Raising the Standard: The Relation of Psychological Safety to Patient Safety and Quality Metrics and Provider Wellness: Part 2

| December 1, 2021

by Kristen Demertzis, PhD, ABPP-CN, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Demertzis is Chief of Neuropsychology, South Shore University Hospital; Director of Resident and Fellow Mentorship and Faculty Development, OB/GYN Departments, South Shore University and Huntington Hospitals; Assistant Professor of Physical Medicine and Rehabilitation and Psychiatry, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health in Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2021;18(12):14–15

This is Part 2 of a two-part Raising the Standard article series that examines the concept of psychological safety and its relation to patient safety, quality metrics, and provider well-being.

Last month’s column addressed the concept of psychological safety, its relevance to patient safety and quality metrics, and its connection to clinician well-being and job satisfaction. This month’s column explores facilitators of psychological safety and interventions to promote psychological safety and related practical suggestions. 

Psychological safety is a perception of low interpersonal risk that facilitates comfort to express oneself and seek input or help from others without fear of damage to self-image or professional reputation.1 Psychological safety within healthcare promotes qualities (e.g., knowledge sharing, error reporting) critical to functioning as a high-reliability organization with patient safety and care quality at its core.2 A work environment high in psychological safety also supports clinician well-being.1,3 Compromised psychological safety is associated with a host of adverse patient care and clinician outcomes.1–4  

Facilitators of Psychological Safety

Facilitators of psychological safety can be conceptualized at the individual, group, and organizational levels. Individual-level facilitators include providers feeling passionate about their work, aligning with team/organizational goals and roles in goal achievement, having a fair work environment with a manageable workload (including having the skills and resources to accomplish work goals), having familiarity with colleagues/work environment, feeling empowered to do their jobs and impact their work environment, feeling respected for their contributions, and feeling supported in professional growth and performance improvement opportunities.1,2,4,5 Prevalence of fear, intimidation, and blame, and prior experiences with shaming, retaliation, or other unprofessional behaviors elevate perceived interpersonal risk and associated negative outcomes of diminished psychological safety.1,2

Organizational-level facilitators include leader qualities (addressed below); establishment of a clear mission, vision, policies and procedures, and effective reporting systems; investment in resources to achieve organizational goals; and organizational commitment to an inclusive, respectful, and fair work culture, characterized by sharing decision making and embracing learning and growth opportunities in the name of patient safety and quality.1,2,4–6

Literature on promoting individuals to organizational facilitators of psychological safety heavily concentrates on leaders’ powerful impact from dyadic to organization-wide dynamics.1,2,6 Leader attributes promoting psychological safety include being approachable, available, humble, willing to model fallibility, aware of/able to effectively regulate one’s emotions, open to and inclusive in inviting input/feedback, mentally flexible and able to perspective shift, able to address errors with nonjudgmental curiosity, respectful, compassionate, an effective communicator, able to inspire collaboration, and an advocate of growth and innovation.1,2 

Interventions to Promote  Psychological Safety

Though facilitators and barriers of psychological safety have been extensively studied, there is a paucity of literature on the efficacy and effectiveness of interventions to increase psychological safety. O’Donovan and McAuliffe7 conducted the first systematic review on interventions geared toward improving psychological safety within the healthcare setting. They reviewed mostly team educational (e.g., simulation, case studies) and noneducational (e.g., holistic facilitation process group) interventions. Individual study limitations (e.g., length of intervention, outcomes measured) and mixed results across studies precluded determination of the most effective interventions for increasing psychological safety. However, education, in the absence of other factors (e.g., facilitation, team cohesion), did not appear adequate for increasing psychological safety; key stakeholders and leader involvement in interventions was deemed important in driving work culture and behavioral changes, and further studies were recommended, incorporating longitudinal and multifaceted interventions and utilization of more objective psychological safety outcome measures. 

Though beyond the scope of this column, meaningful direction can be gleaned from interventional literature targeting facilitators of psychological safety. Emotional intelligence, for instance, has been well studied and is a predictor of psychological safety and various patient safety, quality, and clinician well-being variables.8 The relationship between emotional intelligence and various key outcomes, such as team learning, is mediated by psychological safety, so understanding variable interrelations is significant in determining intervention strategies and outcome expectations.9

The following are practical suggestions for augmenting leader attribute facilitators of psychological safety highlighted before. Many healthcare organizations and professional societies offer continuing education and faculty/leadership development programs that target numerous facilitators of psychological safety. Northwell Health, for instance, has physician leadership development programs that include 360-degrees evaluations to grow in self-awareness and identify professional development targets, professional development seminars (e.g., on emotional intelligence, effective communication skills), peer support, and individualized coaching. Regarding the latter, coaching paradigms have become more prevalent in healthcare settings over recent years and can nicely complement educational and other professional development activities in assisting with implementation and strengthening of desired skill sets/behaviors.10 

More focused professional development opportunities are also available. For instance, Northwell’s Center for Learning and Innovation has a plethora of offerings (e.g., humanism in medicine, communication systems like team STEPPS11,12) that can be customized for teams (e.g., simulation activities).

