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Psychological safety is rarely taught in school, but it's never too late to learn and develop
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Dear IHI: How Can I Encourage Staff to Speak Up about Safety?

By Jennifer Lenoci-Edwards | Thursday, March 3, 2016

Dear IHI

I’m a charge nurse on a hospital ward, and I’m convinced that people on my team don’t feel safe about speaking up. I actually want to hear their feedback, but I realize that not all managers in my organization have the same attitude. We also have high turnover, so it’s hard to change the culture when staff come from other organizations or departments with a weak culture of safety or, even worse, have actually been burned in the past. How can I encourage people to speak up? — ALL EARS

Thanks for your question. The concept that you're talking about is psychological safety — a common belief among members of a team that they can share mistakes, ask for help, and seek feedback without negative consequences. It wasn't taught in nursing school, and so many nurses don’t know that they should feel safe to speak up on their units, in their practices, or in any health care setting. Here are some ideas that might help start to shift that culture:

  1. Lead by example. No one is going to go into dangerous waters without seeing a leader go first. Make sure that your staff see you speaking up with your leaders about your concerns for patient and staff safety.
  2. Talk about psychological safety. Units and practices all over the world — maybe even the healthcare system across the street — are practicing and emphasizing the importance of psychological safety as a key attribute for a safe health care system. Get folks comfortable with the concept.
  3. Close the loop. If you want folks to trust you and the system to report a problem, you need to be sure you are responding to the feedback in constructive way. If folks are contributing to a system that is not giving back, the feedback will stop.  Post the concern and the response anonymously for all the team to notice.  
  4. Lastly, link feedback to patient or employee outcomes. Remember that many of us went into health care to help people — what your staff likely cares about is making a difference for patients. When you link the cycle of reporting, feedback, and action to the prevention of an error, improved clinical outcomes for patients, and greater joy in work for the staff, you go a long way in reinforcing the culture of safety.

Remember that culture does not develop overnight, so be patient. The fact that you are recognizing this challenge means you have already started on your journey to a safer culture. Good for you!

Good luck,


Jennifer Lenoci-Edwards, RN, MPH, Director of Patient Safety at IHI

Editor's Note: "Dear IHI" is an advice column in which IHI experts answer questions from health care change agents in the field. Look for a new installment every other Thursday. Have a question for "Dear IHI"? Send it to info@ihi.org or on Twitter using the hashtag #DearIHI and @theihi.


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