132. Is Your Hospital Toxic? | The Critical Role of Psychological Safety

Psychological safety is a crucial factor in creating a healthy and effective workplace. It involves a shared belief that the team is safe for interpersonal risk-taking. This episode delves into the intricacies of psychological safety, particularly in high-stakes environments like medicine. We explore how rigid hierarchies, cultural biases, incivility, and unrealistic expectations can hinder psychological safety and how fostering a culture of openness and vulnerability can lead to better team performance and resilience. We explore various strategies to enhance psychological safety, including setting clear expectations, modeling vulnerability, and showing gratitude. Finally, we provide actionable tools for leaders to create a psychologically safe team environment.

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Guest Bio: Kim Bambach, MD  is an Assistant Professor of Emergency Medicine at The Ohio State University and Assistant Director of the Kiehl Resident Wellness Endowment 

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We Discuss:

What is “psychological safety”?

• Psychological safety is the shared belief that the team is safe for taking interpersonal risks.
• Interpersonal risk is vulnerability, asking questions, and making mistakes without fear of negative consequences.
• Healthy work cultures support psychological safety, while toxic ones undermine it.
• Psychological safety is crucial not only in medicine but also in various industries for team success.

Google’s Project Aristotle

• Companies have been very interested in understanding why some teams thrive and others falter. In Google’s Project Aristotle, Google surveyed 50,000 people in 180 teams and found psychological safety was the most significant lever for high-functioning teams. 
• Teams with psychological safety engage in more effective collaboration and creativity.
• Psychological safety allows team members to try new things without fear of impression management.
• Example: Kindergartners outperformed MBAs and CEOs in building marshmallow and spaghetti towers because they were less concerned with status management, which impeded collaboration and creativity. 

Why psychological safety is important, even on a SWAT team

• In Stimulus episode #29, Colonel Jim Czarnik, MD and SWAT team member Josh Bucher, MD discussed How To Be An Effective Leader.
• As in medicine, psychological safety is vital in high-pressure environments like SWAT teams and the military.
• Leaders should create environments where team members feel safe speaking freely and offering input. Trust and open communication are essential for effective team performance and mission success.
• Psychological safety prevents the culture of distrust and promotes a cohesive team dynamic.

Threats to psychological safety

• Hierarchical systems, such as those in medicine, can intimidate lower-ranking members from speaking up.
• Institutional cultures that rely on hazing or rigid traditions can erode psychological safety.
• Bias and inequity, especially for underrepresented groups, pose significant threats.
• The mindset of perfectionism in patient care can also undermine psychological safety by creating fear of mistakes.
• Psychological safety is not the absence of conflict or comfort. You can be challenged in psychologically safe environments.  

The Korean Air Crash of 1997

• The crash was partly due to a lack of psychological safety, preventing the co-pilot from voicing concerns.
• Hierarchical culture inhibited open communication, leading to catastrophic outcomes.
• Effective teams need environments where all members feel empowered to speak up, regardless of rank.

Contributors to trainees feeling psychologically unsafe

• Residency is a challenging time, making psychological safety critical for learning.
• Patient safety concerns can conflict with the need for a psychologically safe learning environment.
• Perfectionism in medicine creates fear around mistakes, impacting psychological safety.
• Trainees need support and a culture that allows them to learn from errors without judgment.

Collegiality between specialties and its impact on psychological safety

• Lack of collegiality and incivility between specialties can stress residents and impact psychological safety.
• Interdepartmental communication and respect are crucial for maintaining a supportive learning environment.
• Toxic cultures with poor communication can significantly harm psychological safety and overall team morale.

The Psychological Safety Scale

• A simple seven-question scale can help gauge psychological safety in the workplace.
• It assesses factors ranging from how mistakes are treated to utilizing individual talents.
• Leaders can use this tool to identify areas for improvement and track progress in creating a safe environment.

Six key leadership behaviors to create a culture of psychological safety

• Communicate expectations clearly and concisely without undertones. This helps create a sense of purpose and direction. Defining clear roles and responsibilities and regularly providing feedback fosters an environment where team members feel safe to ask questions and express concerns.
• Vulnerability from leaders promotes trust and openness among team members. This can be done by normalizing “I don’t know” and asking others what they think. Acknowledge your fallibility. Encouraging vulnerability and asking questions promotes a culture of curiosity and continuous learning.
• Showing genuine interest in team members strengthens the team bond and enhances psychological safety. It can start by knowing and using their first names.
• Create a culture of curiosity by inviting questions and modeling curiosity.
• Giving team members autonomy and avoiding micromanagement builds trust and motivation. Unlike in pedagogy where learners are motivated by a gold star, adult learners are intrinsically motivated, goal-oriented, motivated by changing roles, and have rich life experiences. Micromanaging is corrosive to morale for this reason. 
• Regular expressions of gratitude enhance team morale and reinforce a positive, supportive environment. Gratitude is a powerful tool.

Resources:

1. Edmondson A. Psychological safety and learning behavior in work teams. Administrative Science Quarterly. 1999;44(2):350-383. doi:10.2307/2666999 
2. https://www.aliem.com/tldr-book-review-the-culture-code-the-secrets-of-highly-successful-groups/
3. Coyle D. The Culture Code. Random House UK; 2019. 
4. https://www.youtube.com/watch?v=LhoLuui9gX8&ab_channel=TEDxTalks
5. https://hbr.org/2023/02/what-is-psychological-safety
6. https://onlinelibrary.wiley.com/doi/full/10.1002/aet2.10356?casa_token=ZNKQgHucbcQAAAAA%3As8cgjV48sAvK3vtZrFVJxSnAWa29QgiGHKeRX5oMVHrCpWSUWdGXwf_1lDSwAMJnZ867CxDPLiUgVkI
7. Edmondson, Amy C. The Fearless Organization Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Wiley, 2019. 
8. https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html
9. https://www.ted.com/talks/tom_wujec_build_a_tower_build_a_team?language=en
10. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
11. https://accelerate.uofuhealth.utah.edu/resilience/setting-the-stage-for-psychological-safety-6-steps-for-leaders