Table 3 Key target areas for psychological safety

Patient admissions to a psychiatric hospital

Decisions to admit patients depend on system demands (both intra- and inter-organisational), patient presentation and capacity to consent to admission, country-specific legal frameworks and ward resources to care for the patient compassionately and safely. A patient-centred focus can leave nurses feeling that they must always admit patients, irrespective of resource levels, and do not have the opportunity to decline further admissions when they assess safety to be compromised

Psychologically safe teams can discuss decisions that could be viewed as incorrect, subversive or unhelpful and do not align with the intra- and inter- organisational demands, and individual desire to aid all patients. Not only will nurses be empowered to make the difficult decision to decline admission, but leadership will support these decisions

Daily or shift based patient flow meetings, and dialogue meetings to provide staff with the opportunity to openly discuss internal and external demand for capacity in their clinical areas, their concern for impact on standards of care, their compassion for the person needing admission, their safety-based decisions and calibrate these approaches

Leadership training focused on the importance of making patient safety-focused decisions regarding admissions and empowering teams to decline further admissions when it is unsafe for patients and staff to increase care demands on the ward team

Involuntary admission to a psychiatric hospital

Most countries provide statutory powers to admit the most vulnerable into psychiatric inpatient services, and appropriate treatment that may arise from this decision. Involuntary inpatients can feel disempowered and this can potentially influence their recovery

Psychologically safe teams will recognise the importance of seeking shared decision-making with involuntary inpatients. These discussions should include discussing patient options, their preferences, and openly discussing their preferences set against what is possible and safe

Develop and implement a new structured induction plan (or refining an existing one) for all involuntary admissions that focus on patient choice

Communication training that specifically focuses on negotiating with patients and factors in patient preference against what is feasible for their safety

Decisions to use pro-active intervention

In acute inpatient settings, these situations are the precursor to restrictive practice, such as discussing and debriefing patients, providing an opportunity to support them in de-escalating a situation

In community settings, these situations may include introducing a pharmaceutical or therapeutic intervention to help stabilise a patient and avoid admission to a psychiatric hospital

Psychologically safe teams in acute inpatient care (particularly with nursing and practitioner teams) will actively seek to discuss and take action to de-escalate volatile situations, providing support in these actions and not avoiding them

In community settings, psychologically safe teams will involve all relevant professionals, informal support and the patient in openly discussing intervention options available to provide patient-centred care

Dialogue meetings provide opportunities for teams to discuss these difficult decisions and their thought processes, relating to previous experiences

Schwartz rounds provide an opportunity for staff to discuss the emotional components of complex decision-making, particularly balancing patient safety and privacy

Simulations and role-play provide an opportunity for teams to enhance psychological safety behaviours such as team decision-making, diverse thinking, teamwork and speaking up to deliver patient-focused care. Simulations should also include shared decision-makers with key stakeholders beyond the team (e.g., informal support, non-statutory organisations). Most importantly, involving the patient in shared decision-making, both in terms of keeping them informed, providing patient choice and negotiating patient preference with patient safety considerations

Debriefing teams to explicitly discuss thought processes and factors relating to positive risk-taking behaviour. Alongside this, modelling thoughtful risk-taking behaviour from leaders, including a protocol to consider all factors

Decisions to use restrictive practice in acute inpatient settings

Across acute inpatient settings, decisions on the use of restrictive practice (e.g., enhanced observations, seclusion, restraint, and sedation) are often time-pressured and involved complex decision-making, making a trade-off between patient safety and privacy. As such, these decisions require input from all key decision-makers and influencers to make the most informed choice

Teams that are high in psychological safety will be able to speak up and voice their considerations and possibly their concerns on the use of restrictive practice, including challenging the decisions made by others in a collaborative way. As well as speaking up, psychological safety teams will include all members participating in the decision-making process, and ensure full patient involvement

Reducing restrictive practice in acute inpatient settings

Related to the decision to use restrictive practice is to de-escalate or end restrictive practice with a patient. This involves testing whether a patient is able to manage without the imposed restraints. It requires positive risk-taking behaviour to increase patient privacy but not at the expense of the safety of the patient and others

Psychologically safe teams support and collaboratively challenge each other when it comes to patient-focused and positive risk-taking (i.e., experimenting whether a patient can manage without an environmental restraint). Utilising whole team intelligence, full patient involvement (both in terms of informing the patient and discussing the available options) and knowledge sharing enhances the decision-making, mitigates foreseen risks and encourages taking positive risks that benefit the patient

Authorising leave or time away from the ward in acute inpatient settings

As part of a recovery-oriented approach, many patients have planned leave or time away from the ward in the context of the legal framework under which they were admitted to hospital. This positive risk-taking requires ward teams to balance the often complex dynamic between patient autonomy and organisational/societal paternalism

Post-incident debrief/discussion for the use of restrictive practice

Across many countries, debriefing is a mandatory (and legally required) to analyse and discuss all circumstances leading to the decision to use restrictive practice

A psychologically safe team can have candid discussions regarding the use of restraint, even when this practice was not optimal the optimal decision for the patient (e.g., low staffing levels creating a need to use more restrictive practice). These teams should also be able to collaboratively discuss any disagreements regarding decisions made, in retrospect

Teams will also seek patient involvement and family/carer involvement (where applicable) in individual cases, to reflect on the decision made, discuss the reasons why they were made, and actively seek a collaboration to explore alternative options and strategies for avoiding using restrictive practice, where possible

Training provided to teams that support speaking up candidly and communication styles to reflect collaborative rather than combative debate

Organisational policies in place to fairly audit non-optimal decisions regarding restrictive practice, fairly and holistically

