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Why We All Need Psychological Safety

Op-Med is a collection of original articles contributed by Doximity members.

You are standing outside the door to your boss’s office with your hand outstretched toward the doorknob. Your throat tightens and your mind goes blank as you give a futile attempt to rehearse your talking points. Your team deserves much more support from leadership than what they have been getting, and you know this. Although this conversation is crucial, you fear the defensiveness, plausible deniability, and outright disregard that is likely to occur once you open your mouth. 

This experience is so universally understood that it might as well be part of the human condition. Whether it is with your boss, spouse, or friend, there are times when you might feel that approaching certain people about specific topics will almost certainly result in negative consequences. In 1943, Abraham Maslow described what humans need to thrive, going from the most basic needs like food and water to more complex needs like doing meaningful work for others. He described this sequence as the “hierarchy of human needs,” and this hierarchy is often conceptualized as a pyramid.

Toward the bottom of the pyramid, and just above the most essential needs, we find safety. Feeling safe requires more than just being free of physical harm; it also requires people being able to take risks without ineluctable reprisal or reproach. Modern social psychologists have defined a phenomenon called “psychological safety,” which means having the security to broach difficult topics with confidence that it will lead to productive changes.

Consider what it feels like to lack psychological safety: You may fall silent in defeat and retreat from those crucial moments or may have a swell of indignation cloud your mind, leading to combativeness. In either case, you become incapable of thinking carefully about the situation and responding to feedback constructively. Further, our shared meaning and common ground are lost, sometimes irrevocably.

We see this happen all the time in politics: We are often so polarized as a country on issues that affect thousands — if not millions — that we are incapable of seeking win-win scenarios. In the field of health care, we experience this every day, whether it is between patient and clinician or between health care professionals. In fact, psychological safety is arguably one of the most important but often overlooked elements of health care work environments, despite its increasing prevalence in academic and professional discourse.

Patients may feel like they are reaching for the metaphorical doorknob of their boss’s office when they see their physician: They may avoid discussing parts of their health that could garner unwanted critical attention. In response to this, we as health care professionals should leverage psychological safety and empower our patients to share any and all details of their health without fear of chastisement. To normalize this process for our patients, we must extend this practice to our professional interactions.

It is common for health care professionals to put up psychological walls around one another to avoid conflict and establish authority. Unfortunately, it often leads to all parties involved feeling psychologically unsafe. As a result, we may not ask clarifying questions or conscientiously disagree with inaccurate assessments. This leads to the breakdown of multidisciplinary team discussions and failure to question protocols when they are no longer relevant or productive. Perhaps unsurprisingly, this is a direct and preventable threat to patient safety and the quality of care provided.

So, what steps can we take to leverage psychological safety? First, we must recognize that psychological safety — similar to burnout — is not an individual’s sole responsibility; it is inextricably linked to shared culture and organizational dynamics. Therefore, individual professionals and patients do not achieve psychological safety by “fixing” their perceptions. In fact, the strongest and most explicit evidence of this is that people can feel psychologically safe in certain situations but not others, which implies that this phenomenon is highly contextual.

Next, professionals must know the signs of psychological safety: expressions of curiosity, healthy debate, bidirectional feedback, admission of errors, difficult questions, and comfort with asking for help. If these are absent, it is likely that people feel psychologically unsafe. Another vital component to a psychologically safe environment is emotional intelligence, which is one’s capacity to be aware of and manage one’s own emotions and those of others. If emotional intelligence is lacking, there is a high chance that psychological safety may also be lacking.

Imagine this situation: You enter an exam room to find a new patient waiting for you to discuss management of her chronic lower back pain. After going through her history and a targeted physical exam, you conclude that she has non-radiculopathic paraspinal muscle pain and recommend physical therapy. The edges of her lips draw back, and her eyes narrow slightly. You take note of this and intuit that she has heard this before. When you ask if she has questions, her eyes dart toward the wall as she shakes her head.

In response to a lack of psychological safety, health care professionals can utilize evidence-based strategies to make the environment safer: owning up to mistakes, showing concern for others, actively soliciting questions, offering multiple ways for people to share their thoughts, outwardly appreciating ideas, discussing topics nonconfrontationally, providing information clearly, and explaining the reasons for change. Health care professionals are the leaders of their care environments and must set this tone for their patients and recognize that building a psychologically safe culture often takes time.

Let’s return to the previous scenario: After reading the room, you assess that this plan — while demonstrated in the scientific literature to be effective — will not work for this particular patient. You call out what you are seeing, articulate that you want to help her in a way that works for her, and invite other ideas. She looks at you, and you see the muscles of her face relax. She explains that physical therapy has been recommended before and has failed to improve her pain. After a more fluid discussion, she then leads you to a key insight: Anxiety worsens this pain, not activity per se. You know that you now have psychological safety in this encounter.

As a health care community, we need to nurture psychological safety and understand that it is the foundation to flourishing and overcoming the adversity of disease and disability. Whether we are young or old, we cannot learn, innovate, or grow if we do not feel safe, and a large amount of scientific evidence supports this claim. Thankfully, promoting psychological safety is not complicated. It fundamentally involves allowing differing viewpoints to exist in our interactions and exploring what people have to say without preconception. 

We need to listen to understand, instead of listening to form a response. Stephen Covey once said, “When you listen to another person, you give that person psychological air.” Empathetic listening, avoiding conflict when disagreements arise, encouraging inquiry at all levels, and showing that mistakes do not define our worth all leverage psychological safety and allow for fluid bidirectional communication in teams. Psychological safety is not just ideal but also crucial because natural and easy communication of ideas is what makes us unique as humans. Without it, outcomes can never be optimal.

How do you make your patients feel safe? Share in the comments.

Dr. Duncan is a family medicine resident physician and positive psychology researcher.

Dr. Nora Lamartine is a board-certified family physician.

Ms. Esther Tipton, program manager of a family medicine residency program, also contributed substantively and co-authored this piece.

Image by Alphavector / Shutterstock

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