By Marsha Hughes-Rease, MSOD, MSN, RN
NKC Consultant and Educator
One of my favorite questions to ask when interviewing clinical nurses during a gap analysis for ANCC Magnet Recognition® is, “What keeps you here?” The most recurring response is, “The people I work with!” This is especially true when talking to clinical nurses working on units with high retention and low turnover. Further inquiry suggests that the clinical nurses who have a strong loyalty to their unit team feel a sense of psychological safety. A key element of a professional practice work environment is effective teamwork and collaboration. However, psychological safety is an essential antecedent for authentic teamwork and collaboration. Creating a psychologically safe environment at the unit level should be a high priority intervention for organizations on the Magnet journey.
What is Psychological Safety?
According to Amy Edmonson, author of the book Teaming, organizational research has identified psychological safety as a critical factor in understanding organizational behaviors such as teamwork, team learning, comfort level with seeking help, and speaking up or voice. Edmonson describes psychological safety as a climate in which individuals feel free to express relevant thoughts and feelings without excessive self-censorship.
However, interpersonal fear can greatly diminish the psychological safety on a unit. Interpersonal fear is the fear of being perceived by others as ignorant, incompetent, negative, or disruptive. This perception is usually the consequence of a workplace culture that punishes individuals for expressing their work-relevant thoughts and feelings. The “punishment” may be subtle and show up in the form of micro behaviors, but the individuals on a unit recognize it. Rather than take interpersonal risks, individuals will often self-censor especially in the presence of others with formal or informal power or status. This silence or “lack of voice” can negatively impact RN satisfaction and patient safety. In Magnet-designated organizations, both of these indicators are expected to outperform the benchmark at the unit level.
Why is Psychological Safety Important?
Although it does not reflect the absence of problems, the presence of psychological safety on a unit can actually contribute to more creativity and innovating thinking in problem solving and solution finding. Other benefits of a psychologically safe environment include increased risk taking to pursue high standards and challenging goals, increased willingness to report and discuss errors, more thoughtful handling of conflict, and increased willingness to address incivility or behaviors that contribute to anxiety, fear, and stress.
Designing an Intervention to Cultivate Psychological Safety
An intervention is a sequence of planned and deliberate activities and actions intended to help an organization or group improve its performance and effectiveness. There are many different types of interventions, but the high-leverage interventions that impact behavior are interventions that create a change in our mental models or how we view the world. Creating a psychologically safe environment requires an intervention that will shift both mindset and behaviors.
Robust interventions are always preceded by data gathering. Subsequently, the first step in creating a psychologically safe environment is to assess the unit environment. The short questionnaire below is adapted from one dimension of Edmonson’s Is Yours a Learning Organization Inventory? to measure psychological safety. It can be administered using any type of software that your hospital already uses for administering questionnaires anonymously.
The second step is to gather the questionnaire data and create an opportunity for the clinical nurses to discuss the findings. These conversations should be facilitated by someone who can quickly gain the trust of participants and facilitate an open and honest discussion to extract themes. This may be an excellent time to partner with an HR or development specialist in your organization since they often have this skill set and can serve as a neutral party.
The third and critical step of this intervention is to design actions to address how to make changes based on the questionnaire findings. Again, the clinical nurses are invited to create a shared and compelling vision, as well as identify actions needed to achieve this vision. Although this should be a nurse manager-driven initiative, clinical nurses are the key stakeholders and their input is critical to the success of this change. The visioning process can actually serve as the “rallying cry for change,” creating momentum and excitement at the unit level.
The fourth step is to re-administer the questionnaire at different time intervals to determine if perceptions and behaviors have changed. After each “pulse check,” the questionnaire findings are shared with the staff for reflection and learning, as well as identification of next steps. Since this is an intervention aimed at changing the culture of a unit, leaders need to continually focus on achieving the shared vision. They must assume accountability for results and provide support. Ultimately, ensuring psychological safety at the unit level throughout the organization will be pivotal in achieving Magnet success!
This article was originally published in April 2017.