Psychological Safety in Healthcare

Psychological safety plays a key role in healthcare and clinical teams, and indeed is the domain in which some of the foundational research by Dr Amy Edmondson was conducted. Here is a selection of excellent resources from the psychological safety newsletter, studies and examples of psychological safety in healthcare and medicine.

Eve Purdy, applied anthropologist and Emergency Medicine physician, delivered a fantastic talk – “Psychological Safety is no Accident” about psychological safety and emergency medicine teams, and here’s a thread that she put together highlighting the key points. It’s absolutely excellent, from pointing out how hierarchies prevent people pointing out serious problems, to suggesting great practices such as the shift huddle and team briefing. Whether you’re in healthcare or not, this is worth a read and/or watch.

Professor Charles Vincent talks patient safety and improvement through psychological safety in this excellent Quality Improvement podcast from Oxford Health NHS Foundation Trust: 

This paper from the American College Of Cardiology – “Promoting Psychological Safety in Pediatric Cardiology” doesn’t exactly break new ground, but it’s comprehensive and appears to be robust, so it could be a handy resource for evidencing in business cases for psychological safety programmes in healthcare.

This is an excellent healthcare related article about psychological safety and applying the concept of Relational Security: ‘the knowledge and understanding we have of a patient and of the environment, and the translation of that information into appropriate responses and care.“

Here’s a great suite of resources from NHS England with practical tools and methods to aid spread and adoption of innovations to improve health and care outcomes and patient and staff experience.

Thanks so much to Gillian Manson for getting in touch and pointing me towards this excellent work by Padilla, Hogan and Kaiser: “The toxic triangle: Destructive leaders, susceptible followers, and conducive environments“. It’s a really useful model of the toxic combination of “Destructive leaders”, “Susceptible followers”, and “Conducive environments”, and reminds me very much of the epidemiological triad, that describes the three necessary components for a disease to occur, and it makes me wonder if that was the inspiration for it. As always, it’s an oversimplification (as are all models), but it makes for a very accessible framework. It also caused me to wonder if there’s an analog of Rothman’s Causal Pies that we could use in describing or modelling the necessary factors for organisational dysfunction.

And to reflect back on Eve’s piece about emergency medical teams, here’s a paper on cultural barriers to psychological safety in medicine: medicine continues to struggle with providing safe environments for its members. There are several cultural barriers to psychological safety that permit endemic harassment. These include having large power gradients, a weak ethical climate and a number of enabling structural factors that maintain a toxic culture.

Carrying on the healthcare theme, here’s a great open access paper on Harassment in Medicine: Cultural barriers to psychological safety. The authors make a good point about steep power gradients being particularly damaging to psychological safety: in organisations with these hierarchies, “people compete with one another for opportunities to gain more influence within the organization”.

This is a great article by Catherine Harrison (it’s over a year old but I only just came across it), about psychological safety in the NHS. I appreciate how Catherine makes the point that creating organisational-wide psychological safety “…is complex work, but one simple step in the right direction is to reach out, and keep asking, and encouraging others to ask, ‘what do you need?’’ and ensure there are people to meet that need.”

A very in-depth systematic review of the literature regarding the ability to “speak up” in healthcare contexts: https://www.sciencedirect.com/science/article/pii/S0168851021000026

An excellent article in the NEJM: Cursed by Knowledge — Building a Culture of Psychological Safety. 
Lisa Rosenbaum, M.D.
https://www.nejm.org/doi/full/10.1056/NEJMms1813429
(My apologies if you cannot access this journal. An alternative is to contact the author directly through ResearchGate: https://www.researchgate.net/publication/331258910_Cursed_by_Knowledge_-_Building_a_Culture_of_Psychological_Safety)

This is a superb piece in the Annals of Internal Medicine: a set of graphical depictions of behaviours that impact psychological safety in healthcare teams:
https://www.acpjournals.org/doi/10.7326/G20-0059

I’m trying to find more content about psychological safety in global health and humanitarianism (which is what I’m studying in my Masters Degree), but there’s not a great deal out there. From what I can find, it doesn’t look good: Managing stress in humanitarian aid workers: A survey of humanitarian aid agencies’ psychosocial training and support of staff.
https://doi.apa.org/doiLanding?doi=10.1207%2Fs15327949pac1001_4

How is psychological safety related to physicians’ vaccination behavior?
https://perspectivesblog.sagepub.com/blog/research/how-is-psychological-safety-related-to-physicians-vaccination-behavior

Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study:
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06232-7

Just Culture: The Foundation of Staff Safety in the Perioperative Environment
https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1002/aorn.13352

Enhancing psychological safety in mental health services (Note – this is open access, so you don’t need to be part of an academic institution or pay subscription fees to read it.)
https://ijmhs.biomedcentral.com/articles/10.1186/s13033-021-00439-1

The trouble with conflict in General Practice? There’s just not enough of it.
https://ockham.healthcare/the-trouble-with-conflict-in-general-practice-theres-just-not-enough-of-it/

The disruptive physician and impact on the culture of safety – The disruptive physician is a growing problem in medicine. All too often, physician behaviour negatively impacts the delivery of quality patient care.
https://journals.lww.com/co-anesthesiology/Abstract/9000/The_disruptive_physician_and_impact_on_the_culture.98654.aspx

Students value Socratic (questioning) teaching methods, but often feel humiliated if they get a question wrong. Whilst they don’t feel that is the intention of the teachers, it’s clear that a culture of psychological safety would improve clinical teaching.

Debriefing is a reflective practice, where we learn directly from our experiences in real life or in simulation. Plus/Delta (or +/Δ) is a foundational debriefing method and Shannon McNamara has started a bi-weekly publication on it. It sounds awesome, so sign up here!

