In order for teams to work effectively and to have a culture of learning, there are specific skills that need to be employed—and leaders play a significant role in making it possible for these skills to be implemented. At the core is the ability to create the conditions of psychological safety so team members feel free and safe to speak up.
Creating these conditions is dependent on practicing certain skills such as balancing advocacy with inquiry to emphasize curiosity and listening and not just advocating for one’s own point of view. It also entails practicing empathy so that others’ needs are fully understood and appreciated, which aids in more rapid resolution of conflict when it arises.
Significant emphasis is currently being placed on this concept of psychological safety (or making it safe to speak up) in health care, and there is ample evidence of the consequences when we fail to speak up. In 2005, Vital Smarts published Silence Kills in which it documented the results of a study it conducted aimed at discovering how often clinicians (nurses, physicians, and technicians) actually spoke up when faced with situations of incompetence, poor teamwork, lack of support, work-arounds (i.e., not following policy or process), and disrespectful or abusive behavior (Maxfield 2005). Its findings were shocking: only 1 in 10 health care practitioners actually spoke up in these situations; the rest remained silent. How could this be? Of course we knew from previous studies that communication breakdowns are very common in health care, but to suggest that 90 percent of clinicians remain silent is attention-grabbing, and extremely concerning.
A nursing director relayed the following story that she witnessed in an operating room environment:
One of the attending surgeons had a habit of talking to some of the nurses in a belittling tone (or at least that’s how he was perceived). He would throw out an insult or make a derogatory comment about their work, and seemingly think nothing of it. One nurse in particular was deeply troubled (and offended) by this behavior, as she felt she was frequently on the receiving end of these comments. Yet she never took the step to say something to the surgeon—she always just took it, and silently suffered. She was fairly introverted and quiet, so to confront the surgeon must have felt incredibly uncomfortable. She spoke with me a few times about her concerns and I always encouraged her to confront him, but she just didn’t feel comfortable—and perhaps was worried about retribution. One day the surgeon made a comment to this nurse, which she interpreted as being unfairly critical of her competence as a nurse. She looked at the surgeon and said, “Ouch.” He was startled, looked at her, and said, “What did you say?” She repeated herself: “Ouch. When you say those words to me, it hurts.” This story has a good ending. The surgeon was genuinely surprised that his comments had had that effect on her; he had meant the comments to be humorous jabs and not to be taken personally. He apologized profusely and promised to watch himself in the future. And the nurse gained confidence that she could in fact speak up without facing harsh consequences. It was a good lesson for all of us.
We recognize that there is a bit of a risk in sharing this story in that it further perpetuates the stereotype of inappropriate surgeon behavior in the operating room (OR). Certainly there are examples of all of the professions speaking inappropriately, but we felt this was a particularly poignant story with a strong lesson. We frequently choose not to speak up because of fear. Fear that the relationship will be damaged, or fear that the other person will become defensive and retaliate against us, fear that in the long run nothing will change, so why invest all of the emotional energy? The list goes on. And yet, as this story illustrates, if we are mindful of how we surface our concern, it is entirely likely that the other person will respond positively. Or at least the behavior will stop. A favorite quote of ours is: “When you name the game, the game ceases to exist.”
Additional cases have been made for the importance of creating psychological safety. Building on the recent research conducted by Google on its internal teams (Duhigg 2016), where psychological safety was determined to be the key contributor to team performance, Drs. Jessica Wisdom and Henry Wie contend that the health care community can also apply these same lessons (Wisdom and Wei 2017). Many health care leaders are also familiar with resources such as Crucial Conversations, Difficult Conversations, and Getting to Yes, which provide specific skills for creating the conditions of psychological safety. Likewise, many also have experience with team training programs such as TeamSTEPPS, which focuses on building specific skills and knowledge in the areas of leadership, situation monitoring, communication, and mutual support. What all of these resources have in common is advocacy for creating a climate where team members feel safe to speak up and offer their perspective.
While all of these resources make strong cases as to the benefits of psychological safety, it is a lot to take in and it can be difficult for leaders to know where to begin. Therefore, based on our own experiences working with health care leaders and teams, as well as our familiarity with the previously mentioned resources, we would like to focus on the following core skills to create psychological safety:
• Suspend assumptions
• Establish a mutual goal
• Practice inquiry
• Empathy
Suspend Assumptions
To fully understand what it means to suspend our assumptions, we first need to understand the concept of attribution error (sometimes referred to as fundamental attribution error or attribution of intent). The human brain does not like gaps. When we perceive gaps in a situation or an event, we rush to fill those gaps with our own speculations or assumptions about what must have actually happened.
