Evolution of Leadership and Management in Healthcare: Lessons from Aviation and Crew Resource Management.

Introduction

As a result of the ever-increasing scale and complexity of healthcare systems, hierarchies and layers of management have become increasingly necessary (Kumar, 2021). These facilitate operational capability, both in terms of scale and complexity, but also lead to sometimes steep power gradients. It is these power dynamics that can potentially lead to worse patient outcomes rather than better, due to impacts on psychological safety and resultant safety silence amongst those at the sharp end of work (Green et al, 2017, O’Donovan & McAuliffe, 2020, Grailey et al, 2021). This essay explores this phenomenon, drawing on my experience working with healthcare organisations, alongside analogues from work in aviation. It examines the need for psychological safety in healthcare, how leadership and organisational structure influence it, and suggests what the future may hold for mitigating these effects.

Why don’t people feel safe to speak up?

The power structures and hierarchies that have emerged in the healthcare system have, at times, created cultures where people don’t feel safe to speak up and raise concerns to, or about, people in power (Fernandopulle 2021). Prior to the creation of the NHS in 1948, the UK healthcare system was fragmented, without centralised control or budgeting. Healthcare was a mix of private, voluntary, and public institutions such as workhouses, voluntary hospitals, and services covered by National Insurance, each operating independently (Nuffield Trust, no date). The NHS adopted a unified, hierarchical structure where hospitals were nationalised and managed by appointed regional boards. Governance shifted accountability towards Parliament, emphasising central control and ministerial responsibility over local or regional autonomy. The intention was to ensure equitable access to healthcare services across the nation, and operationalising the workforce and resources needed to deliver patient care at scale necessitated multiple management layers and structures (Gorsky, 2015). 

However, this approach has led to tensions; clinicians still bear primary responsibility for healthcare delivery, but may not possess the autonomy to make decisions affecting the quality of care (Barr and Dowding, 2022). Increased power distance negatively impacts psychological safety (Appelbaum et al, 2016) and the traditional Taylorist ‘rigid efficiency’ approach to management (Witzel & Warner, 2015), where the frontline worker is viewed as a cog in a machine, conflicts with reality on the ground, where healthcare workers need to speak up and make decisions in complex, uncertain contexts (Farr & Cressey, 2015). This tension can sometimes mean the interpersonally safest thing to do is to stay silent, which can have disastrous consequences. 

Why psychological safety matters

Counterintuitively, evidence shows that teams who report more mistakes have better patient outcomes than those who report fewer mistakes (Edmondson, 1999). It’s not that these teams make more mistakes, but that they feel safe to discuss them rather than hide them. These are teams with high psychological safety, and they are also more likely to ask for help and experiment, behaviours which are crucial for performance improvement and adaptation (Ito et al, 2022). Similar effects have been shown in airlines, where facilitating discussion of errors enables learning from failure through exploring the conditions that lead to mistakes, rather than focusing on punishment (Dekker, 2002). Conversely, leaders who suppress the ability for workers to admit mistakes hear of fewer mistakes, potentially confirming their erroneous belief that they’ve been successful in reducing the number of mistakes. Making it safe to admit and discuss mistakes leads to fewer mistakes in the future.

Healthcare leadership

In recent years, a number of events have catalysed change in healthcare leadership, with increasing recognition of how leadership behaviours mediate psychological safety. One example is that of 37-year-old Elaine Bromiley, who went into hospital for routine endoscopic sinus surgery and septoplasty. After complications that led to a blocked airway, consulting doctors tried and failed to secure a stable airway for about 20 minutes, during which time Elaine’s oxygen saturations dropped to 40%. This was despite the presence of experienced nurses, who recognised the severity of the situation and even brought an airway kit into the room. However, their concerns and suggestions were not heeded by doctors, because they did not speak up with enough conviction or persistence (Harmer, 2005). Elaine sustained severe hypoxic brain injury and later died. 

This event highlights the importance of ensuring all team members, regardless of hierarchy, are able to speak up and be heard. If everyone in the room during Elaine Bromiley’s surgery had felt psychologically safe, her death could have been avoided. Leadership approach has a strong influence on psychological safety in groups (Edmondson, 1999), and an inclusive leadership style helps cross-disciplinary healthcare teams, such as those in the Bromiley case, overcome the inhibiting effects of status differences, meaning everyone can speak up with concerns (Nembhard and Edmondson, 2006). 

