Organizational and Team Psychological Safety within Health Care and Public Health Organizations

Introduction
This chapter covers psychological safety within a group setting and explores what is meant by psychological safety – what it is, why it works, how it works, and how to build it. The role of trust in organizations, adaptive leadership impacts on safety, and leadership behaviors along with strengths and weaknesses are explored. Google will be used as a cast study example.

Why Psychological Safety is Important
Health care organizations are in the business of making people better. In order to stay competitive in this time of payment reform and heightened transparency of organizations’ outcome metrics, improvement and innovation are required. But, in an effort to generate good outcomes, some organizations have created cultures and policies that inadvertently shut down improvement and innovation. Unequal power distribution and status, automatic consequences for honest mistakes, and unwillingness of leadership to consider the opinions of their employees lead to a workplace or team environment where innovation stagnates and broken systems continue. While this is never the aim of an organization, however, it may be an outcome of a culture that lacks psychological safety.

Google conducted a study of the dynamics of effective teams and found psychological safety to be the most important of the elements identified by the research team. Members of teams with high psychological safety were more likely to be successful in areas including generation of revenue, perception of effectiveness, and innovation; in addition, psychological safety was found to decrease staff turnover, demonstrating that the benefits of psychological safety are extensive and transcend discipline.

Most humans practice a behavior known as impression management: filtering words and actions in order to avoid looking ignorant, incompetent, intrusive, or negative. This serves as an effective tool to keep individuals safe. However, it is detrimental to organizations or teams whose work is both uncertain and interdependent (Edmondson, 2014). In order to innovate and learn, individuals must be willing to share their ideas and experiences and must feel that the benefits of doing so outweigh the likely consequences. In order to flip that switch from fear to assurance, leaders must make a conscious effort to cultivate and build psychological safety into the culture of their organizations and teams.

How does psychological safety work?
In Dr. Amy Edmonson’s 2014 TEDx Talk, she defined psychological safety as: “… a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.” Frankel, et al outlined the key elements of psychological safety as:

• “Anyone can ask questions without looking stupid.
• Anyone can ask for feedback without looking incompetent.
• Anyone can be respectfully critical without appearing negative.
• Anyone can suggest innovative ideas without being perceived as disruptive.”

Generally, psychological safety allows organization and team members to feel safe collaborating and problem solving together. That can be particularly challenging in teams consisting of members of varying statuses. In these cases, the distribution of power often seems uneven, leading those of lower status or power to feel unsafe contributing to team activities or conversations. When this happens, teams function below their potential, regularly missing opportunities for improvements. Link to Amy Edmondson’s TEDxTalk:

https://www.youtube.com/watch?v=LhoLuui9gX8

Trust vs. psychological safety
While psychological safety is closely related to trust, it differs in some key ways, for example, the focus of attention. When an individual does not trust someone, that individual might carefully monitor the other person’s behavior. However, when an individual does not feel psychologically safe, they monitor their own behavior also called self-monitoring (CITE). Judgement is also affected in situations lacking psychological safety in a different way than those lacking dyadic trust. Even though a person’s silence could have severe and long-term consequences, the immediate risks of speaking up feel much larger in the moment than the potential long-term consequences, preventing them from making logical choices in those situations. Another difference is that trust is usually measured at the interpersonal level, whereas psychological safety is generally defined at the group level: it is a facet of the culture of a team or organization. (Edmondson, 2004)

Adaptive Leadership and psychological safety
Among the many leadership theories, adaptive leadership as explained by Northouse 2016, focuses on facilitating change within an organization, stands out as lining up nicely with creating a culture of psychological safety. Key features of this leadership style include giving a voice to the staff and empowering them to do their jobs. Adaptive leadership is noteworthy in that it takes dependence off of the “leader”. All members of the team or organization affected by the necessary adaptation are included in the work. Adaptive leaders don’t exercise dominance over the team members; rather, leaders empower others to do the necessary work, facilitating the process through holding environments, providing guidance and conflict management, and by ensuring the followers are experiencing a productive level of distress: not so high that they become overwhelmed, but not so low that they can avoid the challenge altogether.

In the context of adaptive leadership, there are three categories of challenges that can arise: adaptive, technical, and a combination of both. Adaptive challenges are different than technical challenges in that technical challenges can be solved with current organizational knowledge and capacity. Adaptive challenges tend to be more nebulous, involve values and beliefs, and, because of this, are more difficult to address. There are also challenges that are both technical and adaptive in nature: those with a clearly defined goal, but without a solution already in existence within the organization. In these cases, the leader and followers must work together to come up with a solution. There are four main perspectives that make up adaptive leadership (Northouse, 2016):

1. Systems perspective: Problems are part of a complex system
2. Biological perspective: People are able to adapt and have been heavily influenced by past experiences that required adaptation
3. Service orientation: The leader serves the people by recognizing the problems they’re facing and then proposing solutions to those problems
4. Psychotherapy perspective: People need a safe and supportive environment in which to adapt to change

Leaders encouraging psychological safety are utilizing the psychotherapy perspective of adaptive leadership in order to create a safe environment for innovation and improvement.

