Damian Sendler, M.D. – When working in a high-risk environment like a healthcare facility, it is critical that employees have the freedom to express their thoughts and feelings without fear of being judged by others. In mental health, where recovery-oriented approaches rely on interprofessional teams to make complex decisions, psychologically safe working is particularly important. A lack of attention is paid to the practical steps that can be taken to increase the level of psychological safety in healthcare organizations across and at all levels of the organization.
Damian Jacob Sendler: Patient safety and effectiveness in mental health services are directly tied to the psychological well-being of the patients being treated. A large-scale program in psychological safety with a focus on mental health and drawing from the current literature provides concrete steps for how our current understanding of psychological safety can be implemented.
Dr. Sendler: One of the most important aspects of psychological safety at work is the shared belief that it is safe to take risks with one’s coworkers in order to learn and grow as a team. Employees should be able to freely express their concerns, errors, or problems without fear of retaliation, and should be treated fairly and compassionately when doing so. Aside from fear, they also need to feel safe and secure in their personal, professional and social relationships and their future professional and occupational advancement.
Working in high-risk environments, such as healthcare, where staff are expected to work in multidisciplinary teams where mistakes can have life-threatening consequences, psychological safety is critical [3–6]. A culture of blame and fear is still prevalent in healthcare organizations, which is detrimental to patient safety, staff morale, and organizational performance and results in unreported errors [7–10]. In countries with strict hierarchical structures, where structure and control are paramount, this culture of blame and fear may be exacerbated, with little to no opportunity for candid conversations across different levels of the organization. Countries with market cultures may prioritize competition over open discussion of failures, resulting in an environment that could be poisonous for all parties involved.
The ability of patients and their families to express their ideas, anxieties, and suggestions is a crucial component of mental health, and ensuring that people feel safe in doing so is critical. There is a recovery-oriented approach to many mental healthcare organizations, which focuses on empowering patients and their families/caregivers to build on their strengths, make educated choices, and take an active role in their own health and well-being [11].
In this paper, we’ll look at the advantages of fostering a culture of psychological safety before moving on to the more difficult task of implementing it across the entire organization. Before we address the specific challenge of enhancing psychological safety in mental health services, we first consider the challenges of cultural change of any kind. As part of our research, we outlined a number of concrete ideas for promoting a culture of psychological safety throughout an organization, as well as a number of initiatives that would work in conjunction with it. As part of the design, consideration is given to creating an ethos of psychological safety as well as specific interventions that can have a measurable and impactful effect.
It is the spirit or personality of an organization that is referred to as organizational culture. An organization’s employees’ well-being and productivity depend on it. [12] More specifically, it is a manifestation of the workplace’s shared beliefs [12], behaviors, thoughts, attitudes, and norms. To borrow a phrase from Schein, culture can be defined as the “pattern of shared basic assumption—invented, discovered or developed by a given group” [13, 14]. This interpretation is important because it takes into account the sociocognitive, interpersonal, and symbolic manifestations of culture [15]. Organizational culture acts as a collective, and it has the potential to drive wider organizational innovation and change [16].
A positive organizational culture in healthcare has proven to be difficult to implement and even more difficult to demonstrate, despite the obvious benefits. No reliable results have been found in recent systematic reviews of the impact of organizational cultural change on healthcare performance. [18] Other studies have found that many attempts fail immediately or do not last long [18]. Underlying these challenges is an ongoing discussion about whether or not culture can be influenced directly or whether it simply needs to be taken into account when planning interventions and change [19].
A shift in the healthcare industry’s culture presents additional difficulties. There has been a shift in healthcare needs and behaviors over time as a result of a wide range of patient needs and the complexity of healthcare delivery. With an executive core at the center, healthcare typically consists of nested structures, some clinical, others non-clinical. There are many different types of teams, each with its own set of responsibilities, and each one can be assigned to a different population, provide its own unique service, or be a part of a variety of distinct services [20]. Healthcare organizations have a diverse range of stakeholders with varying levels of interest, which can make it difficult to implement consistent change due to the heterogeneity of their teams. For the sake of creating a work environment where employees can feel safe and secure, all of this is especially important.
Internationally, the national culture will have a significant impact on whether or not cultural change is possible in any healthcare organization in any given country. What can be achieved in terms of cultural change depends on factors such as individualistic vs. collectivist ideologies, patriarchal vs. matriarchal cultures, and levels of tolerance for uncertainty.