The Ockenden Report also highlighted a lack of psychological safety at Shrewsbury and Telford Hospital NHS Trust; staff didn’t feel able to raise concerns or highlight poor practice, which limited the service’s ability to address issues and improve (Ockenden, 2020). While most NHS leaders advocate for eliminating a blame culture, stopping bullying, and promoting speaking up, the implementation can fall short, leaving a gap between the espoused ideals and the real-life experiences within the NHS (DoH, 2015). Where high-performing maternity units exist, leaders actively cultivate an environment of psychological safety in order to better gather soft intelligence, and to sense and resolve safety problems (Liberati et al, 2019).

Learning from incidents

As a result of incidents such as these, a cultural shift is underway in healthcare, towards empowered teams working in psychologically safe environments (Smith and Bhavsar, 2021). Elaine Bromiley’s husband, Martin Bromiley, an airline pilot, went on to form the non-profit Clinical Human Factors Group (CHFG) in 2007 (CHFG, 2023). CHFG promotes the application of human factors and psychological safety in healthcare settings. In my work too, I have seen increasing recognition of the value of this work, and work with a number of NHS trusts to address psychological safety through programmes for leaders and frontline staff, particularly in maternity departments.

The NHS has also established mechanisms including the Freedom To Speak Up (FTSU) Guardian’s Network to encourage staff to voice concerns without fear. Set up in response to failures at Mid Staffordshire and findings from the Ockenden Report, FTSU Guardians offer an alternative channel to traditional management routes for raising issues, escalating concerns while maintaining the reporter’s anonymity. However, there is room for improvement, and in an ideal world, they would not be required. Despite over 11,000 cases reported in 2018/19 (Hughes, 2019), the effectiveness of FTSU Guardians varies across NHS trusts (Jones et al, 2021).

Adoption in healthcare

Psychological safety is beginning to be codified into NHS policy. In August 2022, the NHS launched the Patient Safety Incident Response Framework (PSIRF), which replaced the Serious Incident Framework. The new framework emphasises a systemic, qualitative approach to investigations, acknowledging that an incident’s potential for learning may not correlate with the degree of harm caused (NHS England, 2020). PSIRF underscores the need for honest reporting: without psychological safety, we may only know what people feel safe to share, rather than the truth. 

At a grassroots level, many healthcare organisations have also begun to work to adopt a “Just Culture”. Rather than assigning blame, or punishing people for mistakes, ‘A Just Culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution’ (Williams, 2018, pp.9). In a Just Culture, human error is not punished, because it recognises that “Being blamed in the context of a safety investigation is contrary to the purpose of a safety investigation, partly because it is deathly for an occurrence reporting system, and for any subsequent investigations and learning.” (Shorrock, 2016, no page). 

Parallels with aviation

There are interesting parallels to draw between healthcare and aviation. The 1977 Tenerife disaster that killed 583 highlighted the importance of enabling open communication across hierarchical levels (Walker et al, 2016). This catalysed the introduction and adoption of Crew Resource Management (CRM) training worldwide, which led to a gradual but significant improvement in safety (SKYbrary, no date). CRM aims to foster environments where people can speak up with concerns, mistakes and suggestions despite a hierarchy or power gradient. 

Power dynamics in the cockpit are similar to those found in operating theatres, emergency departments and critical incidents. Research in applying CRM principles to healthcare has shown positive results in improving understanding and behaviour (Buljac-Samardžić et al, 2021), outcomes in Intensive Care Units (Kemper et al, 2017), nursing team task performance (Rahman & Abdelaal, 2019) and fostering safety culture (Gallagher, 2016). However, healthcare faces different challenges in the scaling and dissemination of such approaches. CRM was adopted worldwide in part due to the fact that crews fly all over the world and necessarily integrate with other teams and functions; there is a natural cross-pollination of ideas across locations, cultures, and organisations. Furthermore, Air Traffic Control in one airport can’t have different rules and procedures to another; to do so would lead to disaster. The same is not necessarily true for healthcare, though it may be aspirational.

Healthcare adoption of CRM

As demonstrated, greater psychological safety in teams helps to improve performance and patient safety. I predict that CRM, or a healthcare equivalent, will become more widely recognised and adopted across healthcare. PSIRF is just one indicator of that trend.

