OUT OF COMMITTEE: Patient Safety and Quality Improvement | Creating Psychological Safety in Otolaryngology: Practical Steps to Promote Teamwork and Safe, High-Quality Care

VyVy N. Young, MD, Michael J. Brenner, MD, Jo Shapiro, MD, Cecelia E. Schmalbach, MD, MSc, and Nausheen Jamal, MD

Each of us has had the experience of discovering that we have made a terrible mistake. In the moment it is jarring. A flood of emotions pours forth—shame, fear, panic, anger, or regret. Long after the incident, vivid memories can persist, affecting personal or professional growth. But what if there were a better way? What if such instances were used to foster positive ends such as growth and learning? How people respond to mistakes or other stressors is affected by the surrounding environment and culture. In a highly punitive culture, fear of blame or repercussions has a chilling effect, often delaying the response or impeding learning. In contrast, a positive, team-based environment maximizes opportunities to salvage a situation, minimize adverse outcomes, and prevent recurrence of the problem.

What is psychological safety? Why does it matter?

Psychological safety is the idea that people can feel comfortable to ask questions, admit errors, suggest ideas, voice concerns, or disagree, without fear of negative outcome (e.g., criticism, humiliation, or retaliation).^1,2 In a psychologically safe environment, patient safety, workplace morale, and personal well-being thrive. Otolaryngologists who champion psychological safety are critical for promoting the necessary openness and learning in the workplace. However, all members of healthcare, from frontline staff to high-level organizational leadership, share in the responsibility to promote psychological safety. Both institutional values and practices must be aligned to achieve optimal outcomes. 

What promotes psychological safety?

Several measures support psychological safety. First, communication should be bidirectional, nonjudgmental, unrestricted, and open-ended.^2,3 Second, goals and expectations need to be communicated clearly, with frequent, direct, and specific feedback (both positive and negative).^1,4 It is imperative to have both formal and informal processes to support this culture, which should be developed and monitored by all stakeholders, including healthcare personnel, risk management, leadership, and legal, etc.^5,6 Peer support programs, for example, promote progress toward a culture of learning instead of “shame and blame.” Importantly, hospital and administrative leadership must provide both financial and verbal support for these endeavors as well as model the behaviors that support psychological safety.⁵ Without support at all levels, efforts to create psychological safety will founder. 

What undermines psychological safety?

Fear of retaliation, harassment, or being negatively labeled all erode psychological safety. Open communication is not possible when workers are made to feel shame or embarrassment after making a mistake, when there are barriers to reporting problems, or there is a sense that “nothing will change.”^2,3,7,8 Power differentials are pervasive in healthcare and can amplify these challenges. Unprofessional behavior has a corrosive effect on workplace morale and team cohesion. Actions that disturb or upset others—whether acts of incivility or egregious misbehavior—can negatively impact the healthcare team’s performance. Examples of unprofessional behavior include verbal or physical intimidation, refusal to answer questions or return calls, unwillingness to complete tasks such as timeouts, or use of condescending language or tone.⁹ Team members should be educated, trained, and empowered to respond to unprofessional behavior.^6,8 

Table 1: Factors that promote or undermine psychological safetyWhat about conflict? 

A psychologically safe workplace is not devoid of conflict; rather, it makes productive use of conflict to arrive at solutions and improve performance. Learning skills to manage conflict allows for positive change, minimizes harm, and facilitates communication.^10,11 Although several behavioral approaches to conflict management have been described,¹² an overarching theme is that open communication with active engagement usually achieves more positive results than avoidance.¹¹ For example, microaggressions are negative verbal, behavioral, or environmental communications that convey hostility, invalidation, or insult based on an individual’s marginalized status in society.¹³ Bystanders can mitigate the negative effects of these affronts by performing microinterventions.¹⁴ These microinterventions are a specific set of skills that, once learned, empower individuals to respond to, navigate, and redirect these episodes.¹³ Organizations should be encouraged to provide this type of education to all staff. Training that promotes emotional intelligence can also help in avoiding or defusing charged situations.

Not turning a blind eye to problems

It is incumbent on organizational leaders to respond swiftly and decisively to unprofessional or psychologically unsafe behaviors. Lapses in professionalism that undermine patient safety, degrade fellow professionals, or threaten others must not be tolerated. Effective organizations have transparent, comprehensive, and consistent procedures to hold individuals accountable.^6,15,16 Reporting processes need to be clear and easy to navigate; barriers to speaking up must be identified and overcome. An effective reporting infrastructure supports individual performance, teamwork, and patient safety. For example, tiered professionalism interventions are highly effective in addressing concerns. These begin with an informal conversation and if the problem persists, can proceed to authority-based or disciplinary actions. Institutions also need to invest in resources for education and remediation, with stakeholder engagement by individuals, leadership, and the organization. 

Conclusion 

Creating psychological safety means ensuring that people feel safe to suggest new ideas, admit errors, and improve patient care through quality improvement initiatives. Hiding or minimizing mistakes—as may occur in psychologically unsafe situations—increases the risk of future recurrence. Psychological safety is increasingly recognized as a precondition for professional well-being and patient safety. Psychologically safe environments promote well-being and decrease risk of burnout, not only for physicians but for all members of the healthcare team. Everyone in healthcare shares in the responsibility for supporting psychological safety and addressing individual or systemic factors that undermine it. Working together, otolaryngologists can partner with leadership and interprofessional partners to provide the psychological safety necessary for teamwork and safe, high-quality care. 

Declaration of Conflicting Interests: The authors declare that there are no conflicts of interest.