Create a culture of 'psychological safety'

Although there is much to be learnt from business, the healthcare setting poses specific challenges for leaders. Most organisations provide products and services that do not require close contact and intimate interaction with people who are at their most vulnerable and dependent.

This type of work puts special demands on staff and the organisations that support them.

Social defences against anxiety

‘Most organisations do not require close contact with people who are at their most vulnerable’

Isabel Menzies Lyth, in her influential research in nursing environments, points out that because the primary task of nurses is care of the sick and involves dealing with highly vulnerable people, babies, children, sick adults, the elderly and disabled, it inevitably creates high levels of stress, tension, fear and distress.

The task of caring for others with empathy and compassion is expected to be offered to everyone, at all times. In addition, staff at all levels are confronted with the most hidden, taboo subject – death – every day. Their jobs often involve intimate contact with patients, including performing personal tasks that we would normally shy away from and consider disgusting, frightening and repellent.

‘The sheer complexity of the job will challenge even the most talented leader and it is impossible to avoid feelings of failure and dependence’

In order to manage the anxieties generated by the nature of the work, organisations employ what are often called “social defences” – mechanisms to protect staff from overpowering feelings of helplessness or despair.

Characteristic of social defences is an orientation towards helping staff to avoid the experience of anxiety, guilt, doubt and uncertainty. This is done by eliminating situations, events, tasks, activities and relationships that cause anxiety – distancing mechanisms whose unconscious aim is to avoid feelings of distress, sadness or loss.

Avoiding intimacy

The structure and culture of the organisation is defined by a need to avoid too close contact with patients, too much intimacy, responsibility and emotional overload.

Two basic anxieties are of particular significance. The first is anxiety about dependence and vulnerability, which we all understand as we have all been dependent at some time in our lives, if only as small children.

Dependence and vulnerability are among the most powerful unconscious anxieties we face throughout our lives. It therefore follows that we might wish to avoid feelings of powerlessness, despair and vulnerability and wish to associate “dependence” with patients in order to feel in control.

The second is anxiety about failure and relates to the burden of responsibility we place on clinicians and care staff and their underlying fear that they cannot meet these demands.

There is no doubt that the task of caring for others can be stressful, endless and unglamorous and that healthcare organisations are often not very supportive places to work. The sheer complexity of the job will challenge even the most talented leader and it is impossible to avoid feelings of failure and dependence. Wise leaders are able to tolerate these feelings and help others contain them.

Containment

People vary in their ability and willingness to reflect and to give up defensive behaviour but it is safer to offer support to staff who are exposed to highly charged emotional situations, demanding patients and a critical public than to risk the cost of exposure and system failure.

Space to think, to review, problem-solve and learn from experience should be provided by team leaders in all care settings. Such mechanisms provide a place to unburden, to think about the unconscious processes at work in oneself, the team and the patient population.

‘Space to think, to review, problem-solve and learn from experience should be provided by team leaders in all care settings’

This space needs to be regular, dedicated to the task of reflection, properly facilitated by trained staff. In this way psychological material generated by the patients and anxieties evoked in the professional caring staff can be understood and contained.

An example of one methodology for doing this is the King’s Fund’s Point of Care programme. The programme was developed to improve the experience of patients in hospital and to support staff to provide high-quality, patient-centred care. In recognition of the highly pressurised working environments and the complex, intense and emotionally challenging nature of caring for patients, the programme has introduced Schwartz Centre rounds to hospitals and hospices.

Discuss the emotional challenges

Developed by the Boston-based Schwartz Centre for Compassionate Care, Schwartz rounds are a multidisciplinary forum, led by a senior doctor, designed for staff from across the hospital to come together once a month to discuss the non-clinical aspect of caring for patients – that is, the emotional and social challenges associated with their jobs.

The rounds typically take place once a month and are held at lunchtime, with lunch provided. They last one hour: a patient’s case or story is presented by the team who cared for him or her, after which the themes that emerge are opened up for discussion, guided by a skilled facilitator.

Evaluation has shown that staff who attend Schwartz rounds find that they are highly beneficial, not just for them personally, but also for their relationships with colleagues and patients, and that they are beginning to contribute to culture change within organisations.

Organisational culture and leadership 

Recent research shows that successful organisational and cultural change takes place through engagement rather than a command and control leadership style. We believe this is particularly important in settings where care is the core purpose of the organisation. It is obvious that staff who care for others can only continue do so if they feel supported and cared for as well.

Leaders in healthcare need to create a culture which is characterised by high trust, collaboration and dedication to the core task of providing mindful and safe patient care. Recent research by Amy Edmondson at Harvard has shown that “psychological safety” is a key component of such a culture. This means that all clinical, administrative and support staff are able to engage in conversations about the quality of the care they provide and are not frightened of blame or punishment if they raise concerns. 

‘Leaders in healthcare need to create a culture which is characterised by high trust, collaboration and dedication’

It is vital to create space and time for reflection and problem solving so that mistakes and failures are detected and addressed early on and the team continuously learns from experience, creating a virtuous circle of mindfulness and self-confidence.

Rules and checks

Many healthcare organisations look for solutions by creating rules and checks which attend to the technical risk by focusing attention on adherence to processes and procedures which are necessary and helpful.

But dignified care requires more than process mapping and adherence to rules. It requires emotional intelligence – sensitivity, dedication, self-management and self-awareness. It also requires clinical teams to focus on the humanity of care, to work as a team, to trust one another and put the patient at the heart of their work. This is easy to say but difficult to do. 

Skilled leadership and attention to team dynamics, addressing power struggles, resolving conflict, supervision of clinical and care teams are needed to avoid defences against anxiety becoming a damaging “acting out” of unconscious dynamics such as those described above. It is not surprising that mistakes are hidden, patients are neglected, abuses of power are commonplace and people despair of finding solutions.

It is important that leaders create a culture of “psychological safety” where staff at all levels are able to discuss and raise issues that are of concern to them without fear. Where leaders really care for staff, they are equipped to provide high quality care to patients.

Elisabeth Buggins is chair of Birmingham Women’s Foundation Trust, Jocelyn Cornwell is director of the Point of Care programme at the King’s Fund, and Dympna Cunnane is an organisation psychologist in private practice and a programme director at London Business School