Likewise, when we experience behavior from another person that does not match our expectations, or that disappoints us, we frequently (very frequently, in fact) make assumptions about the other person’s true intentions. Consider driving on the freeway and someone in another car suddenly cuts in front of you, causing you to have to hit your brakes to stop from rear-ending them. Think about your first reaction (well, your first reaction after you have slowed your car down and avoided an accident!). Commonly we vent our frustration or anger at the other driver—“What were you thinking!” we yell. “You’re crazy, insane, don’t you realize you almost killed us all? You’re an idiot!” And maybe we would throw in a few more choice words for good measure. And in one sense, aren’t we justified in our outburst? After all, this other person almost caused a serious accident that could have resulted in injuries.
But something else is also going on here: we begin to make fundamental assumptions about the other driver’s intentions. This person places no value on their own life or that of others, we may tell ourselves. Or perhaps we believe that they are irresponsible and reckless human beings and must behave this way all the time. Or maybe we believe this other driver singled us out from dozens of other cars on the freeway and, at that precise moment, chose to cut us off, intentionally freaking us out and ruining our morning (especially if it caused our coffee to spill).
Here’s another example: a physician and a patient care coordinator (PCC) on a diabetes unit were paired together and had been working together for several months. At some point a misunderstanding occurred that resulted in the two of them avoiding each other entirely, not speaking at all, for several months. The impact of this was felt by their patients and by their team members. When each of them was interviewed by an organization development consulting team called in to assist with the problem, the comments were fascinating. The PCC was confused by the physician’s behavior and was also convinced the doc didn’t like her, thought she was incompetent and was out to ruin her career. The physician also felt confused, and interestingly believed that the PCC was trying to get him fired by going to management with false stories about his behavior.
Of course neither assumption was correct, but in the heat of the battle, none of that mattered. Each was entirely convinced of their interpretation and also believed there was no way out of the predicament. In other words, they treated their assumptions as complete truth. And when we believe something that staunchly, it can be very difficult to move us off of our position, even when presented with alternative or contradictory data or facts.
So what is the fix for this, especially if it is so ingrained in us? A good place to start is to first recognize our reaction for what it is—an interpretation of events that is incomplete. Suspending our assumptions can help us to reengage the cognitive part of our brain, making it easier to consider alternative interpretations.
We all have our biases, opinions, and beliefs about how the world really works, and these have been shaped over the course of our lives by our upbringing, cultural background, education, religious beliefs, personality traits, and so on. The practice of suspension does not ask us to give up any of these beliefs (although it may be necessary for us to sometimes question and explore more deeply why we do in fact hold these beliefs), but rather allows us to set these beliefs, values, and perspectives off to the side, literally suspending them. And it is during that moment of suspension that we are able to be more fully present in the moment and actually see things without bias (or at least limited bias) and to consider other possible perspectives and interpretations.
In his book, Man’s Search for Meaning, Viktor Frankl invites us to own our emotional responses and interpretations of events. He states, “You can take everything away from a human being except one thing: our ability to choose our response to any given situation or set of circumstance. That can never be taken away.” He called this our ultimate freedom (Frankl 1985).
Establish a Mutual Goal
Having a clear, common, articulate purpose can help unify people. In fact, when teams are asked to reflect on successful team experiences, having a common, mutual goal always makes the list—without exception. The question is what can leaders do to ensure this step is never missed, and that the goals are frequently revisited to ensure alignment?
An underlying concept of the team training program TeamSTEPPS (King et al. 2008)1 is that of having a “shared mental model.” When team members have this shared mental model, they are clear about their work, priorities, roles, and responsibilities. Teams that use the TeamSTEPPS methodology will frequently check each other by saying, “We don’t have a shared mental model right now. What do we need to do to get on the same page?” In this context, the language and terms are known, so team members do not act defensively to this statement. They do not take it personally, and instead treat it for what it is, a realization that they need to get clear about their purpose. The environment still feels safe, and the team members can simply have a conversation about the perspectives they have and how to align around a common purpose.
