Tips to Foster Psychological Safety and Trust in Difficult Times

In 2014, a physician wrote in Health Affairs about how a lack of psychological safety — defined by Amy Edmondson as a shared belief that a team is a safe environment for interpersonal risk-taking — within healthcare teams can contribute to medical errors, citing his experience as a third-year medical student on an obstetrics rotation. The student was assisting in the long, stressful delivery of a baby, during which his supervising resident made a minor error, for which the resident’s superior, a very senior physician, scolded her. After fifteen grueling hours, the healthy baby girl was delivered, the senior physician briefly departed, and the supervising resident instructed the student to remove the mother’s placenta.

The student hesitated; he could not remember where to make the incision. The supervising resident, on edge from being criticized by the senior physician and wary of further scolding, reprimanded him for pausing and barked at him to hurry up. Too intimidated to ask for help, the student promptly tore the umbilical cord, which erupted in a geyser of blood.

While the patient was eventually stabilized and safe, the psychologically unsafe working environment, in which minor errors and expressions of uncertainty were punished harshly, had produced an avoidable medical error and put a patient at risk. Research suggests that this anecdote is not an isolated incident. There appears to be a link between care quality and team members’ willingness and ability to ask questions and voice concerns. Even worse, an absence of trust among team members is likely related to elevated levels of stress and burnout, which can both affect healthcare professionals’ well-being and compromise care quality.

A common thread throughout Primary Care Progress’ Relational Leadership™ curriculum is the importance of trust within a team. Though we offer a diverse set of training programs, all sessions are unified by their aim of equipping participants with the tools to foster a greater degree of psychological safety within their team or organization. Unfortunately, in the time of COVID-19, there has never been less time or fewer resources for healthcare professionals to engage in the kind of time-intensive programming which confronts this significant issue; yet, the need for trust is greater than ever. In these times of heightened stress, the risk of preventable medical errors grows, and the rates and intensity of burnout among healthcare professionals will only skyrocket.

While sustained interventions are the ideal long-term solutions to address a lack of psychological safety, there are a handful of best practices you can introduce to your team or organization right away which can meaningfully help foster a greater degree of trust, even in a time of crisis. Here are a few tips to try out:

• Normalize uncertainty, interdependence, and failure

While everyone has a responsibility to contribute to a safer space, those with the most formal power are the ones who can and should be first to model and prioritize psychological safety. Leaders should begin with empathy and connection by highlighting and sharing moments where they benefited from a team member’s help, where they were particularly unsure of how to proceed, or even when they made a wrong decision. A key technique for creating this sort of open dialogue is by acknowledging uncertainty, normalizing mistakes, and offering  a clear mechanism to raise and address concerns.

• Carve out room for listening

Regularly ask team members to share where they are emotionally through open, authentic questions and active listening. One way to achieve this is through a “permission slip” activity, in which, at the beginning of the meeting, everyone shares something they intend to give themselves permission to do or feel during the meeting.

• Invite feedback

Leaders should model the behaviors they want to see their team embrace. This might include asking for help, inviting suggestions on their own work, and offering thanks when they receive feedback. One specific technique a leader can experiment with is an “immediate review,” in which, directly following the conclusion of a project or situation, the leader asks for reflections and thoughts from the team on how it went and how the process could have been improved.

• Amplify voices

Stress the importance of hearing from everyone, especially those whose voices often go unheard. While simply being mindful of who has and hasn’t spoken goes a long way, your efforts can be supported by a variety of formal techniques, including building a “round-robin” into a meeting or huddle, with everyone taking a turn sharing their perspective, or tasking a particular project to a diverse group of team members, intentionally including those who might often be excluded from important processes.

Imagine how the folks in the story at the start of this post could have benefited from these tools. The senior physician could have framed failure in a very different light throughout her relationship with the resident, thoughtfully calling attention to times when she herself made an error and normalizing mistakes. The resident could have checked in to see where the student was emotionally before ordering him to move forward with a new procedure. In either scenario, the student would have been more likely to ask a question about the procedure and avoid a serious error.

There are some examples of what good leadership has looked like so far in this pandemic. Creating the space to endure troubles, share triumphs, and reveal vulnerabilities as a team is vital to establishing the trust that’s needed in a crisis like this.