Modern healthcare involves clinicians partnering with patients to deliver individualised care in a fast-paced environment. Institutions everywhere seek to provide consistent, high-quality care. Yet these complex systems are quite different from machines in a factory producing standardised widgets. One major distinction is the central role of people working in teams; individuals with different functions that need to work together. In recent years there has been an increasing focus on the key determinants of a high performing team. To most people, it is surprising that psychological safety has repeatedly been at the top of the list, as opposed to individual excellence, clear protocols or team training (although, clearly, each of these is useful). The psychologist Amy Edmondson, now based at the Harvard Business School, was a pioneer investigator into the factors influencing team performance and has championed the fundamental role of psychological safety in both healthcare and beyond.^{1 2} In the business world, Google instigated ‘Project Aristotle’ to clarify the key characteristics of their top performing teams. It took them a while to label the ‘missing factor’ but once they had identified it as psychological safety, they reported it was the single strongest influence on performance.³ So why is psychological safety so important?

Optimal team performance hinges on making the most of everyone’s potential value. This is not just the sum of separate inputs. It is about collaboration – how members ‘value add’ to the team by contributing, blending and honing ideas together. In addition, learning and innovation are essential activities in healthcare, as clinicians are often still training or new to the unit, and practice is constantly evolving. This means people need to ask questions, raise difficulties, report mistakes, double check each other’s work and design new ways of doing things, to optimise learning and patient safety.

The central role of psychological safety in promoting collaboration

Yet all of this is ‘tiger country’, fraught with the risk of blowback and conflict. All of us, at some point, have felt uncertain about what to do but not wanted to expose our ignorance; felt concerned that someone else might be making a mistake but not wanted to offend them; or felt hesitant to suggest an embryonic idea in case it seemed stupid when considered in more detail. Anytime we voice our thoughts, there is the possibility that we may be disparaged, rebuked, or offend someone else. Hierarchy exacerbates this risk. So, whenever we consider participating, we analyse the risk-to-benefit ratio. If the risk is perceived as high, we stay quiet. This is the tension between individual reputation and team performance. Yet when there is psychological safety, people will risk their reputation for the sake of the team and a shared objective.

Psychological safety can be defined as ‘a person’s belief that the environment is safe for interpersonal risk taking’;¹ in other words, I feel confident the team will continue to accept, value, and assist me, as I learn and collaborate imperfectly. When Amy Edmondson started investigating the influence of psychological safety on teamwork, one of her first studies analysed the link between psychological safety and drug errors in hospitals.⁴ She was surprised to find, in contrast to her initial hypothesis, that higher psychological safety was associated with higher rates of drug error reports. Further analysis revealed that psychological safety enabled greater discovery and reporting of drug errors. In teams with high psychological safety, people routinely reported their own mistakes so strategies could be developed to prevent others repeating it, and double checked each other’s work to optimise patient safety across the team. The leaders typically had high standards, coached their team, were invested in their team member’s success, acted to level out the hierarchy, and were not offended by well-intentioned questions or problems.

The central role of psychological safety in enhancing quality

Often people fear that high psychological safety may permit sloppy standards but, in contrast, the evidence suggests that peak team performance is not possible without it. Edmondson directly addresses this in her recent book, ‘the fearless organisation’.⁵ She regards the level of ‘psychological safety’ and ‘quality’ in an environment as two separate, yet interacting, parameters. She describes that when leaders foster high psychological safety with their people, it is like ‘releasing the breaks’ on team interactions required to optimise performance. High psychological safety promotes motivation, learning and collaboration, which then enables people to achieve high standards. A cooperative group routinely outperforms an exceptionally clever individual, as combining the power of diverse perspectives enables plans to be refined, challenges overcome, and problems fixed early.^{3 6} To realise the potential value each person can bring – their knowledge, insights, background, questions, concerns, and creativity – requires an atmosphere that encourages them to engage with each together to achieve a common goal. Alternatively, if the psychological safety level is low, people will focus on risk management and self-preservation, and stay quiet.⁷ Another key concept for optimising performance that dovetails with psychological safety is a ‘growth mindset’. This approach focuses on continually developing skills, accepts that mistakes are an inevitable feature of extending skills and sees them as learning opportunities.^{8 9}

Within healthcare, simulation-based research studies have highlighted the powerful impact on team performance from seemingly minor violations of psychological safety. One RCT involved an immersive scenario with NICU teams managing a deteriorating newborn, when when an international expert made mild and general disparaging remarks about the healthcare system at the start, this resulted in substantially worse team performance and poorer clinical outcomes.¹⁰ Jenny Rudolph, at Harvard’s Center for Medical Simulation, proposed the concept of creating a ‘safe container’ for learning.¹¹ Learning and performing complex tasks occur at the distal edge of a person’s skill level, where mistakes or crevices in knowledge are most common. This makes it a high-risk zone for health professionals needing to protect their reputation.

The central role of leaders in fostering psychological safety

Senior clinicians are responsible for setting the standards and creating a framework that encourages a growth mindset and psychological safety. A psychologically safe environment is characterised by qualities such as respect, humility, acceptance, interest, appreciation, care and assistance, which all contribute to creating interpersonal trust. Table 1 suggest some practical ways these qualities could be enacted, based on the literature and our own research on feedback interactions.^{12 13} However, this is not a ‘magic recipe’ that can be thoughtlessly enacted, as the potency lies within the authentic beneficial intent driving each behaviour.

It is increasingly clear that psychological safety plays a central role in high performing teams. I hope the ideas outlined in this article may stimulate your thinking on how to foster it within your healthcare teams.

Table 1. Practical ways for leaders to foster psychological safety within their teams.

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3. Duhigg C. What Google learned from its quest to build the perfect team. The New York Times Magazine, 2016.
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12. Johnson C, Keating J, Molloy E. Psychological safety in feedback: What does it look like and how can educators work with learners to foster it? Medical Education. 2020;54(6):559-70. doi: 10.1111/medu.14154
13. Johnson CE, Keating JL, Leech M, et al. Development of the Feedback Quality Instrument: a guide for health professional educators in fostering learner-centred discussions. BMC Medical Education. 2021;21(1):382. doi: 10.1186/s12909-021-02722-8