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Do your staff feel safe to speak out?

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When did you last fly? Wasn’t it reassuring to know the crew went through a checklist to make sure all was in order before take off? In healthcare we have adapted this concept to make surgery safer.

Most operating theatres in the UK now use the surgical checklist, a simple tool, which, it is suggested, reduces both complications and surgical mortality (Haynes et al, 2009). The efficacy of this checklist continues to be controversial: recent work indicated it had no impact on outcomes over three months (Urbach et al, 2014). As with all research it leaves questions unanswered: was the study long enough? Was it implemented effectively? Was it a tokenistic exercise?

In sites that have implemented the surgical checklist with improved outcomes, is it the questions asked or is it the team communication that was important? Is it easier to speak out to prevent error if you have introduced yourself to other team members first?

The ability to speak out has been termed “team psychological safety” by Edmondson (2012). She introduced this term over a decade ago following research within an American company. She has refined the concept and found it applicable to healthcare.

We know from personal experience that organisations can have different team cultures. It is sometimes easy to blame others for dysfunctional behaviour. “If only our senior manager listened more” or “we need more staff”’ are frequently heard.

How leaders can cultivate psychological safety

Edmondson’s (2012) behaviours to promote psychological safety:

● Are you accessible and approachable?
● Do you acknowledge the limits of your own current knowledge?
● Do you seek out feedback and participation?
● Are you willing to display your own fallibility?
● Do you highlight failures as learning opportunities?
● Do you set clear boundaries?

Research suggests these factors are important but they have not been found to be critical elements in team psychological safety. The key factor that is vital in creating an environment where people can speak out is the behaviour of our closest manager or supervisor (Edmondson, 2012).

Most nurses will work in a supervisory role. Are we making sure staff feel able to speak out? Most people can identify if they feel comfortable to speak out within their team. Sometimes the reasons can be intangible: so what is our responsibility to our team’s psychological safety?

Next time you fly the pilot will go through the checklists. He or she will also make sure the other members in the cockpit feel safe to speak out if they see an error. In healthcare, we too share a similar responsibility to ensure that others feel safe to speak out.


Erica Reid is a senior nurse at NHS Scotland, has a wide experience of frontline nursing and is a Health Foundation quality improvement fellow at the Institute for Healthcare Improvement in Boston


Haynes et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine; 360: 491-499.

Urbach et al (2014) Introduction of surgical safety checklists in Ontario, Canada. New England Journal of Medicine; 370: 1029-1038.

Edmondson A (2012) Teaming: How Organizations Learn, Innovate and Compete in the Knowledge Economy. San Francisco, CA: John Wiley and Sons.

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