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Psychological safety on the healthcare team

Pfeifer, Lauren E. MSN, RN; Vessey, Judith A. PhD, MBA, FAAN

doi: 10.1097/01.NUMA.0000558490.12760.08
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For patients to receive optimal care that integrates the specialized knowledge of all team members, each party needs to feel free to voice their concerns and engage in skilled communication without fear of reprisal. Learn how to promote psychological safety among team members to positively transform the work environment and improve patient care.

At Boston College's William F. Connell School of Nursing, Lauren E. Pfeifer is a doctoral student and Judith A. Vessey is the Leila Holden Carroll endowed professor in nursing.

The authors have disclosed no financial relationships related to this article.

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Have you ever been in a meeting and felt nervous to raise your hand? Have you ever been afraid of being perceived as incompetent by asking a question or voicing an opinion in the workplace? Have you ever wished you worked in an environment where you felt both encouraged and expected to share your thoughts, concerns, and questions? If so, you aren't alone. Current research shows that many nurses are afraid toask questions or seek clarification for clinical issues due to past experiences of intimidation.1-3 In addition, many healthcare professionals work in environments where they don't feel psychologically safe or empowered to pose new ideas, ask for help, or voice concerns.4,5

The complexities of patient care, advances in medical practice, and the rapid development of healthcare technology contribute to the urgent need for improved communication both within the nursing workforce and across interprofessional teams. However, effective communication can only take place if team members feel that their opinions are valued, questions are welcomed, and collaboration is required. Successful communication depends on psychological safety.

According to the American Nurses Association, nurse leaders have the responsibility to establish a culture of safety for patients and employees.6 In today's rapidly evolving healthcare arena, it's paramount to assess the organizational attributes of your workplace culture and develop strategies to improve it. Nurse leaders are in the unique position to promote staff engagement, interprofessional collaboration, and the psychological safety of team members.

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The importance of psychological safety

The concept of workplace psychological safety was first defined in 1965 as an “atmosphere where one can take chances without fear and with sufficient protection.”7 In the psychologically safe environment, nurses and other staff members develop positive interpersonal relationships that are perceived as supportive and trusting.8 When nurses feel psychologically safe, they view the healthcare team as a place where it's okay to share ideas, recognizing that any criticism received will be constructive and supportive rather than destructive and belittling. When working in a psychologically safe environment, nurses feel comfortable and encouraged to ask questions, voice potential concerns, and brainstorm new ideas.

When patients enter the hospital setting, they entrust their lives to physicians, nurses, and other clinicians and expect to receive high-quality care. They're dependent on several disciplines working together to develop an integrated and individualized care plan that fully addresses their needs.2 Given the unique knowledge base of the profession, nurses have an ethical responsibility to engage in collaborative practice and inquiry. However, for this to work, nurses need to feel that they're respected and their contributions are valued.2

In a psychologically safe environment, nurses believe that the benefits of speaking up about a concern will outweigh the costs (such as potential embarrassment). When individuals have high levels of psychological safety, their concerns regarding potential repercussions for speaking up are assuaged. Moreover, when a positive environment is created, nurses' self-esteem is enhanced, enabling them to feel more connected to the healthcare team and the patient care they provide.9 High levels of psychological safety have been associated with more effective team learning and improved performance.10 When nurses engage in clinical inquiry across disciplinary lines, they can develop new ideas to address old problems and provide others with insight into nursing's unique perspective.11

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When psychological safety is threatened

Unfortunately, many nurses work in environments where they don't feel psychologically safe. Nurses who work in unhealthy environments avoid situations where they may be shunned, excessively criticized, or ridiculed.12 Consequently, these nurses are likely to become disengaged, have lower job satisfaction, increased absenteeism, and poorer retention rates—all of which are known to endanger patient care.12,13 In the absence of psychological safety, the open exchange of information among professionals is particularly jeopardized.

Numerous studies over the past 2 decades have revealed that nurses experience bullying, lateral violence, and incivility in the workplace.14,15 Research shows that approximately 33% of all nurses have experienced bullying in the past 6 months and 50% have witnessed it in the past year.15-17 Workplaces that condone these behaviors inhibit the cultivation of psychological safety. When bullying remains unchecked, nurses feel psychologically unsafe and are less inclined to share their ideas and engage with team members.

Positive correlations have been found between workplace bullying and medication errors, patient falls, and delayed medication administration.18 To minimize the likelihood of a future attack, victims will often avoid interactions with the perpetrator, even if it means that patient care may be jeopardized. Victims have reported that they've avoided clarifying orders with physicians, used unfamiliar medical equipment, and even performed procedures they felt unsure about due to bullying.3

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Addressing psychological safety in the workplace

Given how important psychological safety is in healthcare, organizations, nurse leaders, and frontline staff members should brainstorm ways to improve the work environment. As a team, we can strive to enhance psychological safety and develop strategies to repair the psychologically unsafe workplace if low levels of psychological safety are detected.

There are several key strategies that nurse leaders can employ to promote psychological safety. (See Strategies to promote psychological safety.) Seize every possible opportunity to demonstrate your commitment to staff well-being and the delivery of excellent patient care. Staff members must feel that their feedback is welcomed and encouraged both on their units and across the organization. Nurse managers and organizational leaders can work to enhance their visibility on the unit by participating in daily huddles and through the scheduling of open staff meetings. Reinforce openness and model transparency by communicating organizational updates, the frequency of safety events, and important news to staff members on a regular basis.

