My limited understanding of psychological safety is when people feel safe expressing differing opinions, and thoughts in the workplace. Amy Edmondson, a pioneer in this area, defines it as “the belief that the environment is safe for interpersonal risk-taking.”1 Although psychological safety must be part of every organizational culture, it is critical for high-performing teams. Cues and actions to enable this behavior and impact organizational culture are the responsibility of the leader. High-innovation companies thrive on emotional energy compared to healthcare, where a high-safety environment—such as a hospital, for instance—relies on psychological safety. However, healthcare is also a combination of research, innovation and caring for human beings. This requires leadership to share their aspirations and push for a healthy balance of both.
Why is psychological safety important in the workplace? Because it is key for people to perform optimally. A McKinsey & Company survey confirms that 89% of employees corroborate that their ability to voice their thoughts and feel safe is essential in the workplace. Gallup has calculated that doubling the percentage of employees who believe their opinion in the workplace counts from 30% to 60% resulted in a 27% reduction in turnover, a 40% reduction in safety incidents, and a 12% increase in productivity. Not surprisingly, it is also one of the strongest predictors of team performance.
While the lack of such safety for employed physicians can be seen in any scenario, I have been most exposed to it in the academic environment. To assume that the impact of lack of such safety must only be on junior faculty or trainees is erroneous. Surprisingly, even senior tenured professors have expressed fear of speaking the truth in public, and often in meetings. I once had a chair express his fear of speaking out in front of a dean several years ago to me thus: “If anyone says anything to the contrary at a meeting, the dean will cut your b***s out.” Imagine how junior faculty must have felt. One can only assume that expressing an opinion counter to the leader in such an environment could result in ill-treatment in the form of compensation, further career advancement, recommendations and discretionally awarded titles. If senior professors are reluctant to speak up, newly hired or junior faculty will not risk their careers, leading to fear of speaking, a “yes” culture and stunted productivity.
Most of us have encountered leaders who may be successful at soliciting ideas and driving change but lacking in spotting cues at meetings where no one feels free to disagree. Rather than psychological safety, there is a culture of silence. What makes employees feel safe and engaged at work and in teams? Some have described four progressing stages of feeling safe at work: safety to be included, to learn, to contribute and, finally, to feel safe in challenging the status quo.2 William Kahn, an expert on employee engagement in the context of psychological safety, has identified three conditions for optimum engagement: “feeling safe, meaningfulness and having access to the right energy and resources.” There are consequences of a culture where there is lack of such safety. Research shows that this culture leads to an 85% rate of project failure.
Edmondson has offered an interesting two-by-two grid or matrix with performance standards (apathy and anxiety) on the x axis and psychological safety on the y axis (comfort and learning).1 She advocates for leaders to attempt to push people into the right upper quadrant or the learning zone. Learning, innovation, and productivity will proceed with psychological safety, she counsels. However, she warns that this one item is only a part of a range of leadership behaviors that accelerates high-performance teams. The obvious goal is for all team members to be in harmony with each other, able to speak and share ideas towards a common purpose, without fear of appearing inane or fearing reprisal. It is the leader’s job to remove any risk associated with speaking out.
So, how should leaders advance a “speak up” culture in order to enable psychological safety?
First, the leader must remember their role in a team. It is to facilitate, empower others, be a catalyst and model the desired behavior. This means having the awareness to be cognizant of the thoughts and feelings of others. Silence does not equal agreement. Then, asking themselves if the silence is a pattern or a “one-off ” behavior? Solutions for each are different. Are team members actively engaged in making eye contact with you and others? If you sense hesitation, encouragement with a self-deprecating anecdote of some kind may work. Or better still, mention one of your own shortcomings. If you are truly self-aware you know what they are or have heard it said about you.
Second, if the leader senses silence during a discussion, ask for advice, not feedback. This is sometimes called the “feed-forward” technique. Feedback is often understood as either an “ask,” or after a decision has been made and interpreted as being judgmental. Using the word “advice” puts the onus on the other person, as well as being heard as being for the future rather than the past. A safe way to elicit advice is to admit that you are still pondering over the issue and that you are probably missing critical pieces of the matter. Not hearing people with a different mindset, leaders may be missing these pieces at a huge cost.
Ron Carucci, co-founder and managing partner at Navalent, mentions two national disasters as examples where “employee voices” were not given importance because their opinions were either not solicited or ignored. These were the Challenger space shuttle in 1985 and the Columbia shuttle in 2003. Give people room to brainstorm out loud. Even if someone presents ideas or suggestions that lack substance, listen and understand the thought first, show empathy, and offer a counter idea, improving on their own statement by asking if they had considered it. People will generally remember what was decided at the meeting. It follows that if a certain position is accepted at a team meeting, progress must be reported at the next meeting.
Third, every team needs a naysayer(s) or a contrarian. Sometimes uncomfortable? Yes. A facial expression or other tic may indicate disagreement but sometimes not. Ask for other viewpoints. To make a point, express a contrary view yourself to lead the discussion off. This allows others the freedom to express divergent opinions.
Fourth, there is a risk that some team members may see the “safe” environment as a license to say whatever they want. Or, while all ideas may be welcome, many do not fit with the goals, mission, or task for the limited time at a team meeting. Remember, there is an “opportunity cost” associated with ideas/projects that do not sync with the goals and objectives of the team. Time and resources wasted on an unworthy project is time lost from a worthwhile one. After listening, gently steer the discussion away and remind everyone that although the idea was good, we can consider this for another time.
Fifth, while I have seen good and bad leaders in a team environment, successful ones have two qualities that stand out. Calmness and confidence when their status or opinion is challenged. They do not get aggravated when the status quo is contested, and especially if team comportment or performance is deteriorating. Certainly, most team members will make errors. Give team members the freedom to fail as part of the team. Indeed, bring them up as learning opportunities, and avoid finger pointing. Emotions must be controlled. Focus on the error itself and how to avoid it in the future. This is where the fundamental pillar of leadership—self-awareness and knowledge of one’s own triggers—is so important for emotional regulation.
Finally, consider a few steps that clearly demonstrate a team leader’s positive energy. People are loathe to report a problem with culture they see as incompatible with organizational values. The leader must encourage conversation about toxic behaviors in a secluded setting if necessary. Be generous with compliments. And please do not ask for advice from team members as you are close to walking out the door. I have seen this repeatedly.
As I see it, providing psychological safety should be a part of all syllabi associated with developing physician leaders. Part of my learning has come from my own mistakes and being associated with our leadership program where I have watched groups go through the training, particularly during the team sessions. Although, data from McKinsey points to several other skills predictive of positive leadership, training in open dialogue skills, sponsorship, situational humility, and consultative behaviors (as in suggestion one and two) are especially important.3 McKinsey also reports that only 28% of leaders develop skills necessary to create psychological safety in team settings. We can do a whole lot better than that, right?
References
- https://amycedmondson.com/psychological-safety-%e2%89%a0-anything-goes/
- https://www.leaderfactor.com/post/why-are-some-leaders-afraid-of-psychological-safety)
- https://www.mckinsey.com/featured-insights/mckinsey-explainers/what-is-psychological-safety
Bhagwan Satiani, MD, is a Vascular Specialist associate medical editor.