Creating a culture of psychological safety not only benefits the organization’s workforce and patients, but it also lays the groundwork for future cultural shifts. Benefits in health care management and clinical practice as well as foundations for long-term innovation can be found in these technologies. In this section, we provide a brief overview of some of the most important aspects of mental health care.
When it comes to spotting mistakes and near misses, psychological safety is crucial [1, 2, 21]. In situations where there are pressures from within and outside the organization (e.g., concerns about patient safety and bed capacity), speaking up can be especially challenging.
International efforts to remove barriers in healthcare organizations have recognized the importance of speaking up [22, 23]. Some of the most common barriers across countries and cultures include concerns about the negative consequences of speaking up, as well as power and hierarchy, and leadership influence. In the United States and Europe, the majority of studies on psychological safety have been conducted, but the importance of speaking up to prevent errors has been recognized in a wide range of clinical settings [22, 24, 25] The World Health Organization curriculum guide and patient safety teaching programs both emphasize the importance of open communication within teams [26, 27].
Many clinical decisions in mental health are based on a patient’s subjective observations and therefore necessitate open and honest discussions [28, 29]. Employees should be expected to bring up mistakes, not just encouraged to do so. To that end, employees should be treated fairly, and investigations into errors should take into account all possible contributing causes (e.g., staffing levels, patient acuity). Psychologically safe organizations use error management as an opportunity to learn, to improve, and to calibrate expectations among their workforce.
Patients, caregivers, and families in mental health services need to feel comfortable raising issues they are concerned about. There are many people who are afraid to talk about their struggles with mental health issues or treatment. Caregivers and family members play an important role in community mental health care. Patients, family members, and caregivers have the opportunity and space to openly discuss their concerns and care plans are adapted to accommodate these discussions in psychologically safe organizations.
There is a correlation between psychological safety and the capacity for rapid learning and innovation in other industries [30, 31]. The ability of employees to provide feedback on areas that need attention or could be improved is critical to quality improvement and innovation. An organization’s local needs and efforts to embed change are better understood by its employees who are invested and share a sense of collective responsibility. Throughout all stages of Quality Improvement (QI), psychological safety is essential, from open discussions about problems to taking controlled risks and being free of fear of failure.
In all countries, psychological safety and its effects on Quality Improvement (QI) are critical. It’s critical for low-income countries to develop and mature a competent healthcare workforce [32]. The success of newly formed QI teams in these settings is largely dependent on two factors: psychological safety and learning behaviors [23, 32].
Many healthcare organizations have shifted away from assurance-based reporting in favor of QI in mental health. The CQC’s evaluation of mental health in the UK emphasizes the importance of Quality Improvement (QI) approaches [33].
QI projects are more likely to take place in teams that have a high level of trust and respect for one another [21, 34, 35]. The employees of a psychologically secure company know the value of failure as a learning opportunity and that, despite the challenges of organizational change, they are essential to its success.
Promoting employee well-being at work necessitates that they be able to recognize and report when they require assistance or are having difficulty meeting the demands of their current jobs. To admit that you need help is seen as a weakness by some who fear it will harm their reputation, job security, and future career prospects. This problem can worsen over time if it is not addressed, as it can lead to increased levels of work-related stress [36].] Staff in mental health facilities may find it difficult to speak up about their own well-being because they work with patients who face similar difficulties. In addition, some employees may fear that speaking out about these issues will negatively impact their ability to carry out their responsibilities at work.
Damian Sendler
In the midst of the COVID-19 pandemic, where many members of the healthcare team may suffer from post-traumatic stress disorder or other forms of moral injury, the ability of these professionals to speak up is all the more critical (i.e., feelings of guilt in not being able to cope with current work conditions [37]).
There are a number of fundamental principles that underpin any successful program for organizational change in general and culture change in particular. According to a recent review, there are a number of factors that contribute to psychological security. A holistic approach is emphasized in these principles, which take into account behavioral changes in employees who take interpersonal risks by speaking up, leadership support to serve as a model and enable these changes, and facilitation of environmental and organization-wide transformations as well. Before we get into the specifics of mapping and intervention, here are the main principles and success factors to keep in mind.
Damian Jacob Markiewicz Sendler: Every large-scale change necessitates executive leadership. The extended executive must be involved in any organization-wide program in order to simultaneously engage stakeholders from different directorates and core operations. (i.e., HR, Governance). Early executive buy-in is required by discussing research literature, options and developing a preliminary work plan with multiple streams is needed. Furthermore, it increases the likelihood of securing a sufficient amount of funding at an early stage of the business.