There are several behaviors which can lead to successful adaptive leadership (Northouse, 2016):

1. Look at the forest: The leader must step back far enough to see all of the pieces of a challenge and how they interact. Sometimes this means stepping into an observer role for a period of time.
2. Categorize the challenges: Are the challenges adaptive, technical, or both? A leader can generally handle a technical challenge themselves. However, adaptive challenges require involvement of those followers whose values, beliefs, and feelings are being affected.
3. Regulate the temperature: An adaptive leader is responsible for creating a safe environment for the followers to produce change. This means maintaining an environment with the correct amount of pressure to encourage change but also avoid burnout.
4. Direct attention: The leader must assist the followers in staying on task. This includes the prevention of avoidance behaviors such as blaming others for the problem, ignoring the problem, or focusing on unrelated tasks.
5. Step aside: While leaders must provide guidance when needed, they also need to recognize when to hand over the job of finding and implementing a solution to their followers.
6. Give others a voice: Be open to the ideas and opinions of those who may be not be in a position of authority or who feel unheard or disregarded. This may yield innovative ideas and solutions and can inspire additional participation.

A key feature of a psychologically safe environment is that all team members are encouraged and expected to contribute to group conversation and planning. By giving others a voice, leaders are fostering the creation of psychological safety within their team or organization.

Strengths of psychological safety in organizations and teams
Organizations with an ingrained culture of psychological safety benefit in numerous ways, including increases in innovation and improvements in patient safety. Many organizations give contradictory messages by having a benchmark of safety standards that must be met while also making error reporting of these processes a priority. Employees may fear punishment for not meeting the safety standards and, therefore, may not report the related safety errors. As expected, adverse events have been found to be under-reported by front line providers.

Both psychological safety and error reporting rates are positively associated with leader inclusiveness, defined as, “words and deeds that invite and appreciate others’ contributions”. (Applebaum, et al, 2016) When team members feel safe to report mistakes, ask questions, or make suggestions, there are more opportunities for learning. The individual gains knowledge that they can build on, and the organization gains the opportunity to explore where their systems and processes are working and where they’re not.

The created openness can function as a protective factor and a marketing asset for organizations in the age of published metrics by giving leaders an opportunity to address shortcomings sooner and with increased input from those people who know how best to solve them. Similarly, especially in health care, there will be situations involving risk that require coordination within teams. Members must feel free to talk about those risks and to get and give advice as needed in order to minimize them.

Psychological safety was also found to positively influence creativity and innovation in the group setting. A free-flowing exchange of information leads to more comprehensive brainstorming, resulting in an expansion of ideas and possible solutions to issues. And just as leader inclusiveness promotes error reporting, it was also shown to encourage participation in quality improvement efforts (Kessel, et al, 2012).

Another benefit of psychological safety is an improvement in job satisfaction among employees. An increase in employee motivation and a decrease in turnover mean that organizations are retaining trained staff with institutional knowledge, saving money on training new employees, and increasing opportunities for process and organizational improvements (Edmondson, 2014).

Challenges for Psychological Safety
While psychological safety has many resulting benefits, there are also weaknesses.

Creating culture change is not an easy task and requires concerted effort and conscious planning to move a team or organization to a high performing psychologically safe environment. Most organizations or teams are made up of members who already have a history with each other, which can be a hindrance; members must unlearn old habits and inclinations before relearning new ways of interacting. Also, a change of culture does not happen overnight. The process can be time consuming and requires a great deal of planning and attention.

How to Create a Team or Organizational Culture of Psychological Safety
As psychological safety is a group construct, it can best be created through changes in leader behavior as well as through the establishment of ground rules, outlining the expected behavior within the team or organization. Organization or team leaders are in a uniquely powerful position to influence the behavior of their subordinates. In order to plant the seeds of culture change, leaders must ensure that all organization or team members are clear on what cultural changes are expected and how those translate to their own roles, no matter where they are in the organizational hierarchy. A key ingredient to creating psychological safety is “walking the talk”. In the context of psychological safety, that includes encouraging dialogue, inviting input and feedback, being accessible, and modeling openness and fallibility (Leroy, et al, 2012).