The field of dialogue also calls out the importance of creating mutual purpose. Once, when working with the leadership team of a medical simulation center to create a strategic plan, it was immediately recognized that they had never fully articulated their core purpose, their reason for existence. The operation was relatively young (10 to 12 years old) and had experienced fairly significant growth and change. Working with the team to first clarify and articulate their purpose became the first order of business. The conversations they had were enlightening and helped them coalesce their multiple frames and perspectives, into a single, agreed upon purpose statement. This served to make the rest of the strategic planning process move more smoothly, because the purpose statement served as their touchstone.
Some important steps leaders can take to ensure mutual purpose exists are:
• Ask questions of team members to test for goal alignment—do they have a shared mental model?
• Ask, “What is it that binds us together in this effort? What do we have in common?” In health care, it will almost always center around the patient.
• When it is evident that team members are working at
cross-purposes, call it out explicitly; then engage the members in a conversation about the goal they are trying to accomplish.
Practice Inquiry
A key practice of exceptional leaders is to ask really good questions. This does not come naturally to us in health care; we are trained to diagnose, make decisions quickly, and solve problems. In fact it is this “problem solving nature” of ours, along with working in an environment that is very fast-paced, that prevents us from taking the time to explore how others are seeing an issue or a situation. Therefore, a simple practice that health care leaders can adopt is to start asking others questions—inquire into how they are seeing things, what their experiences have been, and what ideas they might have about a challenge or problem.
This is not to say that leaders (or anyone else for that matter) should not share their views, opinions, and perspectives. The problem is we unconsciously practice this advocacy of our own ideas and opinions routinely, and usually forget to ask others what they are thinking. The authors of Crucial Conversations refer to this as balancing advocacy with inquiry (Patterson 2002).
Kurt shares: Frequently, when I am conducting workshops on improving dialogue skills I will hold my arms out to either side, like a scale. I will ask the participants, “Think of our western society for a moment. If my right hand represents advocacy of my own ideas, and my left hand represents inquiry, asking others what they think, which way would you tilt me?” Without fail, they tell me to tilt to the right, toward advocacy. This simple activity reinforces the point that we are generally predisposed to offer our own opinions, and rarely do we explore others’ perspectives.
Steven Covey popularized the notion of “seek first to understand,” and that if we genuinely make an effort to learn how another is seeing the situation, it will strengthen relationships and result in better outcomes (Covey 2014). More recently, renowned MIT professor Edgar Schein published Humble Inquiry, in which he explores in-depth the practice of inquiry (Schein 2013).
Key elements to highlight:
• Make inquiry a habit—notice your own tendencies and create action triggers to help you ask questions first.
• Ask open-ended questions so you can learn what people are really thinking.
• Pay attention to your body language, your nonverbal cues—lean forward, nod, demonstrate your interest, take notes, repeat back what you hear, and summarize.
None of this is rocket science and most of us have heard this before. But it does require discipline—serious discipline. And leaders need to create and hold a container in which this type of communication can occur and thrive.
Empathy (Your Ace in the Hole)
Empathy is emptying our mind and listening with our whole being.
—Marshall Rosenberg
A physician acquaintance of ours had volunteered to organize a bike ride in Oregon that required, among other things, coordinating parking at the start of the ride for the participants. The ride started in a small town and parking options were limited. As it turned out, many of the participants parked along a street that also housed several small businesses, including a restaurant. The physician happened to walk by the restaurant and the owner was out front and visibly upset. He was complaining that the cars belonging to the bicycle riders had taken all of the parking spaces and that his regular customers would have no place to park. Our colleague apologized to the owner and asked what he could do to make it right, perhaps offer him some money for the inconvenience. At that point the owner became irate: “I don’t want your money! You think I want your money? You think you can just give me some cash and it makes everything all right?” Our colleague immediately sensed the shift, as well as his mistake. At this point he changed his approach and said to the owner, “You’re absolutely right. I should not have made this presumption. It must be incredibly frustrating for you to arrive here and see that all of the parking spots in front of your store are taken.” The owner calmed a little and said, “This is a small town, and we don’t get a lot of customers. When you come in here and take up our spaces, it has an impact.”
Our colleague told the owner he was sorry about this significant inconvenience and asked if he could at least buy him a cup of coffee. They went inside and sat down at a table and continued to talk, our colleague learning more about the owner and how he had started his business, and how proud he was of his work. A little later our colleague asked the owner if he would be willing to join their volunteer board. They didn’t have any community members and it would be incredibly helpful if they had a local voice involved in their planning. The event had grown significantly over the years, and they simply had failed to consider the impact on the community as a whole. The owner enthusiastically agreed and a partnership was formed.
