Psychological Safety in the OR Improves Outcomes and Performance

Although it may once have been common for a surgeon to discourage other surgical team members from asking questions, reporting errors, and speaking up, there is growing evidence that this type of hierarchical behavior not only exacerbates an already high-stress environment, but also negatively impacts team function, morale, and patient outcomes.¹

Simply put, an environment in which team members hesitate to speak up or act because they fear criticism or other repercussions from team members higher up in the hierarchy is not conducive to practicing good medicine.

In contrast, a “psychologically safe” work environment is one in which employees share the belief that interpersonal risk-taking is safe.² In the OR, surgical team members feel empowered and enabled to admit errors, ask questions, voice concerns, be creative, and suggest new ideas or raise concerns without fear of humiliation, criticism, or retaliation.³

According to research, a psychologically safe workplace with a culture of trust and open communication among healthcare teams that are providing high-quality patient care is imperative for the high-stress and high-demand space of the OR.⁴

When surgical team members have “radical candor,” mistakes will be avoided, and team members will feel more engaged in and energized about their OR roles, said Amy C. Edmondson, PhD, professor of leadership and management at Harvard Business School in Cambridge, Massachusetts, who also is a psychological safety expert.

When psychological safety is combined with discipline, shared accountability, and high expectations, it can lead to better outcomes, better problem-solving, a better learning environment, increased adaptability, and better psychological health for all members of the surgical team.

In an environment of psychological safety, “it’s okay to take risks, express your ideas and/or concerns, ask questions, admit mistakes, all without fear of negative consequences,” said Harry T. Papaconstantinou, MD, FACS, a colorectal surgeon and the Glen E. and Rita K. Roney Professor and Chair of the Department of Surgery at Baylor Scott & White Healthcare in Dallas, Texas. “It’s the ability to speak up and not be judged.”

What Psychological Safety Is Not

Psychological safety does not describe a work environment that is comfortable, soft, or permissive. This concept isn’t about being nice, and it doesn’t mean an OR team should be led to believe their needs should be met at all times, or that they should be in charge, Dr. Edmondson said.

In a surgical context, psychological safety means absolutely no hesitation if a team member has even the remotest suspicion that the surgeon is about to do something wrong, she said, adding that a psychologically safe environment promotes candor, and candor requires strength, courage, and honesty.

Although such an environment may occasionally divert or distract the team from the task at hand, it is a risk worth taking, Dr. Edmondson said. “While it may be distracting to have someone say something irrelevant or not helpful at the moment, compare that to what might happen if the team member noted a significant error was about to be made but was afraid to speak up.”

In a psychologically safe OR, the surgeon is still in charge. Team members who constantly interrupt an operation with inaccurate, irrelevant, or unhelpful comments should later be taken aside and given feedback to help make them more effective—but in a way that does not discourage them from speaking up in the future, she explained.

How Psychological Safety Affects Surgical Settings

Psychological safety has been shown to improve performance in a variety of areas, including aviation and healthcare.

“Everybody’s prone to error, but better teams are better able to catch and correct each other’s errors,” Dr. Edmondson said.

Research supports that psychological safety benefits patient safety by improving the delivery of clinical care.⁵ For example, in intensive care units, psychological safety is associated with better health outcomes, lower morbidity, and lower mortality, according to Dr. Edmondson. That’s largely due to the fact that staff, such as respiratory therapists or nurses, feel able to speak up about what they see and what they know.

In a study of the impact of psychological safety in radiation oncology, researchers found that psychological safety was associated with more reported near misses because healthcare workers were more willing to point them out. Near-miss reporting is important to quality improvement efforts because it can uncover underlying causes of potential patient harm that could lead to adverse events.⁶

“We think big failures come out of the blue, but they’re actually on top of a pile of often underreported near misses,” Dr. Edmondson said. “The more we hear about what’s really going on, the higher the reliability of our processes and the better we are able to prevent the big, bad ones.”

