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"Psychological safety is quite fragile. People have a strong tendency to avoid speaking up about problems and disagreements."
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Don’t Let Your Staff Suffer in Silence

By Neil Baker | Tuesday, February 11, 2020

Don't Let Your Staff Suffer in Silence Photo by Rob Albright is licensed under CC BY-NC 2.0

I get excited about improvement. When I was a leader of clinical services, I liked to think my high energy was infectious for the providers and staff I supervised. 

But, early in my career, I discovered there was a downside to my enthusiasm. My passion could, at times, inhibit others from speaking up.

For example, I once supervised a manager of a clinical team who, in one of our 1:1 meetings, expressed concerns about a key improvement initiative. I was so enthusiastic about the project, that her worries seemed minor. I gave ideas for quick fixes and moved on to more “important” issues.

Over the next few months, the manager would occasionally bring up the same issues. I offered more quick fixes. In retrospect, I was consumed by many other demands and was not admitting to myself that I was a bit frustrated that she hadn’t solved these problems on her own. Eventually, it was clear her team was not making progress. When I brought this up, she looked so unhappy I was taken aback. I slowed down to ask more questions. I discovered the issue was resistance she was getting from her team about the initiative, especially from a couple of the physicians. She was embarrassed that she hadn’t been able to respond effectively. 


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I apologized for not understanding this sooner and thanked her for her courage in speaking up. With this support, she summoned more nerve and told me she felt I should be the one to talk to the physicians. She had held back due to her own self-doubt and concerns about my busyness. (My perfunctory responses in the past had not helped.) We created a plan that included my meeting with her and the physicians. Over several weeks, the team started making progress.

A Wake-Up Call

I have always been committed to creating environments of psychological safety in which people feel able to speak up about concerns and disagreements. I know it’s important that people know they will be heard, understood, and respected by their peers and supervisors. I’m well-versed in the research showing that psychological safety enhances learning, innovation, and performance.

So, it was particularly distressing to me to learn that my manager had suffered for so long in silence. Over time, experiences like that and others taught me that psychological safety is quite fragile. People have a strong tendency to avoid speaking up about problems and disagreements. This is a tenacious aspect of human nature which is magnified in the presence of power differentials, such as in meetings with supervisors. Even the most high-powered, skilled, and experienced professionals need to be asked about their concerns repeatedly to assure they speak up. And, like the manager I described above, staff also need to feel supported so they’ll openly describe the issues they’re seeing.

Further complicating matters, research indicates that those with more power in a conversation, regardless of their skills and values, automatically tend to talk more, listen less, and assume everything is fine. In other words, supervisors are less likely to repeatedly ask their supervisees about how things are going and exploring concerns.

Survey Data

To learn more about these dynamics, I conducted a survey of the participants in a recent leadership workshop at the IHI Forum. I asked about how often they speak up in meetings with their supervisors. The responses ranged from 1 (rarely or never) to 5 (very often).

Of the 126 participants who responded:

  • Only 24 percent indicated they “very often” feel heard, understood, and respected when they raise problems or disagreements with their supervisors.
  • Only 21 percent indicated they “very often” feel comfortable sharing their mistakes in meetings with supervisors.
  • Only 14 percent indicated they are “very often” asked, in meetings with their supervisors, if they see problems or disagree with the supervisor’s ideas and plans.

This may have been an informal survey, but these are very low rates. Feeling heard, understood, and respected should ideally happen every time someone raises an issue.

Psychological Safety Best Practices for Supervisors

I don’t think this means there are a lot of “bad” supervisors out there. I believe the results underscore how easy it is to get caught up in the fast pace and pressures of our day-to-day work. We are hardwired as humans to respond with quick fixes instead of slowing down for deeper inquiry about problems.

To fully enable others to speak up, supervisors need to check in with themselves before, during, and after supervisory meetings to assure the following practices:

  • Meet 1:1 at least monthly with supervisees.
  • Repeatedly (perhaps in every meeting) ask about problems, disagreements, and concerns.
  • Explore what is said, empathize, and refrain from jumping in quickly to fix things.
  • Summarize what you’ve heard to assure the other person feels understood.
  • Collaboratively define strategies to address the issues raised.
  • Follow-up in each 1:1 meeting until issues are resolved.
  • Repeatedly (perhaps in every meeting) ask supervisees whether your words and actions encourage them to speak up.

Asking the same questions repeatedly can feel awkward. Exploring concerns in more detail can lead to unpleasant discoveries about ourselves. But, the highest levels of success depend on sustaining awareness of these very human vulnerabilities. We are then more likely to create psychological safety in nearly every meeting.

Neil J. Baker, MD, is IHI faculty and principal, Neil Baker Consulting and Coaching, LLC. He will be a presenter on B6: Joy-in-Work: The Risks and Magic of Small Actions and E3/F3: Managing the Risks of Power in Shaping Culture at the IHI Summit on Primary Care (April 16–18, 2020 in National Harbor, MD, USA).

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