Six Ways for Physician Leaders to Build a Culture of Psychological Safety

I like the concept of “psychological safety.” It gives a name to what most groups aspire to, but few achieve.  A culture that values psychological safety often seems utterly at odds with our traditional approach to training healthcare professionals, and to how we lead organizations.  Physician leaders sometimes resist discussions about leadership styles and approaches that will encourage psychological safety – because it’s inconstant with the autocratic leadership approach that is so prevalent in their training. 

The knee jerk reaction of some leaders is that these discussions are about making team members feel better – NOT about making teams more effective. Nothing could be further from the truth.  Given the challenges facing every healthcare organization, teams need to maximize performance. Psychological safety is not an imperative because it makes people feel better.  It’s an imperative because it makes teams more effective.

Psychological safety is not an imperative because it makes people feel better.  It’s an imperative because it makes teams more effective.

Healthcare is notorious for convening accomplished leaders from different disciplines and departments, as a group to solve complex problems.  What we know is that people who excel in worlds that value professional expertise and autonomy are exactly the people who tend to struggle creating high performing, collaborative teams. 

What is Psychological Safety?

The concept originated with the book, Managing the Risks of Organizational Accidents, by James Reason.  It’s been popularized by Amy Edmondson in her writings and in her book, Teaming.

There are four general components to psychological safety:

  • 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.

Psychological Safety in Medicine

Edmonson pointed out that learners naturally seek to minimize the risk of harm to their self-image, and often adopt avoidance behaviors in situations where effects on self-image are uncertain. This tendency is especially prevalent in environments marked by constant evaluation, large power differentials, and pervasive hierarchies, all of which are common in clinical learning environments.

Not surprisingly, research shows that residents are discouraged from reporting adverse events in learning environments with poor leader inclusiveness and large power differentials.  These avoidance behaviors may be even more pervasive  when the culture is one of mistreatment, humiliation, and punitive responses to mistakes.  Psychological safety plays a role in effective GME learning – and in effective peer feedback which supports on-going professional development.*

What We Can Learn from Google

Physicians value autonomy but effective care delivery, today, is driven by teams.  New care delivery models are designed by teams.  Problems are solved by teams.  Physicians need to be good team members, and effective team leaders. 

Google has garnered a lot of attention recently for their focus on the concept of psychological safety and their analysis of team function.  They’ve identified five important attributes of a high functioning team:

  1. Dependability: Can team members count on the others to perform their job tasks effectively and to help when it’s needed?
  2. Structure & clarity: Are roles, responsibilities, and individual accountability clear?
  3. Meaning of work: Are team goals personally important for each member and do they get a sense of personal and professional fulfillment?
  4. Impact of work: Does the team fundamentally believe that the work they’re doing matters?
  5. Psychological safety – The most important dynamic -the underpinning of the other four.

How to Get Started Building a Culture of Psychological Safety

Much of the dysfunction with healthcare teams, in my experience,  is related to issues of trust and psychological safety (or, more accurately, the lack of both).  I believe that some of this is due to:

  • The emphasis on siloed,  professional expertise.
  • Training that values being right over being a good team player; and
  • A complete lack of training of the concept of how effective teams function and the basic communication skills required.

A few practical ideas to get started improving team function and building a culture of psychological safety:

  1. Be vulnerable enough to acknowledge that your team – even if it’s pretty good, is not as effective as it needs to be in order to achieve your goals.  This acknowledgement is not a condemnation of anyone – just a reality.
  2. Establish the fact that team function can improve, and this improvement will impact performance issues that people care about.  Remind everyone that you’ll ground the discussion in operations – in concrete goals.
  3. It’s not an incredibly heavy lift but there is some work to be done.  Yes, it’s a time investment, but ask people how much time they’ve wasted in unproductive meetings, on initiatives that failed, or dealing with relationship issues that arise because people don’t feel valued or that they have a forum to address concerns.
  4. Give the group a framework for improving.  You don’t improve by telling people to “communicate better” or “be more tolerant of your teammates and colleagues.”  Perhaps start with educating people on what psychological safety is and what Google discovered.
  5. Do some training on basic, simple, group communication skills.   There are simple, effective, productive ways to say the things that need to be said – but people need to learn them and practice them.
  6. Consider formally – at least occasionally – doing a 5 minute “meeting effectiveness” review.  Let the group identify what worked and what didn’t.  Praise colleagues for effectively challenging ideas.  Point out communication approaches that didn’t work.  It may seem odd at first, but Google does it and I’ve done it over the years and it’s amazingly effective.  Like anything else – being an effective team member takes knowledge, desire and practice.