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In addition to using positive and supportive language when speaking with staff, participate in employee recognition programs to celebrate frontline staff members' accomplishments and hard work. Consider creating personalized videos that are electronically sent to staff members to announce achievements, deliver holiday greetings, and highlight organizational projects. The recipient of a personalized video will feel more connected to upper administrators and engaged with the message being delivered.19

Nurses are largely influenced by the practices and behaviors of organizational leaders. It's essential that we foster professional practice environments that are perceived as open, civil, and supportive. Nurse leaders across the organization can collaborate with frontline staff to establish position statements and standards to set clear precedents for how professional interactions and conduct should occur. This process can assist all nursing staff to discuss desirable behaviors and set the normative standards for professional interactions.20

However, it's critical to recognize that organizational standards are only likely to be effective if nurses are aware of them, contribute to their development, and feel psychologically empowered to use them.14,20 During this process, collaborate with staff members to brainstorm ways to improve communication, encourage healthy debate, and pose new ideas. Work to improve your own communication skills by role-playing difficult situations at leadership meetings and learning effective strategies to handle misconduct.

One of the most important elements of a professional practice environment is the incorporation of a shared governance model. On the unit level, review the importance of participation in shared governance meetings and projects while also helping staff with scheduling. During unit meetings, encourage staff members who work on shared governance projects to report updates. Throughout the organization, projects can be shared electronically with staff and promoted on the internal webpage.

As leaders, we should acknowledge our own mistakes, questions, and concerns to reiterate that when issues do occur, they're nothing to be ashamed of and should be perceived as learning opportunities. On the unit level, share professional goals with staff members to reinforce their ongoing commitment to personal growth, learning, and improvement. Post information about key nursing quality indicators on unit bulletin boards to reinforce the overarching goal of improvement in patient safety and quality care. On an organizational level, this same concept can be applied by posting the frequency of safety events and near-misses on the internal website's homepage.

According to The Joint Commission, healthcare organizations should encourage nurses to report safety events and near-misses to address systems issues and improve the quality of future patient care.21 To ensure that such events are reported, nurses need to be assured that they won't be punished or judged unreasonably for their disclosure. One way to do this is through “good catch” programs, which positively recognize staff members who report safety concerns.19 When staff members do report a safety event or near-miss, privately thank them for disclosing it. Nurses should also think about how comfortable they are with the organization's reporting system and brainstorm ideas for how it may be improved. These actions demonstrate to frontline staff members that event reporting is appreciated and their feedback is considered valuable. Consequently, reporting won't be seen as something to avoid out of fear, but instead perceived as a valuable learning opportunity.

Organizations should also collect data on staff retention, absenteeism, and patient satisfaction as past research has shown that high nurse turnover is often indicative of a poor work environment.22 The collected data should be synthesized, interpreted, and shared with nurse managers to evaluate for concerning trends. In addition, ask about workplace culture during annual performance reviews and exit interviews.

Nurses can also enhance psychological safety by establishing support programs for novice nurses transitioning into practice. Support programs have been shown to positively influence nurses' confidence, competence, and professional identity.23 Support programs can also transform workplace culture by establishing new expectations of staff to ask questions and seek second opinions.23,24 Staff members working alongside novice nurses should frequently ask their own questions during team meetings and in practice, demonstrating that even seasoned professionals are constantly learning and excited to discuss new ideas. Meet with the new hire and preceptor both jointly and individually to ask about the experience and discuss questions and concerns. Provide preceptors with adequate support and resources before the new hire begins orientation and carefully consider patient assignments.

Although often uncomfortable, healthy conflict and debate are necessary to improve nursing practice and patient care. Moreover, nurses are more likely to be committed to their patients and positions when they feel that they're being listened to and are perceived as valuable members of the healthcare team. Both informal and formal leaders can promote communication and transparency within the workplace by encouraging their colleagues to come to them when minor issues arise and providing opportunities to strengthen communication skills. Across the organization, staff members should complete annual educational modules to review updated policies and protocols. Post updated position statements and relevant journal articles across unit bulletin boards and electronically share them in journal clubs and via email. And consider participating in professional conferences focusing on psychological safety, leadership development, and the professional practice environment.

In addition to implementing strategies to foster psychological safety, frontline staff members must remain on the lookout for disruptive behaviors, including incivility, bullying, and lateral violence. If issues are detected on the unit, staff members can brainstorm ways to ameliorate the existing culture, improve professional relationships, and promote dialogue. This can be accomplished by holding frequent formal meetings, as well as informal gatherings where staff members get to know each other away from the bedside.

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Repairing unhealthy work environments

When it becomes evident that a workplace has low levels of psychological safety, nurse leaders need to join forces with staff to appropriately reconstruct the unit's culture. Once a unit requires such an extensive overhaul, the existing issues are typically widespread and require multifarious interventions focused on both the promotion of psychological safety among team members and frequent evaluation of the unit culture. Share trialed interventions across units so all leaders can learn about successful strategies.

At present, there's a dearth of literature on ways in which units have successfully reconstructed unhealthy cultures. In addition to incorporating the strategies outlined in this article, clinical nurses may also elect to increase the frequency of meetings and discuss strategies to improve unit morale and collaboration and address standing concerns. Organizational educators may hold training seminars on how unit staff can manage difficult conversations, address unprofessional behavior, and report safety concerns. These seminars should be offered at various times and days of the week to ensure that all team members are able to attend. The nurse manager may schedule additional team bonding sessions to improve rapport. It's important that the team building sessions not be held while staff members are also providing care to patients and to compensate participants for their time.

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Positive transformation

For patients to receive optimal care that integrates the specialized knowledge of all team members, each party needs to feel free to voice their concerns and engage in skilled communication without fear of reprisal.25 By promoting psychological safety among team members, nurse leaders can positively transform the work environment and improve patient care.

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