work/
3. Bergeisen, M. (2010). The neuroscience of happiness. https://greatergood.berkeley.edu/ article/item/the_neuroscience_of_ happiness 4. Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons. 5. American Medical Association (AMA). (2020). Jo Shapiro,
MD, explorespeer support implementation during a crisis. https://www.ama-assn.org/practicemanagement/sustainability/joshapiro-md-explores-peer-supportimplementation during-crisis 6. Center for Creative Leadership. (2022). What is psychological safety at work? https://www.ccl.org/articles/ leadingeffectively-articles/what-ispsychological-safety-at-work/ 7. Clark, T. R. (2020). The four stages of psychological safety. Porchlight. https://www.porchlightbooks. com/blog/changethis/2020/ the-four-stages-of-psychologicalsafety#:~:text=Psychological%20 safety%20is%20a%20 condition,or%20punished%20in%20 some%20way 8. O’Donovan, R., Aoife De Brún, A., & McAuliffe, E. (2021). Healthcare professionals experience of psychological safety, voice, and silence. Frontiers in Psychology, 12, 1–16. doi.org/10.3389/ fpsyg.2021.626689 9. Psychological Safety. (2020).
Measuring psychological safety. https://psychsafety.co.uk/measurepsychological-safety/#:~:text=By%20 regularly%20measuring%20the%20 degree,for%20developing%20 and%20maintaining%20it 10. Hogan. (2022). Hogan development survey. https:// www.hoganassessments.com/ assessment/hogan-developmentsurvey/
About the Author
Rosemary Hanrahan, MD, MPH, PCC: After three decades of practice in Anatomic and Clinical Pathology, Rosemary transitioned to executive leadership and academic coaching for individuals in the health care and non-profit sectors. She also supports and encourages medical laboratory excellence as a part-time field representative with The Joint Commission. Rosemary can be contacted at beyondwordswellnessresources@ gmail.com.
The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.
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Continued on Page 14Julie Rost