Culture exists in context: the tools and systems we use affect our behaviour. Just as aviation adopts technologies to catch and prevent human error, healthcare will continue to do the same. As Artificial Intelligence (AI) and Machine Learning (ML) matures, it will be adopted more broadly to detect errors, support decision-making, reduce human error, and automate routine tasks. This also helps healthcare professionals to more safely discuss incidents as part of a system failure, learn from them, and focus more on human-centred patient care and complex decision-making. Integrating AI systems safely into clinical practice is not without its challenges, but again, healthcare can learn from aviation and introduce systemic feedback loops, continuing to foster a safety culture where reporting failures is encouraged (Bondi et al, 2023). 

As I reflect on the evolution of healthcare in the UK from a fragmented, disjointed system to a large, hierarchical and bureaucratic system with the introduction and growth of the NHS, I suggest that over the following decades, much of that power will be devolved further to the frontline of healthcare. Indeed, this is already happening in some of the departments I work with, enabled by improved technology as well as a cultural shift empowering teams to make more rapid and effective decisions on the ground. This isn’t a reversion to the old, uncontrolled fragmented structure, but a progression to a more progressive and adaptable approach to modern healthcare.

The Nightingale Hospital London during the first wave of the COVID-19 pandemic facilitated a real-life experiment in how cognitive unloading, skill mixing, and flattening hierarchies improved organisational agility. The hospital, set up rapidly in an unconventional space, demonstrated agility and adaptability in healthcare delivery. It gave high autonomy to frontline workers, promoting a culture of psychological safety, experimentation and learning. These practices, born out of necessity, show how greater access to mobile technology alongside a move away from traditional approaches enable decentralised decision-making, empowering frontline workers to make rapid decisions (Collins et al, 2021). In the future, this will involve further flattening of organisational hierarchies, ensuring that decision-making authority is as close to the point of care as possible, which will enhance both patient safety and adaptability for future crises. The future lies not in structure, constancy and specialisation but rather in flexibility and adaptability (McConnell, 2005).

In my experience, healthcare is and will always ultimately be about people: both the patients and people who care for them. Technology can improve the way we deliver healthcare, improve safety, and aid efficiency, but it is unlikely to ever replace humans in the healthcare system. It is humans who endow systems with the capacity to anticipate, detect, respond and learn, not technology (Hollnagel et al, 2006). Whilst technology will provide a significant driver for change, the foundation of healthcare improvement over the next three decades will be cultural and systemic, recognising the necessity of psychological safety and inclusive cultures where people can work and communicate effectively without interpersonal fear. These predictions are based upon my work with both healthcare and aviation teams, and observing the parallels between these domains.

As the world inevitably becomes more globalised and connected, greater formal and informal networks between healthcare professionals will emerge, enhancing capacity to share practices, resources, and learning from both failures and successes. This will mirror the global adoption of CRM from the early 1980s, which was facilitated by the global nature of the aviation domain. Thus, failures or mistakes in one location need not be painfully repeated in order to learn the same lesson elsewhere. Instead, they can be rapidly disseminated and amplified worldwide. A foundational element of shared learning in aviation is having access to systems that enable confidential, non-punitive reporting of safety concerns – even mistakes you made yourself – such as NASAs Aviation Safety Reporting System (ASRS). These systems allow everyone working in aviation to highlight concerns or report a lesson learned without fear of punishment, thereby empowering all to learn and make improvements (Billings, 1998). 

People cannot adequately speak up about concerns, mistakes and ideas if they are operating at capacity (Edmondson, 2003, Rosenstein and O’Daniel, 2008). Improvements in predictive analytics and workforce planning have already begun to be used for strategic workforce planning (Sriram et al, 2021), and in the future will be used to further anticipate patient care needs, alongside ensuring that staffing levels and skills are adequate, reducing burnout and improving patient safety.

Most crucially I predict that a healthcare equivalent of CRM will emerge over the coming decades as the dominant paradigm for healthcare leadership, with great potential to enhance efficiency, reduce errors, and improve team dynamics, underpinned by psychological safety (O’Keefe et al, 2022).

Conclusion

The trajectory for healthcare leadership and culture will continue to evolve. The increasing integration of technologies offers promising avenues for enhancing decision-making, error detection, and operational efficiency. However, the essence of healthcare remains irrevocably human. Future challenges and opportunities necessitate a cultural and systemic shift that places psychological safety and adaptability at the core of healthcare delivery. The globalisation of healthcare, paralleled with the aviation industry’s global adoption of CRM, presents an opportunity for learning from success and failure that crosses geographical and organisational boundaries. 

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