Psychological Safety – what is it and why is everyone talking about it all of a sudden?

By Benna Waites, Consultant Clinical Psychologist, Clinical Lead, Improvement Cymru, Joint Head of Psychology Counselling and Arts Therapies, Aneurin Bevan University Health Board

Benna Waites

Psychological safety is a key priority for the Safe Care Collaborative, aiming to create the conditions  for change, fuelling momentum by removing barriers and supporting improvement  across the system. Psychological safety plays a key role in the Institute for Healthcare Improvement’s Framework for Safe Reliable and Effective Care and will continue to be a focus throughout the Collaborative.  

I’ve been talking about psychological safety since 2016 when we first started including it in the in-house Leadership Programme I was running with colleagues in Aneurin Bevan University Health Board. Back then it felt like a niche topic that few people had heard of, but that was always received really well by our participants. People seemed to like that the idea spoke to the realities of their day to day working lives and to name something that they felt was highly relevant to their experience in work. Fast forward to 2023, with a global pandemic under our belts and facing the biggest workforce and financial challenges we have ever known, the world is finally catching up with the importance of psychological safety.

So what is psychological safety?

Psychological safety is about interpersonal risk taking – it’s the shared belief that people can speak up with ideas, concerns, mistakes or questions without being dismissed or made to look foolish. In teams that are high in psychological safety, team members are able to question and challenge each other openly, respectfully and with confidence, secure in the knowledge that their working relationships will not be threatened by these conversations. When this happens, it means that the work benefits from the eyes, ears and brains of everyone belonging to that team.

Why is everyone talking about psychological safety?

The big shift from academic construct to popular discussion came from a study named Project Aristotle undertaken by Google, that was written up in the New York Times in 2016. Having set out to try to build the perfect team (with performance and profit uppermost in their minds), the Google researchers did not at first find what they were expecting. Experience, qualifications and personality variables appeared to have no predictive power. However, once they factored measures of psychological safety into their analysis, the researchers said it was “as if everything fell into place”, it enabled far greater prediction of team performance than any other metric.

How is this relevant to health settings?

Since Amy Edmondson, the Harvard Business School Professor at the forefront of the field, first published on psychological safety in 1999, there has been clear linkage to health. In fact, her excellent original Ted Talk starts with the example of a nurse in a busy hospital noticing a possible medication error but deciding not to speak up for fear of irritating medical staff.

Some of the thorniest problems we face in health, including the challenge of turning “never events” into things that genuinely never happen, will often have a recognisable strand of less-than-optimal psychological safety contributing to poor outcomes – team members who know there’s a problem but don’t feel able to speak up. A lack of psychological safety is often present in serious incidents and can be detected in a range of inquiry findings (though it may not always be named as such). A group of obstetricians and gynaecologists I was presenting to recently felt it was highly relevant to the Kirkup review published last year on Maternity and Neonatal services in East Kent.

Research has taken place in a wide range of health settings showing that high levels of psychological safety correlate with a wide range of highly desirable team outcomes including creativity, error reporting and performance, as well as staff well-being and turnover intentions.

When I co-chaired the Health Foundation Q community’s work on Psychology for Improvement, psychological safety emerged as one of the most relevant areas for improvers to understand and to be able to bring to their improvement work with healthcare organisations.

So what are we going to do about it?

Psychological safety is a complex topic, influenced by many different variables. Leaders have a key role to play in establishing cultural norms in teams, and improvement work done in the right way can be an excellent mechanism for enabling teams to work together with greater psychological safety.

But simply knowing about psychological safety is an important first step – thinking about how you contribute to your teams, and invite and respond to the contributions of others in a way that might increase the chances of people speaking up in future is a good place to start.

Where next?

Psychological safety is not an end in itself – it is the soil not the seed, the conditions in which teams can flourish and do their best work. If you want to find out more, these resources will help you to deepen your understanding: