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28 August 2019 by Juliette Kumar

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Every single day in health and care organisations catastrophes are prevented from occurring. This is not just because people are highly trained, but also because they work in teams where they are able to speak out when they see a problem. Psychological safety is the term that describes this phenomenon; it is where people in teams are not afraid to admit mistakes and where problems are seen as learning opportunities. 

The quality guru W Edwards Deming recognised this in his early work, acknowledging the human nature of people in organisations and teams.  Deming knew that people were fundamental to any attempt to improve and made psychology one of the four areas of his System of Profound Knowledge. He said simply, ‘we must first drive out fear’, acknowledging that the presence of fear stifles any ability to learn.

The other night I finished watching Chernobyl, a HBO dramatisation of the 1986 nuclear accident; one of the worst man-made catastrophes in history. The story of the disaster and the subsequent clean-up effort that took place to prevent unimaginable human suffering, provides a masterclass in the perils of heroic leadership and of self-serving behaviours in organisations.  From an organisational psychology perspective, we saw how reckless behaviours were reinforced and even rewarded by a wider system whose predominant mental model was to drive failure underground.

The show highlights how human factors play an essential part in safety, and how latent weaknesses in every step in a process or system can align (aka the Swiss Cheese Model), leading to catastrophic failures. Part of the solution to preventing such a chain of events is developing good team working and allowing workers to call out problems when they see them. Yet, what we saw in the TV show, and sadly in some of our health and care organisations, is that contrary views and outside perspectives are seen as challenges to authority; it takes a very brave person to stand up against a culture such as that. As a result the truth is hidden, stealing from us the opportunity to learn and improve.

Cultural norms are hugely powerful in setting unseen boundaries for what is acceptable and what is unacceptable behaviour in organisations and teams.  Organisational Culture has been described as ‘how we do things around here’ and is reinforced by behaviours (what we do), artefacts (the things we see) and the beliefs and assumptions held (how we feel). When teams work in a culture where they feel unable to speak up or ask questions, where fear is present, we can describe this as having an absence of psychological safety.

Back in 2000, Prof Amy Edmondson coined the term ‘psychological safety’, describing it as ‘shared understanding by team members that the team is safe for interpersonal risk taking’.  She led a team of researchers who performed studies into medicine errors with the aim of identifying which teams were safest and why – summarised in a great TED Talk.  Her researchers observed various medical teams and discovered that the safest teams had higher reported medical errors or near misses.  They found that teams who felt safe to report errors or mistakes without fear of being shot down, ridiculed or unjustly blamed were the safest. Google further confirmed the concept of psychological safety as a key factor in high-performing teams after they carried out their own study, Project Aristotle.

The topic of psychological safety is something that I have been interested in for a while.  For me personally, it explains how in some teams I have thrived, grown, developed and learned and in other teams I have just kept quiet, done my job as well as I could, and left as soon as I was able to. I believe in the saying ‘people don’t leave organisations, they leave people’.

Recently, I was able to meet Amy Edmondson, the guru of psychological safety herself, having been invited to chair a session at The King’s Fund. On meeting her, I was struck by how passionate she was about team behaviours and how skilled at engagement she was as the audience hung on to her every word. Her session was about the journey of one hospital in leading and developing a learning process.

Here are a few of the learning points I took from the session, which has enhanced my knowledge and informed my leadership approach:

  1. In order to build psychological safety we need to believe that changing behaviour takes time, we can’t do it alone, we need help, we won’t get it right all the time and it’s our own responsibility to learn. 
  2. Classical (recipe driven) change models are not designed to deal with change in highly complex organisations; rather, change should be seen as a continuous learning process that has inquiry at its core. 
  3. Implementing learning processes in organisations and teams is primarily a matter of reducing employee fear. The presence of fear in organisations dampens the ability to learn.
  4. Psychological safety is not the same as ‘a safe space’ where anything goes. There should be no trade-off with maintaining high standards of care (it is sometimes not possible to avoid hurt feelings).
  5. Setting clear boundaries actually supports psychological safety. It is worth agreeing what are ‘blameworthy acts’. These might be: reckless behaviour, knowingly violating standards, working beyond your own boundaries etc.

Having worked with a large number of health and care teams across the region, I always wonder how psychologically safe people in our systems feel.  Are you able to bring problems and issues to your team meetings and discuss them openly? Do you feel valued and that your skills are utilised? 

Please do post your comments and get in touch if you are interested in this topic and finding out how we can support you.

The Coaching Academy runs a culture improvement programme which includes sessions on psychological safety in teams. We use a comprehensive culture diagnostic and coach teams to identify areas for improvement and develop improvement cycles. We have seen some great initiatives and improvements as a result of the programme, some of which are described in our case studies. If you would like to find out more, email us at coach@innovationagency.nhs.uk

Juliette.kumar@innovationagencynwc.nhs.uk

@juliettekumar

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