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.