Holding a degree in Ecology, an MBA, and currently pursuing a Masters in Global Health and Humanitarianism at the University of Manchester, Tom merges academic knowledge with real-world experience. His focus lies in leveraging the transformative power of psychological safety, which stems from his understanding and experience of organisational dynamics and the complexity of workplace environments. Tom shares his personal experiences...
For a very long time, I’ve known what it feels like to be trapped by an absence of voice. As a child I struggled with verbal dyspraxia that made it hard for me to speak clearly, and I developed a stammer in my teens. At school, some teachers were great – they made it safe to speak and listened, whether I stammered or not. Some were too impatient, and I often felt too wary to attempt speaking up in class. Then, as an adult working in an environment in which the leader cultivated fear, I began to question whether there was a better way of doing things, a way that encouraged people to speak up rather than making it harder, the opposite of an environment of fear. And this is what drew me to psychological safety.
Psychological safety is the belief that we are safe to take interpersonal risks in a group. It means being able to speak up with ideas, questions, concerns and mistakes, and believing that we won’t suffer negative social or professional consequences as a result. It’s the very foundation of high-performing teams [1].
Conversely, a lack of psychological safety has been shown to be a causal factor in many, if not most, human disasters, from the Challenger space shuttle disaster in 1986 to the recent maternity services scandal at the Shrewsbury and Telford Hospital NHS Trust. These, and many others, could have been prevented had people felt safe enough to raise their concerns and do so assertively enough that they would be heard. These incidents underline that the need for psychological safety, as well as skill and expertise, are crucial to prevent harm to people at work, and the people we serve.
Psychological safety doesn’t look the same for everyone
When we say, “speak up” it’s worth acknowledging that we don’t necessarily mean verbally. In organisations, speaking up often happens via emails or other written formats and there might be many other channels through which we can communicate. It would be reductive to assume that psychological safety only means people boldly speaking up in the moment, whilst maintaining eye contact and without hesitating, stuttering or stammering. In reality, that’s often not a realistic or necessary ask.
Many folks in healthcare work in environments where the local language is not their native tongue. Many of us (in fact up to 20% of the population) suffer from a stutter, stammer, tic or other speech difference [2]. A great deal of us, especially those with autism, attention deficit hyperactivity disorder (ADHD), dyslexia or dyspraxia, benefit from a little thinking time to gather our thoughts and prepare what we want to say before doing so. We need to consciously create spaces at work where people can speak up in the way that works best for them, not just the way that seems ‘normal’ for others.
Tom Geraghty speaking at the NHS Midwifery, Nursing and AHP conference, 2024.
Psychological safety: Everyone’s responsibility
Fostering psychological safety also isn’t solely the responsibility of those in leadership roles, although they shoulder somewhat greater responsibility due to their power. We all have a role to play: if we can belittle someone’s idea, blame them for a mistake, dismiss their concern, or tell them, “You should know that by now,” then we can damage their psychological safety. And given that we have the ability to damage it, we also bear the responsibility to foster it.
In teams and organisations that we work with where psychological safety is high, it is at least in part due to the creation of ‘shared norms’. This may involve the co-creation of a social agreement or team charter and is a powerful practice in itself; discussing team values, aims and ways of working helps the team bond. Using the team charter in practice and continually evolving it ensures it has an ongoing positive impact on psychological safety. If done well, this means that everyone on the team, including new joiners, understands what’s expected and what the boundaries are.
If someone repeatedly breaches the agreement, the team charter should also provide clarity about what the team can expect. This is an important, and often overlooked, element of psychological safety; it requires greater accountability and higher standards, not lower.
The punishment trap
It’s said that we get more of the behaviour that we reward, and less of the behaviour that we punish. In most cases that’s true. If we reward speaking up, it makes it more likely that people will, and over time, people will feel safer doing so. It’s why we emphasise the importance of thanking people when they speak up. Even, or especially, if it’s something that we’d rather not hear, such as a problem or concern about something we’ve done. We have to welcome the bad news, and acknowledge the courage it took to share it.
Where this breaks down, as shown by Amy Edmondson’s original 1999 research, is where mistakes are punished [3]. Punishing people for making mistakes does not result in fewer mistakes being made. It simply results in mistakes being hidden. And that leads, eventually, to more, and larger, mistakes being made – because the opportunity to learn from our own and others’ mistakes has been taken away from us. Unfortunately, we’ve seen this play out multiple times in the healthcare system in the UK and elsewhere.
We’re rarely going to be able to respond to bad news in a genuinely positive way – after all, there’s a reason it’s called ‘bad’ news – but we can attempt to respond in ways that acknowledge the courage it took to bring the news or admit the mistake and suggest ways that we can maximise the learning from it. We should never let a good failure go to waste!
Addressing power gradients
Through our work with UK maternity departments, a frequent issue is the lack of psychological safety across organisational hierarchies and departmental boundaries. It can be particularly hard to speak up against a power gradient, for example for a junior midwife to suggest an idea, question or raise concerns with a senior consultant.
Flattening that power gradient is an effective way to improve psychological safety. This is difficult, because those hierarchies exist and are deeply entrenched. As shown by the cases of Elaine Bromiley or the Tenerife disaster of 1977, even when lives are at risk, people may not speak up against a power gradient, or they may not do so with enough candour and clarity to invoke action.
However, there are some basic practices to employ
A very simple, very effective one is to ensure everyone identifies themselves using their first or preferred names, rather than their title or credentials – ‘Sara’ rather than ‘Doctor Smith’ or ‘Consultant Jones’. This is a practice well established by flight crews trained in crew resource management (CRM), and it has been found to make it much easier to speak up to authority, particularly in a critical situation [4].
PACE or ‘graded assertiveness’ is another practice to make this easier [5]. It starts with Probing: asking a low-threat question such as, “What’s the patient’s O2 stats?” If that doesn’t sufficiently highlight our concern, then we can move to Alert, such as, “Oxygen is at 80% and falling.” If that fails still, we can move to Challenge: “We’ve attempted intubation for too long. We should change our approach.” And if that fails, we escalate to Emergency. For example: “Stop! This is unsafe.” In knowing these levels, we can also match our assertiveness to the urgency of the situation – for instance going straight to Emergency if the situation requires it.
PACE makes it safer to speak up through establishing a shared norm about how to do so in a critical situation. And even more than that, once we learn it collectively as a team, we tend to detect earlier in the process when people are doing it to us, meaning that we can take action before someone has to escalate all the way to Emergency. Practising PACE together in a simulated environment helps increase psychological safety and makes it second nature when we need to use it for real.
Psychological safety at scale
Psychological safety is low in many parts of our health system, and systemic resource deficits alongside pressures to hit targets within the NHS often only make the problem worse. People are less likely to speak up about problems and concerns if they’re likely to create more work for themselves and others in an already overwhelmed system. But even if large-scale systemic changes for our healthcare system are some way off, we can all make little changes to our own behaviour and practice, which cumulatively, could foster dramatic improvements in our experience at work, as well as patient safety.
References
1. https://psychsafety.com/googles-project-aristotle
2. https://eresearch.qmu.ac.uk/bitstream/handle/
20.500.12289/2013/communication_support_needs
_lit_review_2007.pdf?isAllowed=y&sequence=1
3. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly 199;44(2):350–83.
4. www.caa.co.uk/publication/download/12363
5. https://psychsafety.com/pace-graded-assertiveness
[All links last accessed January 2025]
Declaration of competing interests: None declared.
This article originally appeared in wellbeing II, published by Eye News. Bayer PLC provided hands-off commercial funding for the creation of this content but has not been involved in its development, review or finalisation.
