October marked ‘National Speak up Month’, led by the National Guardian's Office, with the aim that speaking up becomes business as usual (https://tinyurl.com/ftvpnc9v). Every NHS trust in England (and any organisation providing services under the NHS Standard Contract) must have a Freedom to Speak Up (FTSU) guardian to give independent support and advice to staff who want to raise concerns (National Guardian's Office, 2021: 7). Guardians work with all staff to help NHS trusts become more open and transparent places. Employees are encouraged to ‘speak up’ without fearing the consequences. The key metric for organisations to assess their speaking up culture is the FTSU Index, which is published annually by the National Guardian's Office. The FTSU Index is based on the percentage of staff who ‘agree’ or ‘strongly agree’ with four of the questions in the annual NHS Staff Survey.
- If you were concerned about unsafe clinical practice, would you know how to report it? (Q17a)
- Does your organisation encourage you to report errors, near misses or incidents? (Q16b)
- Would you feel secure raising concerns about unsafe clinical practice? (Q17b)
- Does your organisation treat staff involved in an error, near miss or incident fairly? (Q16a)
I am hugely supportive of the role of the FTSU guardians, and the alignment of these questions to patient safety—however, I do feel that we must strive towards a consistent environment where colleagues are able to raise concerns with their direct line managers and feel listened to, respected and confident that they will be heard.
As a team we were discussing the concept of psychological safety and this has made me reflect on how best to create this environment.
Edmonson (1999) decribed psychological safety as: ‘
‘A shared belief amongst individuals as to whether it is safe to engage in interpersonal risk taking in the workplace.’
Delizonna (2017) shared research showing that the highest-performing teams have psychological safety in common. These teams share the belief that you will not be punished if you make a mistake. In fact, the studies have shown that psychological safety allows for moderate risk-taking, speaking your mind, and creativity.
Edmonson (2014) found psychological safety to be the single greatest predictor of team learning and performance, she reflects that complex, uncertain, and risky workplaces demand collaboration, which requires freedom to speak up without fear of rejection, ridicule, humiliation, or exclusion, which alleviates the effects of power differentials and hierarchies enabling creativity, learning from failure, employee engagement, and improvement. Edmondson argued that unsafe team climates enable poor outcomes, hidden error, defensive practice, learning paralysis, fear.
As leaders we often find ourselves with individuals or larger groups trying to ‘listen’ to their concerns. Edmondson's (1999) advice for leaders to build psychological safety is as follows:
- Approach conflict as a collaborator, not an adversary. We humans hate losing even more than we love winning. A perceived loss triggers attempts to re-establish fairness through competition, criticism, or disengagement, which is a form of workplace-learned helplessness.
- Speak human to human. Underlying every team who-did-what confrontation are universal needs such as respect, competence, social status, and autonomy. Recognizing these deeper needs naturally elicits trust and promotes positive language and behaviours.
- Anticipate reactions and plan countermoves. Thinking through in advance how your audience will react to your messaging helps ensure your content will be heard, versus your audience hearing an attack on their identity or ego.
- Replace blame with curiosity. If team members sense that you're trying to blame them for something, you become their sabre-toothed tiger.
- Ask for feedback on delivery. Asking for feedback on how you delivered your message disarms your opponent, illuminates blind spots in communication skills, and models fallibility, which increases trust in leaders.
- Measure psychological safety. By periodically asking the team how safe they feel and what could enhance their feeling of safety.
In summary, culture is complex and we will see variation dependent on the pressures on a team and the context in which they are functioning. It is critical as leaders that we take time to support and enable the creation of psychologically safe environments for our teams.