Encourage Dialogue and Inviting Input
Approaching a situation with the expectation that everyone will deliver flawlessly is a recipe for failure. To err is human. If team members feel like they can’t or shouldn’t ask questions, then the whole team is more likely to make a mistake. The best way to counter this is to explicitly frame the work as a “learning problem, not an execution problem”. Remind them that the only way to succeed is together, utilizing the questions, viewpoints, and opinions of everyone on the team. (Edmondson 2014

Group meetings can also be used as a tool to promote psychological safety. These are opportunities to demonstrate that the environment is safe. The team should be provided with the leader’s undivided attention during meetings. Demonstrate engagement by asking questions and responding both verbally and through body language. (Re:Work) Engage an organization or team member ahead of time to request that they bring up issues during the meeting. Leaders can be prepared to respond in a way that demonstrates to the other members that the unit is a safe space. Also, by asking questions of team members, leaders show interest in their opinions and promote further dialogue. Even if it hasn’t previously been a psychologically safe environment, simply modeling this new behavior can spur change.

Accessibility
Supervisors who are open, available, and have a routine presence on healthcare teams foster better psychological safety within the teams. In addition to having an open-door policy, being physically present, and getting to know staff members in all positions, leaders should also support and encourage their mid-level managers and supervisors to develop this kind of open team culture.
Modeling Openness and Fallibility

In order to foster psychological safety, leaders need to function as coaches: guiding their staff and minimizing judgement. Also, leaders should view their own mistakes as opportunities to model psychological safety. By owning up to their own mistakes in front of them, the team will see that it’s safe for them to share their mistakes as well. One of the features of the health care environment is that status and power are derived largely from position. Those in higher positions are in a place of greater default psychological safety than those in lower positions.

Power distance, defined as “the extent to which an individual perceives and accepts unequal distributions in status and power within institutions and organizations” has been shown to negatively affect psychological safety and adverse event reporting. However, leader inclusiveness can have a moderating effect on psychological safety with regard to status. So, in addition to training staff to comment and share their thoughts more freely, organizational and team leaders should also be trained in how to both invite and reward these comments, ensuring that everyone feels valued and respected.
Stacking Teams

In order to encourage culture change, leaders can stack teams with members who are more likely to see the team as safe and to build friendships amongst the team members, which has been shown to increase team psychological safety. However, managers should also be aware that the opposite can happen as well: there is a risk of decreasing team psychological safety by including members who are previously inclined to perceive low psychological safety (Shulte, et al, 2012).
Psychological Safety through the establishment of ground rules

Ground rules can be a helpful method of encouraging team members to feel a sense of ownership and buy-in to the key concepts of psychological safety. Cave, et al conducted a 2016 study of CENTRE, a framework of ground rules which was developed to encourage psychological safety. The study suggested that Confidentiality, Equal Airtime, Non-Judgemental listening, Timeliness, Right to Pass, Engagement) (CENTRE) was useful for participants, although it did not establish details of what made it useful. Regardless, it can be used to create a pre-defined agreement on interaction and expectations within the team. Please keep in mind that setting effective ground rules requires buy-in from the team members prior to implementation, which means they must be informed and allowed to give feedback and request changes. CENTRE includes the following rules:

1. Confidentiality – Team members are expected to share only what the team agrees can be shared outside of the team, and are expected to speak from an individual point of view only (do not speak for the group);
2. Equal airtime – All members are to be given equal opportunities to attend, speak, and present at meetings, which, while under the management of the group leader, is the responsibility of all of the members;
3. Non-judgmental listening – Starting out listening to understand rather than listening to respond; one person speaks at a time; team members speak in “I” statements and trust that others’ are speaking their own personal truths; members respond with only constructive feedback that focuses on behaviors and never personal character; and mobile devices are either turned off or other members of the team are notified of the possibility of receiving an important notification prior to the start of the meeting;
4. Timeliness – All team members are provided with set start and end times for each meeting beforehand, those start and end times are respected, and all members arrive for the meetings on time;
5. Right to pass – All members have the right to pass up an opportunity to speak any time they are invited to do so;
6. Engaged – All team members should take note of what may be distracting them and are encouraged to engage as much as is possible for them

Google’s Psychological Safety Toolkit: https://rework.withgoogle.com/guides/understanding-team-effectiveness/steps/foster-psychological-safety/

Summary
Psychological safety is a group construct in which members feel that they “…will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.” (Edmondson, 2014) Members of teams with high psychological safety are more likely to report mistakes and to be successful in areas including generation of revenue, perception of effectiveness, and innovation. Psychological safety can also result in significant benefits to teams and organizations, such as improved patient safety and decreases in staff turnover.

In order to cultivate a culture of psychological safety, leadership must create an environment where members feel that the personal benefits outweigh the risks or consequences of speaking up with ideas, concerns, or mistakes. By encouraging dialogue from all team members, inviting input and feedback on leader behavior, being accessible and developing relationships with team members, and modeling openness and fallibility by sharing personal examples of failures and lessons learned, leaders can model psychological safety for their teams and help promote culture change. While culture change can be a long, challenging process, the benefits of psychological safety can facilitate successful teams and organizations in growing and adapting to ever-changing environments.