Resources

Although boards are ultimately accountable, and responsible for oversight and strategic direction, clinical governance begins and ends with those who deliver clinical care. We have previously suggested that ‘culture impacts how individuals feel in workplace - and in turn the manner in which they conduct themselves.’ Do they feel supported in the workplace - or are they afraid to seek help? Do they feel safe to speak up if they have any concerns? Do they feel free to share their ideas, mistakes, and feedback - fostering a learning and collaborative environment, in a united vision to deliver optimal care?

Negative behaviours such as discrimination and harassment are likely to adversely affect the quality of care delivery, and therefore patient outcomes. However the concept of psychological safety stretches beyond avoidance of negative behaviour, and is about promoting and facilitating positive behaviour.

Psychological safety refers to ‘an individual’s perception of whether it is safe to take interpersonal risks’. This includes whether a person feels they can express themselves and challenge the status quo where necessary. Psychological safety is said to be ‘particularly important within healthcare teams who need to work interdependently to co-ordinate safe patient care within a highly complex, dynamic and high stakes work environment’. The absence of psychological safety can create a ‘culture of fear’ - where practitioners fear ‘retribution, disapproval, career limiting consequences, and worse if they dare to question or challenge colleagues.’

The importance of psychological safety is exemplified in the recent NSW Code of Practice for Managing Psychological Hazards at Work (NSW Code), an approved Code of Practice under the NSW Work Health and Safety Act 2011. The NSW Code defines a ‘psychological hazard’ (in the context of work), to be a situation that may cause a ‘stress response’, and includes social interactions at work. Whilst not specific to healthcare, it sets out risks and principles which are translatable to all sectors.

For example, burnout is a common problem amongst healthcare workers - even prior to the pandemic, albeit exacerbated by it. The NSW Code acknowledges this risk in the context of ‘role overload’, or ‘high workloads or job demands’ - suggesting specific examples which reflect conditions inherent to provision of healthcare, such as safety-critical decisions that may seriously impact the health and safety of others, and cognitively challenging work.

Burnout is relevant to clinical governance because it can impair the delivery of safe and quality care. Bullying is also common and known to impact patient outcomes. It too is addressed in the NSW Code, which acknowledges ‘incidents of bullying by workers, clients, patients, visitors or others’ as a common psychosocial hazard. The effects of burnout and bullying can be mitigated in a psychologically safe environment, where individuals are not afraid to speak out.

Psychological safety in healthcare workers impacts the safety and quality of care delivered to consumers. An understanding of team dynamics is crucial in supporting and promoting psychological safety. Such dynamics may be a consequence of the hierarchy embedded in healthcare culture, and if so, should be addressed through strong leadership to support cultural change. This is because ‘situational context’, influenced by organisational culture, can determine workers’ perceptions, feelings (and hence a psychologically safe culture). This is impacted through all levels of an organisation.

In summary, psychological safety promotes effective communication, which in turn facilitates collaborative decision-making and teamwork towards the delivery of optimal clinical care. Clinical governance strategies should always consider supporting and improving psychological safety in their organisations, which may entail profound cultural change.

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All accessed on 7/2/22:

‘Culture and clinical governance’. AICG, 19 December 2021. Accessed at: https://www.aicg.edu.au/resources/culture-and-clinical-governance/

L. Guo et al. ‘Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review’. BMJ Quality & Safety, 19 January 2022. DOI: 10.1136/bmjqs-2021-013955. Accessed at: Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review | BMJ Quality & Safety

R. O’Donovan et al. ‘Healthcare Professionals Experience of Psychological Safety, Voice, and Silence’. Frontiers in Psychology, 19 February 2021. DOI: 10.3389/fpsyg.2021.626689. Accessed at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.626689/full

R. O’Donovan & E. McAuliffe. ‘Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data’. BMC Health Services Research, 31 August 2020. DOI: 10.1186/s12913-020-05646-z. Accessed at: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05646-z#:~:text=Psychological%20safety%20allows%20healthcare%20professionals,of%20psychological%20safety%20is%20needed.

N. Ladher. ‘End the culture of fear in healthcare’. BMJ, 25 October 2018. DOI: 10.1136/bmj.k4467. Accessed at: https://www.bmj.com/content/363/bmj.k4467

‘Code of Practice: Managing psychosocial hazards at work’. Safework NSW, May 2021. Accessed at: https://www.safework.nsw.gov.au/resource-library/list-of-all-codes-of-practice/codes-of-practice/managing-psychosocial-hazards-at-work

S. De Hert. ‘Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies.’ Local and Regional Anesthesia, 28 October 2020. DOI: 10.2147/LRA.S240564. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604257/

H. Dobson et al. ‘Burnout and psychological distress amongst Australian healthcare workers during the COVID-19 pandemic’. Australas Psychiatry, February 2021. DOI: 10.1177/1039856220965045. Accessed at: https://pubmed.ncbi.nlm.nih.gov/33043677/

L. H. Hall et al. ‘Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review.’ Plos One, 8 July 2016. DOI: 10.1371/journal.pone.0159015. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938539/

‘Bullying and harassment of health workers endangers patient safety’. The Conversation, 5 November 2018. Accessed at: https://theconversation.com/bullying-and-harassment-of-health-workers-endangers-patient-safety-106167 

K. E. Grailey et al.  'The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis'.   BMC Health Services Research, 5 August 2021.  DOI: 10.1186/s12913-021-06740-6. Accessed at: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06740-6