A healthy work environment (HWE) is required for high reliability. The 2004 IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, emphasized the dominant role of the work environment within health care organizations and the importance of the work environment in which nurses provide care to patients. A HWE is one that is safe, empowering, and satisfying. HWEs are settings with policies, procedures, and processes designed to empower nurses to meet the organizational objectives and achieve personal satisfaction (Huddleston & Gray, 2016a). It is not merely the absence of real and perceived threats to health, but a place of “physical, mental, and social well-being,” supporting optimal health and safety (ANA, 2016). A HWE includes appropriate staffing, authentic leadership, effective decision making, meaningful recognition, skilled communication and true collaboration (AACN, 2005). Huddleston and Gray (2016b) recommend the addition of two new characteristics: genuine teamwork and physical and psychological safety. Psychological safety means ensuring that no one is penalized if they ask for help or admit a mistake and they can openly disagree without fear of ridicule or punishment (Edmondson, 2008; Edmondson, 2016). Psychological safety is crucial in organizations where knowledge constantly changes, where workers need to collaborate, and where those workers must make decisions without management or leadership intervention (Edmondson & Lei, 2014).
A culture of safety and resilience is paramount in a HRO. All leaders, managers, health care workers, and ancillary staff have a responsibility as part of the patient centered team to perform with a sense of professionalism, accountability, transparency, involvement, efficiency, and effectiveness. All must be mindful of the health and safety for both the patient and the health care worker in any setting providing health care, providing a sense of physical and psychological safety, respect, and empowerment to and for all persons (ANA, 2016). HROs must adopt a fundamental HWE approach in how they communicate and how individuals interact. Organizational leaders must ensure there is a free flow of information; a safe environment in which to speak up and respectful interactions (Chassin, 2012; Chassin & Loeb, 2013; DuPree, 2013). Organizations require resiliency to achieve high reliability. A resilient organization maintains a high level of performance despite mounting pressures, threats and uncertainties, and is able to withstand disruption and recuperate while resuming operations (Boin & Van Eeten, 2013). When employees feel psychologically safe, meaning staff is empowered to have a voice without being retaliated against; they will be more likely to report concerns and near misses. Therefore, patient safety and quality outcomes improve in every day clinical practice.
Purpose: The purpose of this presentation is to describe how psychological safety in the work environment at two acute care facilities contributed to the facilitation and sustainment of a culture of safety and organizational resilience.
Scope: The scope of this project encompasses two acute care hospitals; a 50-bed community hospital and a 350-bed quaternary hospital with specialty service lines. It includes 650 clinical nurses, advanced practice nurses and nursing leadership across the spectrum of care including outpatient and ambulatory settings.
Methods: Leadership commitment to psychological safety serves as the paradigm for two organizations to be resilient, maintain gains and sustain the success of high reliability. In 2002 Dr. Amy Edmondson, a Harvard business professor expert on psychological safety in the workplace, published a seminal work describing psychological safety. Psychological safety describes individuals’ perceptions about the consequences of interpersonal risks in their work environment. It consists of taken-for-granted beliefs about how others will respond when one puts oneself on the line, such as by asking a question, seeking feedback, reporting a mistake, or proposing a new idea. Nurse leaders play an important role in creating cultures that are psychologically safe. The commitment of leaders to a transformational style of leadership in order to facilitate psychological safety is essential in a resilient, learning and highly reliable organization. Transformational leaders transform organizations by motivating followers to transcend their own self-interest to improve performance though organizational learning and innovation (Grant 2012; Garcia-Morales, Jimenez-Barrionuevo, and Gutierrez-Gutierrez, 2012). Leaders within the organizations facilitate psychological safety by developing and reinforcing civility, respect, support, professionalism and accountability. Leaders insist on civility for all interactions (Blouin, 2013). Respect is the cultural norm; thereby employees are more likely to communicate with the greater team (Sutcliffe, 2011). The use of supportive language towards others is an expectation as is professionalism with accountability. Alignment of senior leadership, managers and front-line nursing staff in a psychologically safe work environment is crucial for an organization to be resilient, maintain gains and sustain the success of high reliability
The five principles of HROs served as a guiding framework to embed safety practices into two organizations with a culture of psychological safety. HRO principles (Deference to expertise, Preoccupation with failure, Sensitivity to operations, Reluctance to simplify, and Commitment to resilience) are woven into the fabric of one small and one moderate-sized healthcare organization.
Outcomes: Perception of psychological safety improved from 66% to 74% of staff feeling free to speak up if they see something that may negatively affect patient care on the AHRQ Hospital Survey on Patient Safety Culture. Vigilance drove detection analysis and constant surveillance. Increased near miss and self-reporting demonstrate enhanced organizational transparency and professional accountability. Between 2013 and 2016, preventable harm incidents decreased 33% while patient volume and case mix index increased.
Implications for Practice: Nurse leaders play an important role in creating organizational cultures that are psychologically safe for staff to question practices, report problems or propose new ideas. Resilient organizations have high reliability, maintain a high level of performance and have a psychologically safe work environment. HRO principles translate to the point of care, apply to hospital environments of any size, and can be utilized effectively in every patient encounter to drive positive quality outcomes. Comprehensive integration of HRO principles results in exemplification of nursing staff understanding that their actions contribute to organizational quality and safety. A culture of safety encourages open discussion of tough issues, tolerance of disagreement, and nurtures contrasting points of view. Making this cultural shift is crucial to organizational resilience and proactive adverse event management.
See more of: Evidence-Based Practice Sessions: Symposia