Empathy is truly an underutilized skill, and a real difference maker in creating a safe environment. We often refer to empathy as “our ace in the hole” when conversations or interactions start to go south (or sideways, as a good colleague, Michele Hamilton-Lane likes to say). Empathy is a concept we are all familiar with, but unfortunately not very good at practicing—or at least not as good as we think. Daniel Goleman believes empathy may be the most important skill for enhancing our emotional intelligence and making social connections with others (Goleman 1995). He also believes we are inherently poor at practicing empathy; the paradox is that most of us believe we are quite good at empathy. We would like to challenge that mindset.
The late Marshall Rosenberg devoted much of his adult life to practicing and teaching others the skill of empathy. His book Nonviolent Communication: A Language of Life devotes two chapters to the practice of empathy, but it appears consistently throughout the entire body of work, speaking to the importance he placed on it (Rosenberg and Chopra 2015).
When I ask participants in my leadership workshops to describe or define empathy, what I generally hear are statements such as putting yourself in someone else’s shoes, seeing the situation from another’s perspective, and there is quite often confusion between sympathy and empathy. When the participants are then presented with scenarios and asked to write out an empathic response, 95 percent of the responses are not empathic (at least not as defined by Rosenberg). So what then is this so-called ace in the hole that can rescue us from getting sucked into a downward spiral of conflict?
In its simplest form, empathy (as described by Rosenberg) invites us to acknowledge the emotion another person is experiencing and to seek to understand the unmet need that lies behind that emotion. We offer the following practices (along with the strong encouragement to read the resources listed at the end of the chapter).
Go to the balcony—imagine you are in a room full of people engaged in very lively conversation, perhaps even heated conversation. How do you react? Generally our tendency is to get completely absorbed in the conversation, and can even become emotionally attached to the content. Now imagine you remove yourself to a balcony that looks down upon the floor where all the people are gathered. How does the scene change? What are you more apt to notice now? Bill Ury is the first we are aware of to use this metaphor (Ury 1991), and we find it to be incredibly useful. This act is about changing our perspective, and the image of going to a balcony that both removes us from the immediate situation and also results in new observations can be powerful. Empathy is about getting out of ourselves so that we can better understand what is going on for the other person.
• Identify and acknowledge the emotion—we, as humans, actually have a very limited vocabulary to describe the emotions we experience. This is unfortunate.
• Understand the unmet needs of others—as discussed earlier, we experience strong emotions when we have needs that aren’t being met. According to Rosenberg, we are often unaware of these needs because they are deep-seated.
One would think that those who have committed their working lives to the health care profession would all have a natural inclination toward empathy. Of course our own personal experiences, whether as patients in our health care systems, or working with others within the profession, do not necessarily support this. Or perhaps we encounter a health care provider who demonstrates empathy with her patients, but not with her coworkers. In fact, it may actually be possible that we all believe we are better at empathy than we really are.
For our purposes, we wish to highlight the importance of leaders practicing empathy because of the significant positive impact it can have on the team. Rosenberg describes empathy as the ability to acknowledge the emotion of another person, and to then understand the unmet need that lies behind that expression of emotion (Rosenberg and Chopra 2015). For example, if a team member makes a mistake that impacts others on the team, emotions they express could include distress, anxiety, worry, fear, and sadness. Being able to observe and sense these emotions in the team member is the first step. Next, we need to try to understand what unmet need lies behind the expressed emotion. At this point we also need to realize that we are, in effect, making an educated guess. What needs might this team member have based on the expressed emotions? A sample of possible needs include: being seen as competent in their job, to make a valuable contribution to the team and its work, and to feel supported by the other team members.
If the leader, or any other member of the team, is able to make an expression of empathy (“You seem upset and worried. Are you concerned the team is questioning your capabilities, and you want to know that we still support you?”) it is highly likely that the team member will feel heard and understood, and will then be more likely to speak up and talk more about the event.
The “equation” we suggest for leaders, both to use themselves and also when coaching others, is:
Strong emotions = unmet needs
Here are a few barriers that can impede empathy, followed by some tips for practicing more empathy:
Barriers to Empathy:
• Problem solving—we get focused on offering solutions, when what the other person is really needing is to be heard.