At this point, however, data related to the influence of psychological safety on surgical outcomes are limited. That said, Dr. Papaconstantinou maintained that there is intuitive logic to the idea that if everyone in the OR feels empowered to point out a potential error, the result would be fewer errors because they would have been prevented or corrected. In addition, pointing out a potential error creates the opportunity for the surgical team to learn how to avoid that same error in the future.

Improved Team Performance

A psychologically safe OR is an environment safe for learning, with mutual professional respect, open communication, and suspended judgment.⁴ The result often is that clinicians are more engaged and better able to learn and creatively solve problems. OR teams demonstrating higher levels of psychological safety also are better able to successfully implement new technologies.⁷

“Work is more engaging and meaningful if you believe you matter and if you believe your voice is expected and welcome,” Dr. Edmondson said.

Psychological safety supports three other conditions that help make work significant and attractive:

• Purpose and meaning
• Culture and community
• Growth and development

Dr. Edmondson described how it’s difficult for people to feel purpose and find meaning in their jobs if their input is not welcome. Likewise, it’s tough to feel part of a community in which you are not encouraged to participate. Finally, opportunities to gain experience and develop new skills require an environment conducive to learning from and engaging with others in the OR.

“If you are in the OR and not in a state of learning, then you’re not doing your job as well as you should be,” Dr. Edmondson said.

Improved Mental Health

When a patient does poorly after an operation, especially due to a mistake, surgeons have a heightened sense of responsibility that can lead to emotional turmoil, anxiety, sadness, guilt, and shame. It may even lead to burnout.

By helping to create an environment of psychological safety in the OR, surgeons not only can help avoid errors, but they also share responsibility with others by allowing team members to have a more important role in the process.

“A psychologically safe environment takes some of the burden off of the surgeon’s shoulders,” Dr. Edmondson said.

Creating a Psychologically Safe OR

Because surgeons are considered captains of the OR, team members are highly attuned to their leader’s actions, which can shape their own perceptions of appropriate behavior.⁴

“Leaders always have an outsized impact on the culture,” Dr. Edmondson said. “Whether it’s a surgeon, team leader, or CEO, the proximal leader will always have a bigger effect on perceptions of what’s expected or appropriate than others.”

To help create a psychologically safe OR, surgeons can stress the uncertainty and interdependence of work, model fallibility, and solicit peers and subordinates for suggestions and feedback, and embrace those who do speak up.⁶

Self-awareness also is critical for surgeons. They need to know how they are perceived because they need to model the desired behavior.

“You have to tell them it is okay to raise questions, and then you have to respond in a way that encourages that,” Dr. Papaconstantinou said. “People listen to intent first, then content. Therefore, the way a surgeon responds to team members in the OR creates the work environment that determines if it is possible for team members to ask questions or raise issues.”

In addition, it is important for surgeons to realize that they cannot control others; they only can control themselves. When a member of the surgical team points out a potential error, patient concern, or observation, surgeons need to train themselves to respond in an emotionally intelligent way. “The second you show frustration, the second you show a negative emotion, that’s going to give the signal to the person that maybe they shouldn’t have asked the question or spoke up,” Dr. Papaconstantinou said.

One way surgeons can help adjust the way they respond is to remember that correcting an error means that the patient will receive better care, according to Dr. Edmondson. “Surgeons need to create a culture in which candor is expected. It’s what we do around here.”

What Surgeons Can Do to Create Psychological Safety

How do surgeons create an environment of psychological safety? Dr. Edmondson views it as a three-step process:

Set the stage.

Be inclusive. Tell the team that you want their candor. Explain to them that since no operation (and no surgeon) is flawless, they need to say something if a mistake is made or is about to be made. Come from a place of humility, not false modesty. Admit that you’re a fallible human being, and the last thing you want is for something to go wrong that could have been prevented.

Seek feedback. Be approachable.

Ask good questions during the procedure, such as: I’m about to close up, have we missed anything? Do you see anything? Is everything accounted for?

Respond appropriately.

