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17.09.20

Psychological safety in a world of Covid-19

Catherine Harrison, Policy Advisor, NHS Providers

As we move into winter amid the prospect of a second wave of Covid-19, the focus on health and care workers’ wellbeing and safety in the run up to this year’s World Patient Safety Day could not be more pertinent. The increased impact of the pandemic on those from Black, Asian and Minority ethnicity groups and female workers, along with the extra strain, stress and threat of burnout for everyone who has, for months, been working flat out in response to the crisis, means that the needs of staff, as well as patients, are at the forefront of everyone’s minds.  

Our own recent survey showed that 93% of NHS trust leaders are concerned about staff wellbeing, stress and burnout following the pandemic. Trusts are doing all they can to support staff, including setting up a range of services such as relaxation and wellbeing hubs, and safe spaces.

Looking after staff safety means paying attention to the physical, emotional and psychological wellbeing of the health workforce, from frontline to board. Given that the term ‘wellbeing’ means different things to different people, in this blog we explore the importance of psychological safety, its role as a foundation for wellbeing and patient safety, and why it matters now and into the future.

A moral and practical imperative

The people who work for the NHS are its greatest asset – as We are the NHS notes: “If we don’t look after ourselves, and each other, we cannot deliver safe, high quality care.” Helping colleagues deal with the daily stresses within a system under pressure is the right thing to do. There is also a direct correlation between patients’ wellbeing and the wellbeing of those who care for them so the case for investing in staff wellbeing is multi-faceted, and clear.

The idea of psychological safety was first introduced by organisational behavioural scientist Amy Edmondson, who defined it as “a shared belief held by members of a team that the team is safe for interpersonal risk-taking.” It is about candour, and whether we feel able and supported to be direct, take risks, and be willing to admit mistakes. Teams need psychological safety to be effective.

Psychological safety plays a role in wellbeing by creating an environment in which change can be embraced, with confidence that there is a mechanism in which to resolve conflict. This supports new approaches being tested and reflected on without threat to the unity of the team as a whole. It also supports learning from those times care doesn’t turn out as expected, allowing space for reflection without the fear of unjust blame.

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Inclusivity, trust and respect are central, and valuing diversity, critical. Appreciating what can be gained from diversity of thought and in gender, age, ethnicity and power can give everyone a voice, increasing learning and creativity.

The NHS Patient Safety Strategy 2019, importantly, recognises the significance of psychological safety and articulates the journey being taken by the NHS as a whole in terms of its overall approach to safety; from talking about harm to talking about safer systems that provide the right care as intended, and moving on from a preoccupation with failure to also learning from work that goes well. The strategy outlines how important it is that this work happens “in a just culture where psychological safety means we can all hear more, learn more and can act more to improve care”.

In the context of Covid-19, with whole organisations re-orientated to meet new challenges, new approaches to workforce flexibility and a need to continue to react to necessary changes, psychological safety must play a key role in helping teams succeed.

An early warning system for boards

Working in healthcare rarely creates an environment of certainty and predictability. There are a huge number of stakeholders with sometimes conflicting goals, multifaceted interactions, and constraints, and multiple perspectives that change daily.  In this changing environment, safety is constantly being managed through the interaction of numerous relationships, processes and events day to day.

Amidst this complexity, any provider board needs to have a full and frank understanding of exactly how robust safety and governance processes actually are, rather than how they may be thought or imagined to be.

People’s voices can be viewed as an early warning system; boards need to trust they’re getting the information they need to know. Enabling each individual to feel able to speak up about anything they feel or know isn’t working as it should be, is an essential part of being assured that safety is being proactively and effectively managed. Psychological safety therefore plays a critical role in helping boards govern effectively, as well as laying the groundwork in caring for and supporting staff.

Psychological safety in action

So, what are the tangible steps a board can take? Talking to one of our members recently, it was clear that supporting the right cultures and enabling the right behaviours to support safety is one of their biggest and most important challenges. It is complex work, but one simple step in the right direction is to reach out, and keep asking, and encouraging others to ask, ‘what do you need?’, and ensure there are people to meet that need.

As West et al said in 2014 “Every interaction by every leader at every level shapes the emerging culture of an organisation”. This speaks to the central role of behaviour, along with the importance of a collective mindset. The leadership behaviours that make a difference to psychological safety include being accessible, inviting and thanking others for input, acknowledging and modelling fallibility, and providing fair accountability.

There are a number of steps underway from NHS England and NHS Improvement to help achieve a balance of fairness with accountability; with Just and Learning Culture Training now available free for all staff – which highlights the importance of full commitment from the board, the new role of Patient Safety Specialists expected next year, plus a framework for responding to patient safety incidents being piloted that will support organisations to take a more systems-focused approach, underpinned by behaviours, decisions and actions that assist learning and improvement in a fair way. There is also much to be gained from hearing the experiences and ideas of those who are fostering a speaking up culture well, with an opportunity coming in October’s Speak Up Month.

Embedding psychological safety across the NHS remains a work in progress.  But the experiences of recent months, and the priority to protect the wellbeing of staff and patients alike, means we should all seek to learn more about it as we work to improve safety in the NHS.

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