Psychological Safety

In 1991, a first-year PhD student named Amy Edmondson began visiting hospital wards, intending to show that good teamwork and good medicine went hand in hand. But the data kept saying she was wrong.

Edmondson was studying organizational behavior at Harvard. A professor had asked her to help with a study of medical mistakes, and so Edmondson, on the prowl for a dissertation topic, started visiting recovery rooms, talking to nurses, and paging through error reports from Boston hospitals. In one cardiac ward, she discovered that a nurse had accidentally given a patient an IV of lidocaine, and anesthetic, rather than heparin, a blood thinner. In an orthopedic ward, a patient was given amphetamines rather than aspirin. “ You would be shocked at how many mistakes occur every day,” Edmondson told me. “ Not because of incompetence, but because hospitals are really complicated places and there’s usually a large team-as many as two dozen nurses and techs and doctors-who might be involved in each patient’s care. That’s a lot of opportunities for something to slip through the cracks.”

Some parts of the hospitals Edmondson visited seemed more accident prone than others. The orthopedic ward, for instance, reported an average of one error every three weeks; the cardiac ward, on the other hand, reported a mistake almost every other day. Edmondson also found that the various departments had very different cultures. In the cardiac ward nurses were chatty and informal; they gossiped in the hallways and had pictures of their kids on the walls. In orthopedics, people were more sedate. Nurse managers wore business suits rather than scrubs and asked everyone to keep the public areas free of personal items and clutter. Perhaps, Edmondson thought, she could study the various teams’ cultures and see if they correlated with error rates.

She and a colleague a survey to measure team cohesion on various wards. She asked nurses to describe how frequently their team leaders set clear goals and whether teammates discussed conflicts openly or avoided tense conversations. She measured the satisfaction, happiness, and self-motivation of different groups and hired a research assistant to observe the wards for two months.

“ I figured it would be pretty straightforward,” Edmondson found exactly the opposite. The wards with the strongest team cohesion had far more errors. She checked the data again. It didn’t make any sense. Why would strong teams make more mistakes?

Confused, Edmondson decided to look at these nurses’ responses, question by question, alongside the error rates to see if any explanations emerged. Edmondson had included one survey question that inquired specifically about the personal risks associated with making errors. She asked people to agree or disagree with the statement: “ If you make a mistake in this unit, it is held against you.” Once she compared the data from that question with error incidence, she realized what was going on. It wasn’t that wards with strong teams were making more mistakes. Rather, it was that nurses who belonged to strong teams felt more comfortable reporting their mistakes. The data indicated that one particular norm- whether people were punished for missteps- influenced if they were honest after they screwed up.

Some leaders “ have established a climate of openness that facilitates discussion of error, which is likely to be an important influence on detected error rates,” Edmondson wrote in The Journal of Applied Behavioral Science in 1996. What particularly surprised her, however, was how complicated things got the closer she looked: it wasn’t simply that strong teams encouraged open communication and weak teams discouraged it. In fact, while some strong teams emboldened people to admit their mistakes, other, equally strong teams made it hard for nurses to speak up. What made the difference wasn’t team cohesion- rather, it was the culture each team established. In one ward with a strong team, for instance, nurses were overseen by “a hands-on manager who actively invites questions and concerns….

In an interview, the nurse manager explains that a ‘ certain level of error will occur’ so a ‘ nonpunitive environment’ is essential to deal with this error productively,’ Edmondson wrote. “ There is an unspoken rule here to help each other and check each other,” a nurse told Edmondson’s assistant. “ People feel more willing to admit to errors here, because the nurse manager goes to bat for you.”

In another ward with a team that, at first glance, seemed equally strong, a nurse said that when she admitted hurting a patient while drawing blood, the nurse manager “ made her feel like she was on trail.” Another said doctors “ bite your head off if you make a mistake.” Yet measurements of group cohesion on this ward “ prides itself on being clean, neat and having an appearance of professionalism.” The nurse manager for the ward dressed in business suits and when she delivered criticism, she considerately offered her critiques behind closed doors. The staff said they appreciated the manager’s professionalism, were proud of their department, and felt a strong sense of unity. To Edmondson, the team seemed like they genuinely liked and respected one another. But they also admitted that the unit’s culture sometimes made it hard to confess making a mistake.

It wasn’t the strength of the team that determined how many errors were reported- rather, it was one specific norm.

When Edmondson started working on her dissertation, she visited technology companies and factory floors, and asked people about the unwritten rules that shaped how their teammates behaved. People would say things like, ‘This is one of the best teams I’ve ever been on, because I don’t have to wear a work face here,’ or ‘We aren’t afraid to share crazy ideas,” Edmondson told me. On those teams, norms of enthusiasm and support had taken hold and everyone felt empowered to voice opinions and take risks.
“And other teams would tell me, ‘ My group is really dedicated to each other and so I try not to go outside my department without checking with supervisor first’ or ‘ We’re all in this together, so I don’t like to bring up an idea unless I know it will work.” Within those teams, a norm of loyalty held sway- and it undermined people’s willingness to make suggestions or take chances.

Both enthusiasm and loyalty are admirable norms. It wasn’t clear to managers that they would have such different impacts on people’s behaviors. And yet they did. In that setting, enthusiastic norms made teams better. Loyalty norms made them less effective. “Managers never intend to create unhealthy norms,” Edmondson said. “Sometimes, though, they make choices that seem logical, like encouraging people to flesh out their ideas before presenting them, that ultimately undermine a team’s ability to work together.

As her research continued, Edmondson found a handful of good norms that seemed to be consistently associated with higher productivity. On the best teams, for instance, leaders encouraged people to speak up; teammates felt like they could suggest ideas without fear of retribution; the culture discouraged people from making harsh judgments. As Edmondson’s list of good norms grew, she began to notice that everything shared a common attribute: They were all behaviors that created a sense of togetherness while also encouraging people to take a chance.

“ We call it ‘ psychological safety,’ she said. Psychological safety is a “shared belief, held by members of a team, that the group is a safe place for taking risks.” It is “ a sense of confidence that the team will nor embarrass, reject, or punish someone for speaking up,” Edmondson wrote in a 1999 paper.  “It describes a team climate characterized by interpersonal trust and mutual respect in which people are comfortable being themselves.”

Julia and her Google colleagues found Edmondson’s papers as they were researching norms. The idea of psychological safety, they felt, captured everything their data indicated was important to Google’s teams. The norms that Google’s surveys said were most effective- allowing others to fail without repercussions, respecting divergent opinions, feeling free to question others’ but also trusting that people aren’t trying to undermine you-were all aspects of feeling psychologically safe at work. “It was clear to us that this idea of psychological safety was pointing to which norms were most important,” said Julia. “ But it wasn’t clear guidelines for creating psychological safety without losing the capacity for dissent and debate that’s critical to how Google functions.” In other words, how do you convince people to feel safe while also encouraging them to be willing to disagree?

“For a long time, that was the million-dollar question,” Edmondson told me. “ We knew it was important for teammates to be open with each other. We knew it was important for people to feel like they can speak if something’s wrong. But those are also the behaviors that can set people at odds. We didn’t know why some groups could clash and still have psychological safety while others would hit a period of conflict and everything would fall apart.”

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