There are likely to be many subcultures in healthcare organizations [19]. Each subculture’s level of psychological safety varies. In some organizations, it is encouraged to speak your mind, while in others, it may not be possible. In order to keep their jobs, employees may be afraid of being punished or having their job prospects harmed. Psychological safety may be a higher priority for some teams. The opposite is also true: some people will resist change and insist on sticking with the status quo.
The success of a company-wide psychological safety program depends on the development of a flexible program that can be tailored to meet local needs. Indeed, there is a wide range of views on the importance of psychological safety in the workplace. Local manager styles and the consequences of taking an interpersonal risk by speaking up can influence these [2, 40]. Transformational leadership, inclusiveness, managerial openness, trustworthiness and behavioural integrity have been found to enhance psychological safety in the workplace [21–44]. In addition, teams may differ in terms of the operational processes they use to ensure psychological safety in the workplace (e.g., meeting structures, content and frequency).
In addition to recognizing effective leadership styles, the executive and local levels of the organization should model psychologically safe practices in their leadership values and behaviors. Instead of encouraging confrontational behavior within and amongst teams, this strategy aims to keep issues from festering and growing into much more serious problems down the road. Leadership at all levels must therefore provide opportunities for subordinates to speak up while also managing contributions in a positive and collaborative manner.. Leadership must also have the courage to limit or even halt contributions that jeopardize psychological safety. In other words, the goal of psychological safety is to encourage open, honest, and focused discussions rather than a free-for-all approach that accepts all ideas. In addition to their role in fostering psychological safety, leaders must also feel safe in their managerial duties and have HR practices that support them.
Co-production demonstrates and utilizes the value of the experience of staff, patients, and their caregivers and families in the field of health care. Health-related research frequently employs this strategy [45, 46]. In various contexts, the term “co-design/production” has a variety of meanings. It is everyone’s responsibility to contribute to innovation and change, which may lead to safer patient care, for psychological safety. Contributing ideas for improvement, experimenting and providing feedback are all examples of this. It also includes making an effort to put changes into action.
Damian Jacob Sendler
For the development of psychological safety interventions, this is critical. To begin, it gives employees a chance to participate in collaborative and co-designed interventions, allowing them to apply their knowledge of regional nuances to organizational plans and thereby maximize their chances of success [47]. For one thing, the experience of collaboration itself can foster psychological safety and convince employees that the leadership’s intentions are genuine. Co-design/production, on the other hand, increases the intrinsic motivation of employees and increases their involvement in these changes, which in turn promotes sustainability. A final consideration is the importance of involving employees in the design and production process, which gives them a voice and enables them to take an active role in promoting a climate of psychological safety.
Damien Sendler: People’s behavior, particularly that of the organization’s leaders, has a significant impact on the organization’s culture. Organizational culture is also reflected in its written documents, procedures, and symbols. Some policies would benefit from a psychologically safe focus. ” There should be psychologically safe practices embedded in whistleblowing policies so that the whistle blower, those who might be implicated, as well as the organization itself, can have an honest discussion about their concerns. The first step is to encourage employees to speak up, and it’s essential that the organization’s practices support what happens after someone has spoken up. Near miss policies should shift from being an assurance-based tool to encouraging and even rewarding employees who speak up, as well as promoting transparency, in order to show how learning and improvement are looped back into the organization. Policies enacting organizational change should adopt a similar strategy, laying out a framework for employee participation in order to take advantage of available local knowledge and secure their support.
All levels of the healthcare workforce are provided with a variety of educational opportunities, both formal and informal. Many of the induction programs include essential training on governance and information security, but other courses may focus on the various methods of caring for people. Years of formal education and multiple placements are required for some roles (e.g., nurses, allied healthcare roles, and doctors). For both local and company-wide induction training, the antecedents of psychological safety should be addressed: teamwork, voice behaviors, and respectful listening. A strong emphasis on inclusive, compassionate, and collaborative leadership is essential to creating psychological safety in the workplace [6, 31].
Knowing whether or not an effort to promote psychological safety has been a success and how to assess that success are difficult tasks. Team surveys [1] are the most common method of gauging psychological security. Individual and organizational psychological safety can be assessed using this survey (see, for example, [42, 49]).