Related to debriefing practices are retrospectives, where the team come together to examine success, failure, and ways of working. They are incredibly powerful ways to improve performance and increase psychological safety.

Can Mandela’s model for restorative justice work in healthcare? Rather than being motivated by the desire for vengeance, Mandela was a driving force behind the establishment of the Truth and Reconciliation Commission in 1995, a distinctive approach to addressing the aftermath of harm that emphasised healing over punishment. This has really interesting echoes to creating environments of psychological safety.

This week, I discovered “Schwartz Rounds“. Schwartz Rounds are a really powerful practice that comes from the field of clinical healthcare, but I see no reason they couldn’t be utilised in any other field. You could think of them as a kind of human-focussed retrospective exercise. Watch an example Schwartz Round here. [Note: possible trigger warning – this round focusses on the treatment of a sick baby]

This is absolutely fab: The patient safety team at University Hospitals Sussex made an art gallery as part of the recognition of the importance of psychological safety. I love these powerful portraits of front line staff.

This is excellent, by Michael Sykes (@Msykes09), an animation describing a monthly audit of ward quality at NHS hospitals. Verbal feedback described as a “whipping” & a “slap”. Ward visits intended “to be persuasive or coercive. It depends on your viewpoint”

And continuing the NHS theme, here’s an EXCELLENTguide to the art of psychological safety in the real world of health and care, by Sasha Karakusevic and the NHS Horizons team.

Check out this really fascinating piece about healthcare teams in training simulations. In situ simulation has highlighted an issue – what level of psychological safety do real world healthcare teams (including facilitators) bring into their simulation-based learning?  They can’t suddenly ‘create’ psychological safety in education if healthcare teams have dysfunctional hierarchies and poor relationships in their real clinical work. Aim for ‘safe, not soft’ in design, delivery and debriefing of simulation.

The NHS Horizons team really are amazing. This is a superb collection of great sketchnotes, from “10 things fab leaders do” to “Conferences vs Unconferences”. Every single one is downloadable to use in presentations or posters, and there’s a readable text version of each one. 

If you work in or around healthcare, here’s a brand new comprehensive literature review of the evidence base for psychological safety in healthcare teams. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. (Open access paper)

And an environment that I don’t believe we’ve highlighted before: Psychological Safety in the Dental Office – a good piece by Ricardo Mitrani.

I came across this quite a while ago in Atul Gawande’s “Better” book (which is excellent and well worth a read). Patients admitted for acute cardiovascular conditions whilst surgeons are away at a conference (and thus cannot operate) actually have slightly better outcomes than those admitted whilst surgeons are in the hospital. Sometimes it is better to do nothing and wait, rather than act. I suspect that the psychological safety required to restrain from doing the thing you’re paid to do is rather high, especially in high-consequence environments. If someone dies, are you more comfortable saying “We did the best we could.” or “We thought the best thing to do was to wait and see”?

Many of you will be aware of Sidney Dekker and his work around human error and the concept of “Just Culture”. Here’s a great Youtube video – “Just culture: The Movie”. This film documents the transformation in one organisation — Mersey Care, an NHS mental health trust in the UK. In the trust, blame was common and trust was scarce. Dismissals were frequent and caregivers were suspended without a clear idea of what they might have done wrong. This video describes the journey of people in Mersey Care toward a just and learning culture where people feel more valued, possess greater psychological safety, and mistakes create learning, not punishment.

Dr Eve Purdy has featured in the newsletter previously, and for good reason. Here, Eve is on the Mind Full Medic Podcast, talking about team culture and cultivating psychological safety in healthcare and emergency medicine. There are so many takeaways here for clinical teams, including team huddles, after-action reviews and an onus on senior clinicians to set the tone.

Here’s an article by Dr Bob Klaber at Imperial College NHS trust: How acts of kindness can improve care and strengthen teams. It’s a great piece that emphasises the importance of kindness not only to patients but to colleagues, particularly in the face of what could be a challenging winter for the NHS in the UK.

Here’s a great piece about psychological safety in healthcare from Brendan Murphy: “Resident physicians should not be expected to have every answer. They should be allowed to ask the tough questions. And, when necessary, residents should feel comfortable speaking up.” How psychological safety can help resident physicians flourish.

Thanks to Alicia King for sharing her research (alongside Tracy Lee Fortune, Louise Byrne and Lisa Mary Brophy) into workplace factors supporting safety to share mental health challenges, at two mental health services in Australia.

Thanks to Alicia King for sharing her research (alongside Tracy Lee Fortune, Louise Byrne and Lisa Mary Brophy) into workplace factors supporting safety to share mental health challenges, at two mental health services in Australia.

Here’s an episode of the new Health and Wellbeing Podcast from Primary Care Excellence (a UK NHS organisation) – Lynn Marsland’s guest is Pete Ledwith, Quality Improvement Programme Lead with AQuA and an expert in psychological safety.

For those in healthcare, and those of us want to learn from healthcare, this is a fantastic write-up of Edmondson’s The Fearless Organisation by Dr Philip Berry. I particularly like how Dr Berry describes a Morbidity and Mortality (M&M) meeting, where active sharing of observations and ideas from all quarters (including non-clinical staff) is an essential ingredient to learning and quality improvement, and where psychological safety is absolutely foundational to that aim.

 Here’s a great article about East London NHS Trust and how chief people officer Tanya Carter and colleagues worked on ways to surface issues and conversations around race, privilege, menopause and more. “We asked, people told us what they needed, and we found a way to make it happen.” Some of that work necessitated fostering an environment of psychological safety simply so that some of the issues that faced workers, through storytelling initiatives, could be talked about.