• Empathy = agreement—we worry that if we show empathy toward someone, that equates to agreement.
• Our judgmental nature—we are hardwired to make judgments about others; often these initial judgments are wrong (refer back to the fundamental attribution error in Chapter 3).
• Confusing sympathy with empathy—empathy statements begin with word “you,” as in “You must be feeling _____.” Empathy attempts to reflect back to the person what is going on for them. Sympathetic statements begin with word “I,” as in “I am saddened by your loss.” The speaker is attempting to state their reactions, thoughts, or emotions.
• Humanize the other person; ask yourself: “Am I seeing this person as another human being, who has wants, needs, hopes, fears, and dreams, just like me? Or am I seeing this person as merely an object or an obstacle that is standing in my way?”
• Be fully present. This requires that we not bring anything from the past into the conversation. Martin Buber says, “This is the most powerful gift one person can give to another.”
• Connect to what’s alive in the other person; get in touch with their “life energy” by connecting to their feelings and needs. This means we have to totally “tune in” to the other person and move away from problem solving and engaging in “intellectual understanding.” Marshall Rosenberg refers to it as, “emptying the mind and listening with our whole being.”
• Try using the phrase, “Are you feeling (x) because you’re needing (y)?”
• One way to make sure the person has said all they want to say is to use the phrase, “Is there more you’d like me to hear before I respond to what you’re saying?” This lets the other party know we are engaged and interested in what they have to say, and it demonstrates respect by offering to take more time to listen.
• Work to understand what the other person is feeling and needing before offering correction. This empathic connection often makes the task of offering the correction much easier, both for you and for the receiver.
Source: Handout from Empathy Workshop: Chuck Pratt and Kurt O’Brien
In Summary
Clearly, health care leaders need to be tuned into how psychologically safe their team members feel to speak up and offer different perspectives or concerns. Of course the challenge lies in how to do this effectively. It is our hope that the strategies outlined here (suspending assumptions, establishing a mutual goal, practicing inquiry, and using empathy) will help leaders take definitive steps to improving the culture of psychological safety within their own teams, and thus positively impact the experiences of the patients and families they serve. The ability to foster an environment of psychological safety will also allow teams to be more flexible and adaptive as they respond to a constantly changing environment; we will examine this idea of adaptability more closely in the next chapter.
End of Chapter Reflective Questions
• How do you, as a leader, determine whether or not your team members feel safe to speak up? What methods do you employ?
• What steps have you taken to increase psychological safety among your team? How do you know whether these steps are effective?
• How could you implement the ideas presented in this chapter with your team? Create an action plan for you to follow.
References
Covey, S.R. 2014. The 7 Habits of Highly Effective Families. St. Martin’s Press.
Duhigg, C. 2016. “What Google Learned from its Quest to Build the Perfect Team.” The New York Times Magazine, 26.
Frankl, V.E. 1985. Man’s Search for Meaning. Simon and Schuster.
Goleman, D.P. 1995. Emotional Intelligence: Why It Can Matter More than IQ for Character, Health and Lifelong Achievement. New York: Bantam Books.
King, H.B., J. Battles, D.P. Baker, A. Alonso, E. Salas, J. Webster, L. Toomey, and M. Salisbury. 2008. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety.
Maxfield, D. 2005. Silence Kills: The Seven Crucial Conversations for Healthcare. VitalSmarts.
Patterson, K. 2002. Crucial Conversations: Tools for Talking When Stakes are High. Tata McGraw-Hill Education.
Rosenberg, M., and D. Chopra. 2015. Nonviolent Communication: A Language of Life: Life-Changing Tools for Healthy Relationships. PuddleDancer Press.
Schein, E.H. 2013. Humble Inquiry: The Gentle Art of Asking Instead of Telling. Berrett-Koehler Publishers.
Ury, W. 1991. Getting Past No: Negotiating in Difficult Situations. Bantam.
Wisdom, J., and H. Wei. 2017. “Cultivating Great Teams: What Health Care Can Learn from Google.” Retrieved from http://catalyst.nejm.org/psychological-safety-great-teams
1 The TeamSTEPPS curriculum is available through Agency for Healthcare Research and Quality (AHRQ); the link to its website is: https://ahrq.gov/teamstepps/about-teamstepps/index.html