Psychological Safety and Talking the Walk
In 9-out-of-10 cases where an error occurs in a healthcare setting, another healthcare professional is fully aware of the error – and yet they say nothing.
Years ago, I witnessed something that sticks with me still today. At the time, I was working in a hospital with residents in training. On staff was a medical resident who had developed a reputation for having a flippant, half-hearted, bravado-like attitude. She was one of the few residents I ever worked with whose clinical judgement I did not trust. I felt she did not take the gravity of her position and medical decisions seriously, and worried she would harm a patient with her irreverence.
While in the exam room, the resident took several actions that potentially exposed others to harm. Proper procedures were not followed, the patient and everyone in attendance were put in harm’s way, and the resident’s actions were both irresponsible and reckless.
No one, however, spoke up.
The incident impacted the safety of the patient and providers present, as well as the quality of care. Fortunately, no one was harmed, but the careless, reckless nature of the behavior that I witnessed has never left my mind.
Why it still haunts me
I still think about that incident to this day for several reasons. First, I wonder about her: I wonder if she is still practicing, if she has been sued for malpractice, or if she harmed any patients. But mostly I think about myself. Why hadn’t I spoken up? Why hadn’t anyone else? I knew she was practicing unsafely and was placing the patient and herself at risk.
(Side note. While I didn’t speak up initially, I did, later that day, inform her supervising chief of the behavior.)
The science behind why we don’t speak up
Not speaking up is based in a powerful social science phenomenon. The “spiral of silence” theory, named by German scientist Elisabeth Noelle-Neumann, states that people often don’t speak up, but for differing reasons: those in the majority assume that everybody thinks like them and people in the minority think they’re the only ones. The minority fear risk of social isolation should they speak up.
With leadership tactics, it’s possible to empower employees to speak-up and reduce this problem within a practice or organization.
Amy Edmondson is a professor at the Harvard Business School. Her research focus is on the psychology of “teaming” and organizational learning. She founded the term “Psychological Safety”, which is the shared belief that the team is safe for interpersonal risk taking. In psychologically safe teams, team members feel accepted and respected.
Dr. Edmundson offers 4 leadership behaviors that support creating psychological safety:
▶ Acknowledge our own fallibility
Own up to mistakes. In this way you destigmatize failure. A key principle of High Reliability Organizations (HROs), such as nuclear power plants and aviation, is that they embrace failure. We are all fallible and through our failures we learn. At Eli Lilly, when a drug fails in testing, they have “failure parties” realizing that from failure also comes innovation. They say… “Fail often in order to succeed sooner”.
▶ Embrace the messenger
Remember that your actions speak louder than your words. It’s important to recognize that in any relationship which demands loyalty, the loyalty works both ways. In a Just Culture, a non-punitive approach to reporting concerns is embraced and is the cultural norm. Behaviors are judged, not outcomes.
▶ Listen with intention
Stephen Covey wrote 7 Habits of Highly Effective People and says to listen with the intention to understand instead of listening with the intention to reply. When you listen with empathy to another person, you give that person psychological air. When that need is met, the focus can be on problem solving.
▶ Encourage dissent
Lower the cost of speaking up and proactively invite input. The quality of decision-making depends on casting a wide net and gathering diverse information. Each team member in a practice or organization has a unique view and expertise. In HROs there is a high regard for the unique knowledge of each team member and deference to their expertise. This is crucial to sound decision making.
Behavioral science research that shows many positive behaviors, like integrity, honesty, and performance can be passed from leaders to others. The science says behaviors are contagious. Through our action and behaviors, we can say, “this is how we do things here”.