When someone speaks up, monitor yourself. Whether the comment is right or wrong, helpful or unhelpful, don’t look annoyed or angry. Just thank them for their input in a positive manner.

In addition, surgeons need to learn to respect and trust their team members.

“Too many people think trust is something that must be earned, when in fact, trust means a willingness to act despite uncertainty,” said Dr. Edmondson.

To trust a team member is to believe they are willing and capable of doing the assigned task. To build trust, start by assigning small tasks and graduate to more important, high-stakes tasks.

Dr. Papaconstantinou agreed that trust helps create an environment of mutual professional respect that is essential to psychological safety. Trust makes it possible to manage conflict in a productive and healthy way, allowing questions to be raised about important issues such as patient safety or operational efficiency.⁸

“If you avoid conflict, then you have a lack of commitment and a lack of accountability because the team is not engaged in decision-making, and that negatively impacts results,” he said.

Consistent Teams Are More Likely to Be Psychologically Safe

Surgical teams that have worked together before are more conducive to psychological safety and higher performance than surgical teams that haven’t.⁴ In contrast, most team members who rotate on to ad hoc teams reported decreased psychological safety due to communication problems worsened by a lack of team identity, familiarity, and trust.

“We talk about how having a consistent team in the OR really improves patient safety,” Dr. Papaconstantinou said. “To me, the reason why is that they have already developed a relationship with each other.” In addition, consistent teams are more likely to have trust, commitment, and the ability to manage conflict—all factors essential for psychological safety.

Prioritizing Psychological Safety

Making ORs psychologically safe starts with surgeons and other OR leaders learning more about the concept through articles, podcasts, and research studies, Dr. Edmondson suggested. They should encourage and support education and training programs that teach the importance of psychological safety to future surgical team members.

“To change the culture requires a multipronged attack,” she said.

Creating an environment of psychological safety improves outcomes, problem-solving, learning, adaptability, and psychological health for surgical team members. But at the heart of psychological safety is patient safety. Anyone’s voice could make a difference at a crucial time, but without psychological safety, that voice may never be heard.

“You will probably not hear that voice without proactive leadership,” Dr. Edmondson said. “It may not matter for weeks, even years—until the day it does. That will be the day that breaks your heart.”

Jim McCartney is a freelance writer.

References

1. Adair White BA, Picchioni A, Gentry L, et al. Closing the educational gap in surgery: Teaching team communication and conflict management. Am J Surg. 2022;224(6):1488-1491.
2. Edmondson AC, Bransby DP. Psychological safety comes of age: Observed themes in an established literature. Annu Rev Psychol Org Beh. 2023;10:55-78.
3. Psychological Safety for Surgeons: Building Trust, Teamwork, and Well-Being. Oct. 2, 2023. American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). https://www.aaohnsfmeetingnewscentral.com/aao-hnsf-2023/article/22874900/psychological-safety-for-surgeons-building-trust-teamwork-and-wellbeing#:~:text=Oct%202nd%2C%202023-,Psychological%20Safety%20for%20Surgeons%3A%20Building%20Trust%2C%20Teamwork%2C%20and%20Well,of%20all%20healthcare%20team%20members.
4. Lin MW, Papaconstantinou HT, White BAA. Moving beyond teamwork in the OR to facilitating mutual professional respect. Proc (Bayl Univ Med Cent). 2022;36(1):45-53.
5. Grailey KE, Murray E, Reader T, et al. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773.
6. Jung OS, Kundu P, Edmondson AC, et al. Resilience vs. vulnerability: Psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. JT Comm J Qual Patient Saf. 2021;47:15-22.
7. Swendiman RA, Edmondson AC, Mahmoud NN. Burnout in surgery viewed through the lens of psychological safety. Ann Surg. 2019;269(2):234-235.
8. White BAA, Fleshman JW, Picchioni A, et al. Using an educational intervention to map our surgical teams’ function, emotional intelligence, communication and conflict styles. J Surg Educ. 2023;80(9):1277-1286.