In the midst of a busy hospital shift, a new nurse named Sarah found herself facing a critical decision. The patient under her care displayed unexpected symptoms, but Sarah hesitated to voice her concerns to the medical team. You see, she had previously witnessed a nursing colleague receive a look of scorn from one of the consultants when they had raised a similar concern. Because of this, she feared being perceived as incompetent or challenging the doctors’ decisions. Tragically, her apprehension led to a delay in necessary treatment.
This situation is sadly far from a rare occasion in healthcare.
What was missing? What is it that makes people stay silent, even when lives are on the line?
The answer lies within something called “psychological safety”.
What is Psychological Safety and Why Does it Matter in Healthcare?
Psychological safety refers to an environment where individuals feel safe to express their thoughts, voice concerns, and take calculated risks without fear of negative consequences.
In healthcare, where split-second decisions and precise teamwork are paramount, psychological safety acts as a beacon, guiding effective communication, error reduction, and innovative problem-solving.
Psychological safety exists on multiple levels. The extent to which we feel safe to express ourselves, share ideas or concerns, or give others feedback will vary depending on context and can vary throughout the day.
For example, it may be that you feel psychologically safe with a senior colleague in a clinical supervision session. But in a multi-disciplinary team meeting that follows, you do not feel safe to speak up. It is likely that the person or people chairing such meetings have set things up in a way that creates an underlying sense of fear in one or several members of staff.
Ultimately, psychological safety is about relationships. On its most basic evolutionary level, the foundation of ANY meaningful and open relationship is to feel safe with that person. Once we feel safe – i.e. respected, valued, listened to, understood – we are then able to be ourselves. And being ourselves means sharing more of our emotions and thoughts.
So, what stands in the way so often of psychological safety in healthcare?
Barriers to Psychological Safety in Healthcare
Research has examined and discovered a number of barriers to psychological safety in healthcare. Have a read of these examples and reflect on whether you’ve experienced any:
1. Top-down hierachy
Having a perceived, rigid and top-down hierachy is known to impact nurses’ feeling of psychological safety. This is because we may feel that our opinion is valued less when high value is placed on the “experts” at the “top”.
2. Authoritarian or dictatorial leadership
Authoritarian leadership exists when decisions are enforced, and not discussed within a team. This is in contrast to flatter, more distributed leadership where decisions are democratically agreed upon. When we are faced with authoritarian leaders, we do not feel safe to express dissent from an opinion. In fact, we’ve probably not even been given the opportunity to raise concerns or share ideas.
3. Lack of knowledge
The willingness to speak up about a specific issue is related to one’s knowledge of the subject matter – this could be a clinical issue, or simply knowledge of a patient.
4. Culture of perfection
Healthcare is complex and risky. Mistake and errors occur frequently. Ironically, when leaders do not acknowledge this and consciously create a space where mistakes can be shared and learned from, the reality is that more mistakes can occur, and those that do occur may be hidden or covered up.
4. Culture of blame
If you work in a team where you fear you will be individually blamed and shamed for any type of mistake, you are unlikely to share your views or ideas. You may feel safer by staying quiet and keeping yourself to yourself on a range of issues, not just related to patient safety. Even when organisations purport to learn from a mistake in a collective way, often there is still an implicit drive to find the “single” cause of an error. This erodes psychological safety.
So, you may be asking, “Why does psychological safety metter? What are the other negative outcomes of a lack of psychological safety”?
Let’s dive in….
Why does psychological safety matter?
1. Reduced Communication and Collaboration: A lack of psychological safety can discourage open communication and collaboration among nursing teams. Nurses may hesitate to share their ideas, concerns, or ask questions, leading to missed opportunities for innovative solutions and improved patient care.
2. Medical Errors and Quality of Care: Psychological safety is crucial for addressing medical errors and promoting a culture of learning from mistakes. When nurses are afraid of admitting errors due to potential blame or punishment, critical incidents may go unaddressed, affecting patient safety and quality of care.
3. High Turnover and Burnout: Feeling unsafe or unsupported in the workplace can contribute to nurse burnout and high turnover rates. Nurses who experience constant stress and lack of psychological safety are unlikely to gain the emotional support from leaders that they require. They are thus more likely to seek alternative employment, leading to staffing shortages and compromised patient care.
4. Diminished Job Satisfaction: Psychological safety is closely linked to job satisfaction. Nurses who feel safe to express their opinions and concerns tend to experience greater job satisfaction. On the contrary, a lack of psychological safety can lead to frustration, disengagement, and decreased morale.
5. Impact on Patient Outcomes: Patient care is directly affected when nurses don’t feel safe to speak up or share their insights. Critical information may not be communicated, leading to misdiagnoses, medication errors, or delayed interventions that can negatively impact patient outcomes.
6. Resistance to Change and Innovation: Without psychological safety, nurses may resist changes or innovations in healthcare practices. This can hinder the implementation of evidence-based practices and advancements that could improve patient care and outcomes.
7. Poor Interprofessional Relationships: Nursing often involves collaboration with other healthcare professionals. A lack of psychological safety can strain relationships between nurses and other team members, affecting the overall coordination of care.
8. Decreased Patient Satisfaction: When nursing teams are not functioning optimally due to a lack of psychological safety, patients may perceive the tension and lack of coordination. This can lead to lower levels of patient satisfaction and trust in the healthcare team.
The good news is that psychological safety can be addressed within organisations.
There are some tangible, practical things you can do as a leader to enhance it in your own work, and support others to do so too.
We’ll be addressing these in another article soon.
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