Psychological safety

In psychologically safe environments, people are able to:

• speak up, and offer ideas, observations, questions and concerns
• think clearly, free from fear of humiliation and embarrassment
• thoughtfully handle constructive conflict while remaining respectful of colleagues
• report and discuss failures in order to learn
• innovate and think creatively
• focus on achieving goals rather than focusing on self-protection

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In order for psychological safety to take hold and grow, physicians must explicitly express their intent to promote it. They must also take action to model psychological safely and continually mentor others in practising it.

Three practical steps may be helpful to establish psychological safety within a team:

• using the platinum rule
• promoting healthy conflict
• encouraging speaking up

The platinum rule

• The golden rule states, “Treat others as you would want to be treated”. When it comes to psychological safety, however, the platinum rule prevails: “Treat others as they would want to be treated”. Frontline providers, who are intimately familiar with the issues at hand, want to contribute and make a difference. Psychological safety encourages the sharing of ideas and the proposal of solutions empowering better care for all.

Promoting healthy conflict

• In a high-stakes environment like healthcare, tension can be expected. Physicians can help normalize respectful conflict and ensure that all team members feel valued by including clear expectations for and in support of collegial, courteous workplace discussions. Leaders set the stage for healthy discussions by reassuring team members that the ultimate goals are patient safety and quality improvement. Team leaders make it clear that they will not tolerate behaviours that belittle, embarrass, or ostracize team members.

Encouraging speaking up

• Patient safety incidents are often due to a complex set of contributing factors such as cognitive overload or unconscious drift away from safe practices. Unfortunately, an individual often cannot recognize they are about to commit an error until it is too late. While individuals may be blind to their risk of error, their co-workers might see and hear things differently and thus see an otherwise unappreciated risk.
• In healthcare, fear of offending someone perceived to be higher up in the hierarchy and fear of being ridiculed are widespread. As such, coworkers often hesitate to say something, especially to a physician, when they think a situation may present a risk. This can lead to unnecessary, avoidable harm. One of the strongest predictors of clinical excellence is therefore a culture that encourages speaking up.
• Patients and their family members are valued members of the healthcare team. To promote safe care and weave a tighter safety net to prevent patient safety incidents, it is important to empower patients and their families to speak up and to ask questions.

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There may be times when patients, family members, trainees, or other healthcare providers find it difficult to speak up and share their opinions or concerns about an evolving clinical situation or impending patient safety incident.

These challenges may include the following: ²

• not wanting to appear ignorant or incompetent
• not feeling confident in their observations
• fear of being judged negatively
• fear or embarrassment
• lack of knowledge about how to speak up effectively
• believing it is the wrong time, not wanting to interrupt
• intimidation by other health providers
• workplace culture that does not support psychological safety

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Because of the unique relationship between speaking up and psychological safety, how we react when someone speaks up will either encourage it or suppress it. Speaking up is important, but we must also learn to “listen up”!

Physicians can foster speaking up by inviting it frequently and openly. Using a statement like “I may miss things, so please tell me if you see me do something that might impact patient safety.” Repeated invitations are as important as the words used in the creation of psychological safety.

Additional suggestions to promote speaking up include:

• demonstrating a willingness to listen
• expressing appreciation when someone speaks up to raise a patient safety issue
• reacting supportively when you are right, and the individual speaking up is wrong, since you want to avoid discouraging people from speaking up again
• inviting opinions or questions from team members, patients, families, and colleagues
• leading by example and teaching speaking up to learners
• discussing the concept of speaking up with your team and exploring ways to promote it

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Graded assertiveness

Graded assertiveness refers to an approach to team communication that aims to be respectful and polite while ensuring it is effective. If the team members are listening for critical language, fewer steps of graded assertiveness will be required. At the lowest level of concern, neutral statements may be made that are not necessarily directed at any one individual. As one progresses up the levels of concern, the statements become more direct, and may go from suggestions to instructions or outright orders, and the words used to address other team members become more direct, yet always respectful.

Effective assertiveness is:

• respectful and polite (not aggressive)
• appropriately timed
• constructive and focused on achieving clarification and a solution
• mindful of the clinical experience and wisdom of others.

Rather than relying on vague language that relies on "hinting and hoping", some clinical units have adopted the use of critical language to get another team member's attention.

5-step advocacy is one way to improve being heard ³

• Get the person’s attention: Excuse me, can you please clarify the dose of medication?
• State your concern: That's a higher dose than I was expecting.
• State the problem as you see it: It may cause an unwanted side effect.
• State a solution: I would like to consult with the pharmacist.
• Obtain agreement: Would that be all right with you?

CUS is another way to voice one's increasing concern with a situation:

• C - "I'm concerned"
• U - "I'm uncomfortable" or "This is unsafe"
• S - "This is a safety issue" or "I am scared"

If attempts at speaking up are unsuccessful after stating “I’m concerned about …,” the next step involves stating “I’m uncomfortable with…,” and eventually ending with “This is a safety issue….”

Because we may lose situational awareness and risk getting “tunneled in” at certain times (e.g., doing a procedure, or managing a crisis), some units have found success in using a previously agreed-upon keyword or phrase such as “Let’s chat” as code to help caregivers recognize that speaking up is taking place and to pay attention.

The use of these simple communication tools alone may not achieve better communication. Training your team to use, recognize, and respond to these key phrases is important in creating an effective speaking up culture that is responsive, promotes learning, and focuses on safe medical care.

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Sometimes, despite our best efforts to speak up, we may fail to be heard.

In such instances, considering the possible reasons for the failure of communication may provide a solution.

• Did you fully engage the attention of the person you are speaking to?
• Is the environment too noisy?
• Have you clearly articulated your concern while remaining respectful?
• Did the person hear you, consider your words, and decide to proceed anyway, without explanation?
• Has this person lost situational awareness?
• Is this person exhibiting reckless behaviour?

The appropriate next step to take when someone fails to listen up when you have spoken up will depend on the situation. In cases where a bona fide patient safety issue exists, enlisting the help of a supportive colleague or escalating the matter to a higher level of authority (department head, clinical lead, or chief of staff) may be reasonable options.

For more information on the responsibilities of supervisors and trainees see Delegation and supervision of trainees.

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• Invite speaking up and appreciate the contribution of others.
• Acknowledge human fallibility. For example, hold debriefs asking what the team did well, what it could do better, and what lessons were learned.
• Be willing to acknowledge your own fallibility. A genuine appreciation of your fallibility encourages others to follow suit and speak up with any concerns.
• Use direct language such as structured communication tools, SBAR, closed loop communication, and repeat back.
• Listen intently.
• Be accessible and approachable.
• Recognize failures as opportunities for learning and coaching.

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Speaking up is a clinical communication tool meant to improve the quality of communication to enhance patient safety. As such, it does not require documentation in every instance. However, on the rare occasion where failure to listen up may lead to a patient safety incident (accident in Québec) or where there is a significant disagreement between providers as to diagnosis or treatment, objective documentation in the medical chart of the facts supporting the various opinions will help establish the reasoning behind clinical decisions.

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