Typically, healthcare organizations send out surveys to their employees to get feedback on various aspects of their work experiences.. If a team or service has a low score on these surveys in areas that can indicate psychological safety (perceived organizational support, perceived compassion), they may also feel unsafe psychologically. This is preferable, however, to conduct a specific survey of psychological safety at the beginning and at regular intervals throughout a major program. These surveys are short and take only a few minutes to complete, so they aren’t a burden on employees. There are ways to limit how many people are needed to complete new surveys or add new questions to existing surveys, such as using careful sampling strategies. To identify groups of people who have scored low on psychological safety or who do not feel able to complete a survey, surveys can be helpful. To build trust across the organization, executive leaders must provide extra assistance to these individuals and groups.
Future research in this area will benefit from the use of objective measures of psychological safety. The use of observational frameworks relating to the verbal and nonverbal indicators of psychologically safe and unsafe practices may be particularly useful in simulation interventions around speaking up and decision making, for example. Behavior markers provide a way to measure good or poor practice once psychological safety behaviors have been agreed upon. These frameworks are used in simulation-based education in order to measure and assess non-technical skills among medical teams [50, 51]. As a result, the use of observational frameworks for behavior provides a means of gauging psychological safety. In particular, some of the below-discussed targeted interventions will be evaluated for their psychological safety.
To improve patient safety and staff engagement in the long run, it is important to foster and enhance psychological safety. As a result, it’s difficult to determine whether or not psychological safety has any effect on these indices. Immediate consequences like more people speaking up or reporting near misses could be a more realistic target earlier on. In addition, by focusing on these areas, a connection can be made between the impact of psychological safety and other important outcomes, like the safety of patient care. An organization’s current and new employees will have to adapt to a new way of working and a new culture, which will take time and effort. Staff surveys and long-term evaluations of current practices allow for a better understanding of the long-term effects that a program like this one can have.
The idea of psychological safety is simple on the surface, but it turns out to be more nuanced than it first appears. For a variety of reasons, it can be difficult for organizations to take concrete steps to improve psychological safety. First and foremost, psychological safety is a multi-faceted issue, which necessitates a multi-faceted approach to solving it. For the first time, the majority of the workforce at all levels must be involved in the effort to improve psychological safety. Third, measuring psychological safety in terms of its impact on patient safety, healthcare improvement, and overall well-being is particularly challenging. Finally, and most importantly, it is difficult to identify what concrete steps to take to enhance psychological safety, in what order and over what timescale. Even though there are many inspiring stories of organizations that have embraced psychological safety, little research provides any kind of defined set of steps or interventions to follow. There will be a unique journey for each organization, but defining the essential components of a psychological safety program will help.
It is the goal of the majority of psychological safety interventions to affect a broad range of attitudes, values, and trust across an entire organization. Creating an atmosphere of psychological safety is what we call this strategy in general. A complementary approach is to use targeted interventions in settings and activities where psychological safety is particularly important. A person-centered organization that is also one that listens and learns should be the focus of any effort to promote a psychologically safe work environment. A patient-centered organization will enable employees to participate in the creation of an engaging workplace that emphasizes patient safety and quality. An organization that values hearing its employees’ suggestions for improvement, as well as their mistakes and blunders, is one that is committed to listening and learning from its mistakes.
Innovative practice and safe patient care can only be achieved in mental health if a healthy and engaged workforce provides it. Despite the fact that psychological safety is an easy concept to grasp, making it a reality at a large scale is extremely difficult. Two things make it relevant to mental health. In the first place, many mental health organizations focus on recovery-oriented practice, which requires a lot of involvement from patients and their families. Second, mental health decision-making is frequently based on subjective observations and necessitates input from the entire team. Safe and optimal care for mental health patients requires that all parties involved feel free to speak up and participate to their full potential.
To the best of our knowledge, this overview and proposed plan for enhancing psychological safety is only applicable to the mental healthcare system in the United Kingdom. Many aspects of this plan may not be applicable in all countries or cultures because healthcare organizations differ greatly in structure, investment, and prevailing culture. Despite these differences, many of the challenges and suggested solutions will be applicable to countries and cultures around the world. When it comes to things like the importance of speaking up when something goes wrong or when you have an idea for a better solution, the barriers are universal.
It is possible in all settings to establish a patient council and to actively encourage family/carer participation, even if it is more difficult in some cultures. So, while the plan itself may not be applicable to a variety of healthcare organizations, many of the recommendations can be applied individually or tailored to fit the needs of a particular organization.
When conducting research in non-traditional organizational settings, it is important to consider the cultural and structural differences that exist. As an example, healthcare organizations may differ in societies with a strong emphasis on collectivism or individualism.
