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Even skilled quality improvers can have difficulty creating or maintaining psychological safety.
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5 Ways to Improve Psychological Safety

By Neil Baker | Wednesday, November 7, 2018
November 7 blog post

Several years ago, I joined a virtual group of quality improvement consultants working on a major regional improvement initiative. I was excited to participate because of the group’s stated commitment to creating joy in work through psychological safety.

The presence of psychological safety means that people feel free to voice concerns, new ideas, disagreements, and negative feelings. It means people can trust that what they say will be heard and fully explored rather than discounted or ignored. The teams I have loved being on the most have been psychologically safe. The energy, creativity, and collaboration that develops on such teams is infectious.

From my first meeting with this group of quality consultants, however, I noticed something was off-kilter. Two of the participants tended to dominate the meeting while several were almost completely silent. It made me uncomfortable but, as a new team member, I didn’t feel right speaking up.

Within a few months, the initiative was embroiled in conflict involving multiple participant groups in addition to the quality consultants. People were unhappy about the group’s direction. Those who had initially been silent were now speaking up and expressing their frustration and dissatisfaction. What I experienced during that first consultants meeting — unbalanced participation — turned out to be a sign of a more widespread problem.

Ironically, all the participants in the initiative had committed to guidelines for communication that explicitly supported psychological safety. Many had even been through communication skills trainings.

So — despite the skills and commitment — what in the world happened?

I have 30 years of experience helping people to develop communication skills. Why didn’t I speak up about what I had observed?

The answer is that we were all simply human. Early in our evolution, our brains were hardwired for fight or flight reactions in response to stress. Today, neuroscience has shown that even minor stresses can activate these same pathways, leading to a tendency to see new or difficult situations as unsafe, often outside of our awareness. In turn, this leads to withdrawal into silence — as a type of “flight “reaction — or pushing our ideas on others — as a form of “fight” reaction. All our skills and experience do not protect us from the risks of falling into such behaviors.

The minor stresses that can lead to this are pervasive, everyday parts of the health care environment, such as our fast pace of work and the high pressure to perform. Combined with our survival brains, these ubiquitous stresses make psychological safety fragile.

There are also indications that, in health care, we are not sufficiently active in assuring psychological safety by following norms. In a survey I gave at the IHI National Forum a couple of years ago, 80 percent of the 345 participants stated their organizations had norms for communication that encouraged speaking up and active listening. Less than 30 percent, however, indicated that these norms were actively applied when needed.

So, if psychological safety is fragile, what can we do about it? Five actions will help to strengthen it on your team:

  1. Make the elements of psychological safety explicit parts of team norms, e.g., invite everyone to participate and offer concerns, disagreements, and negative feelings.
  2. Create team awareness about the fragility of psychological safety. Talk about the challenge of sustaining it. Acknowledge that well-meaning people may not follow team norms at all times.
  3. Regularly ask for feedback about how comfortable people feel speaking up. Use feedback to help everyone be at their best, not for punishment.
  4. Learn about your own fight or flight reactions to stress by reflecting on your behavior each week. Note when you withdraw or get argumentative. Regularly seeing and accepting such reactions as normal in yourself will enhance empathy and compassion for others.
  5. Be the first to be vulnerable and openly acknowledge when you have not been following a norm. Leaders with positional authority can have an especially powerful impact by acknowledging their own mistakes.

The evolving conflict in the regional initiative made me realize that I had been hijacked by my survival brain and needed to get more active in giving feedback. Others also made the same decision on their own and, in a few short weeks, things were back on track. The experience was a humbling reminder that none of us can be at our best at all times. We must remember our very human tendencies to react to stress in ways that impede communication. In doing so, we can help each other establish and maintain the kind of psychological safety that is essential for joy in work.  

Neil J. Baker, MD, is IHI faculty and principal, Neil Baker Consulting and Coaching, LLC.

Editor’s note: Neil J. Baker is IHI faculty and principal, Neil Baker Consulting and Coaching, LLC. He will be a presenter for “Managing the Risks of Power in Shaping Culture” at the IHI National Forum (December 8–11, 2019 in Orlando, FL, USA).

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