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

| November 1, 2021

by Kristen Demertzis, PhD, ABPP-CN; Dominick Gadaleta, MD, FACS, FASMBS; and Anthony T. Petrick, 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. Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in Danville, Pennsylvania.

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(11):14–16

Psychological safety is a concept that emerged in the organizational psychology literature in the 1960s and has been widely published on across diverse contexts.1 Psychological safety has gained increasing attention within the healthcare sector in recent years, though many within the medical community are still unfamiliar with the concept. Psychological safety is defined as comfort communicating concerns, questions, errors, and ideas and seeking feedback and help without fear of humiliation, disrespectful treatment, punishment, retaliation, or some other form of damage to self-image or professional reputation.2 Amy Edmondson, who has studied this concept extensively, describes psychological safety in the work environment as “’If I do X here, will I be hurt, embarrassed, or criticized?’ A negative answer to this tacit question allows the actor to proceed. In this way, an action that might be unthinkable in one work group can be readily taken in another” based on different perceptions of interpersonal consequences.3 

The impact of psychological safety is particularly critical in environments, such as healthcare, involving high-pressured circumstances and uncertainty that make collaboration, information sharing, critical reasoning, creative problem solving, learning, and innovation essential to effectively meeting work demands and achieving individual success through organizational stretch goals.1 As it relates to organizational priorities within healthcare, psychological safety holds tremendous value with respect to patient safety and quality metrics, as well as provider well-being and job satisfaction. 

High Psychological Safety

It is reasonable to experience varying levels of psychological safety as we move through the contexts of our work day (e.g., interactions within a surgical team, committee, or research team).4 Studies have demonstrated numerous benefits to work environments perceived as high in psychological safety, including, but not limited to, increased team cohesion and effective communication,1,3 error reporting across disciplines,5–8 successful patient rescue from major surgical complications,9 integration of surgical checklists,10 infection control practice compliance,11 new surgical technique and equipment implementation,12 employee engagement,4,13–15 job satisfaction,16–18 fostering creative learning,4,18–20 engagement in performance improvement,21,22 and team and process innovation.23–25 Decreased readmission rates,26 healthcare operational failures (e.g., missing equipment/information),27 provider burnout,7,28 disruptive behaviors (e.g., bullying),29 and turnover intent15,30,31 have also been reported. 

Benefits of psychological safety are diminished in the absence of vision, goals, strategy, designated roles, and other critical elements of organizational performance and success.2 Furthermore, team and organizational productivity and success involve balancing encouragement of open communication with steering away from paths that might derail goal accomplishment and growth. A ratio imbalance caused by excessive psychological safety can undermine efficient resource use, goal realization, and team morale.3 When foundational organizational elements are present, however, promoting psychological safety in our work culture is a powerful means of optimizing both patient safety and quality metrics and provider well-being and job satisfaction. The lens of psychological safety affords appreciation of the bidirectional relationship between provider well-being and patient safety and quality measures.7,32–34 

Low Psychological Safety

When perceived psychological safety is low in a work environment, individuals might hesitate to voice a concern or question, to report an error, or to express a dissenting opinion, as the associated interpersonal risk is perceived as too great.2 As a result, qualities critical to functioning as a high-reliability organization (e.g., prioritizing patient safety) are compromised. Conditions of low psychological safety and use of fear and intimidation are unfortunately present within many healthcare organizations, and have been referred to as the ABCs of medicine (i.e., accuse, blame, and criticize).2,4,35 

Applebaum et al,8 for instance, examined self-reported intention to report adverse events in 106 residents in an academic teaching hospital from the departments of neurosurgery, orthopedic surgery, general surgery, obstetrics and gynecology, emergency medicine, otolaryngology, neurology, and pediatrics. Events ranged in severity and were relevant to each resident’s respective department. Psychological safety directly predicted intention to report adverse events (β=0.34, p<0.001), and mediated the relationship between perceived power distance and leader inclusiveness and intention to report adverse events (indirect effect: -0.09, 95% confidence interval (CI): -0.13–0.04, p<0.001; indirect effect: 0.17, 95% CI: 0.08–0.27, p=0.001, respectively).8 

A powerful and real example of the impact of low psychological safety on patient safety is found in Swendiman et al,7 which described a case involving a complex abdominal operation. During the surgery, multiple providers manipulated an overhead light missing a sterile cover, thereby contaminating the sterile environment and placing the patient at risk for infection. A medical student observed that the sterile cover was missing and watched providers handle the light, but did not speak up due to fears surrounding the attending surgeon’s reputation for verbally and sometimes physically aggressive behavior in the operating room. The student’s assessment of high interpersonal risk in that situation (i.e., low psychological safety) overpowered the obligation to speak up about a patient safety issue. Upon discovering the issue, the surgeon’s response was reportedly accusatory and disrespectful and lacked productive team discourse regarding why the error had occurred and how to prevent a repeat incident moving forward. 

Reading this scenario might conjure up memories of work environments we perceived as low in psychological safety and, for instance, we had either chosen not to speak up regarding a medical error or concern or we had spoken up and regretted doing so based on the subsequent reaction. Reflecting on such experiences, potentially even long after the incident occurred, can produce palpable, negative emotions. Powerful emotions, such as fear and anxiety surrounding speaking up in hierarchies or seeming incompetent or ignorant, coupled with the brain’s desire to protect itself (e.g., from humiliation or retaliation), has the capability to override logical thought and ethical practice in the moment and drive behavioral responses that might be discordant with our professional identities, safety and quality practices, and learning and professional growth.36,37 Coping in the aftermath can involve intense feelings of guilt, shame, fear, anger, and other emotions surrounding the decision not to speak up, and we might still struggle with whether we would react differently in a similar context in the future. The impact of low psychological safety on patient safety, quality of care, and provider well-being is tangible.

For many in healthcare, our professional identities are a significant component of our self-identities. It has taken years to achieve the necessary training to practice in our chosen professions; we spend long hours at work, and central elements of our job satisfaction include feeling respected, valued, supported, and as though one is able to continue evolving professionally. Experiences that damage psychological safety and our professional quality of life, therefore, can greatly influence overall well-being and personal quality of life, and have been associated with adverse mental health outcomes, increased burnout and turnover intention, and decreased retention.7,32–34  

In contrast, the emotions and potential impact on safety and quality and professional well-being are likely quite different for professional experiences we recall characterized by encouragement and receptiveness to speak up about a safety concern, to ask for help, to disagree with a proposed treatment plan, or to challenge the status quo and engage in academic discourse for performance improvement and innovation purposes. Fostering psychological safety at the individual, team, and organizational levels is central to optimization of safety, quality, and provider well-being. In next month’s column, we will explore facilitators of psychological safety and the literature surrounding interventions to promote psychological safety.


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