Incorporation of psychological safety related measures (e.g., Team Learning and Psychological Safety Survey2) in 360-degrees and team evaluations and serial assessment to evaluate temporal change are suggested. Process groups can also be employed to examine team psychological safety levels and formulate action plans to address growth opportunities. 

To optimize psychological safety, leaders are encouraged to consistently model desired behaviors and work culture (e.g., ask questions and invite team input at meetings, acknowledge an error made and resulting learning opportunities). Julie Morath, President/CEO of the Hospital Quality Institute, reportedly regularly reflects that “healthcare is a very complex system, and complex systems are, by their very nature, risk prone. The culture of healthcare must be one of everyone working together to understand safety, identify risks, and report them without fear of blame….”13 Disseminating this philosophy into work teams can involve simple acts, such as encouraging your team to speak up because you might miss something. As a means of fostering team cohesion and mitigating hierarchical intimidation to speak up, Northwell’s perioperative committee leadership recommends a practice where the surgical time out starts with all team members introducing themselves by their first name and role on the team.

Leaders can also empower staff to assemble performance improvement workgroups, such as a simulation curriculum workgroup focused on goals, including effectively managing high-acuity situations, learning to use new equipment, and practicing new safety protocols. Remtulla et al6 found that even in the absence of positive leader behaviors, multidisciplinary primary care teams tried to augment psychological safety through various means (e.g., same-discipline peer support, rotating the meeting chairperson). Allowing all team members to actively engage in promoting a psychologically safe culture encourages self-efficacy and shared ownership of optimizing work culture dynamics, patient safety, quality, and clinician well-being.

Overarching organizational support for psychological safety can be demonstrated by emphasizing purpose and importance of work, encouraging speaking up and shared decision-making, onboarding and mentoring leaders to promote the desired organizational culture, distributing employee engagement surveys and using the results for performance improvement, implementing organizational town halls, forming multidisciplinary committees/collaborative care councils that interface with senior leadership, and utilizing anonymous/confidential systems to report concerns to leadership (e.g., improveNorth). 

Given the broad-reaching, positive implications of psychological safety, we encourage readers to identify formal leadership roles and other professional activities involving a leadership component, from dyadic to larger team contexts and including clinical, committee, research, mentorship, coaching, and teaching interactions. Many of us have opportunities to promote psychologically safe work cultures, and it behooves us to attempt our best to do so. Having agency to impact cultures within our clinical teams, departments, mentorship relationships, and other contexts can be empowering, augment professional quality of life and clinician well-being, and facilitate team growth and safety and quality optimization.

References

  1. Edmondson AC. The fearless organization: creating psychological safety in the workplace for learning, innovation, and growth. Hoboken, NJ: John Wiley & Sons;2018.
  2. Edmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–383.
  3. Swendiman RA, Edmondson AC, Mahmoud NN. Burnout in surgery viewed through the lens of psychological safety. Ann Surg. 2019;269(2):234–235.
  4. Edmondson AC, Lei Z. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav. 2014;1(1):23–43.
  5. Edmondson AC. Psychological safety, trust, and learning in organizations: a group-level lens. In: Kramer RM, Cook KS (eds). Trust and distrust in organizations: dilemmas and approaches. New York, NY: Russell Sage Foundation;2004:239–272. 
  6. Remtulla R, Hagana A, Houbby N, et al. Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study. BMC Health Serv Res. 2021;21(1):269–281. 
  7. O’Donovan R, McAuliffe E. A systematic review of factors that enable psychological safety in healthcare teams. Int J Qual Health Care. 2020;32(4):240–250. 
  8. Karimi L, Leggat SG, Bartram T, et al. Emotional intelligence: predictor of employees’ wellbeing, quality of patient care, and psychological empowerment. BMC Psychol. 2021;9(1):93. 
  9. Ghosh R, Shuck B, Petrosko J. Emotional intelligence and organizational learning in work teams. J Manag Dev. 2012;31(6):603–619. 
  10. Grant AM, Curtayne L, Burton G. Executive coaching enhances goal attainment, resilience and workplace well-being: a randomized controlled study. J Posit Psychol. 2009;4(5):396–407.
  11. Agency for Healthcare Research and Quality TeamSTEPPS®. https://www.ahrq.gov/teamstepps/index.html. Accessed 29 Oct 2021.
  12. Dahl AB, Ben Abdallah A, Maniar H, et al. Building a collaborative culture in cardiothoracic operating rooms: pre and postintervention study protocol for evaluation of the implementation of teamSTEPPS training and the impact on perceived psychological safety. BMJ Open. 2017;7(9):e017389. 
  13. Edmondson AC, Roberto M, Tucker AL. 2001 (revised 2007). Children’s hospital and clinics (A). Boston, MA: Harvard Business School Publishing. (HBS No. 302-050).  

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Category: Past Articles, Raising the Standard

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