Train and simulate shared decision-making approaches, inclusive of patients in these discussions

Planned discharge from a psychiatric hospital

The transition from inpatient to the community can be a difficult inpatients, particularly for patients with long lengths of stay

A psychologically safe approach to the transition in care between inpatient and community settings will involve the patient in discussing the plan, openly and actively listening to any concerns the patient may have, and to ensure continuity of care between inpatient and community teams

Involving all relevant statutory and non-statutory organisations, and informal support in the planned discharge

Dialogue meetings and reflective sessions to understand the barriers and discuss ways of ensuring continuity of care for this transition period

Mapping and refining the transition aspect of a care pathway to ensure full patient involvement and involvement of relevant services and informal support

Decisions regarding particularly vulnerable groups

Decisions regarding the care of vulnerable groups such as older people and young people require collaboration between clinician’s informal support and the views of the person themselves. In particular, the process of making decisions regarding the care provided by carers, partners, family and friends vs what professional assessment determines to be the best approach

This should also include other statutory and non-statutory organisations that are involved in supporting the patient

As such, patient-centred care often crosses professional and organisational boundaries, requiring open and candid communication for inter-professional working, and shared decision-making that involve patients and their informal support network

Safe patient-focused care relies on the continuity of care and collaboration between professional services and other statutory and non-statutory organisations (e.g., charity-sector organisations involved in supporting a patient); and informal support provided by carers, friends and family. Psychological safe teams can engage in supportive and candid discussions between formal and informal care to agree to care packages that are always in the interests of the patient

Engagement strategies and training that bring together formal and informal support to integrate and create continuity of care—providing opportunities for people to speak up about parameters, opportunities and challenges to providing care

Clinical handover

The definition of clinical handovers is the transfer of clinical responsibility and accountability of some or all aspects of care for a patient or group of patients to another person. Functional handovers underpin consistent and continuity of care. In the case of an inpatient setting, this handover will typically be at the end of one shift pattern to the beginning of another. Handovers should include enough information to plan for the next shift compassionately and safely

As such, teams that are high in psychological safety will be able to have candid and pro-active discussions that could aid the effective care of particular patients. For example, speaking up about some of the behavioural difficulties with one patient may provide insight that helps to avoid an aggressive situation later that day

Create a research action team with key decision-makers (clinical and non-clinical staff) across the Trust to map how handover process and discuss restructuring it with a focus on psychological safety

Informal disputes between staff members

Providing opportunities and structure to handling disputes between staff members is essential to resolving disputes before they reach formal grievance procedures

Psychologically safe teams provide an opportunity for staff members to have candid conversations about professional conflicts and seek opportunities to resolve such issues successfully. In particular, a focus on understanding each other’s view and recognising commonalities in occupational practice. Where possible, staff should take opportunities to take ownership of the issue and seek to resolve it in an appositive manner

At an organisational level, there should be structure and opportunities to facilitate staff resolving such issues at the early stages

Specific training provided to staff members and, in particular, to leaders to help mediate and resolve disputes and conflicts. Training should also focus on respectful listening and divergent thinking

Organisations may seek to provide mediation from internally-appointed individuals or external services to facilitate pro-actively handling disputes

Workplace bullying and harassment

Individuals who misuse their authority to gain personal and political power, and ultimately undermine a psychologically safe culture

At a group level, informal peer support networks are beneficial in a workplace setting, they can also serve as cliques, creating favouritism for those within the group and exclusion for those outside of the group

Psychologically safe teams create professional boundaries, understanding the difference between their professional and personal lives. Irrespective of informal relationships, colleagues still foster a relationship of candid discussion that is equal across all colleagues. When witnessing bullying and harassment, they are openly willing to challenge this behaviour and follow through with any action arising from the incident

Creating a code of conduct in which team expectations are agreed upon, laid out and repeatedly reinforced

Policies that protect and support those who are implicated in bullying and harassment incidents, both for the person who reports the incident and the implicated staff

Leadership training with a specific focus on handling bullying and harassment, from proactive strategies to promote candid but fair conversations, to handling grievances arising from this any reported incidents

Grievance procedures

All organisations have formal positions in place to handle grievances, whether they are through internal HR processes or whether they involve independent union organisations

Psychologically safe teams will be able to have candid conversations about any dispute or differences in personality or workplace differences that, in most cases, can be resolved before reaching formal stages

Providing independent and informal routes specifically designed to work towards resolving grievances collaboratively. Creating local charters with expectations for staff to openly, candidly and respectively discussing grievances before they escalate to formal stages

Professional Development Review (PDR)

Professional development reviews (PDR) provide opportunities for both the staff and the managers to reflect on performance from the previous year as well as plans for the next year. It provides opportunities to engage in short-term planning for role fulfilment and long-term career aspirations and how the organisation may play a part in this

Those who are psychologically safe will be free to engage in candid conversations regarding where they want to be in their position and will facilitate their engagement. The PDR should primarily seek to serve and develop the individual, and for organisational performance viewed as a secondary focus. It can provide opportunities for staff to discuss how the role fits with their current career aspirations and how this fits with the current role and what the organisation needs

Review of current PDR across the organisation and interviews to discuss whether staff the plans reflect their true aspirations, goals and plans

Return to work interviews

Return to work interviews are short, informal meetings held with an employee on their return to work after an absence. As well as discussing details around the absence and the planned return to work, it provides an opportunity to explore any work-placed contributions

Psychological safe individuals will be able to speak candidly around any work-related stress that contributed to their absence. Receptive managers will be able to respond to these concerns and, where possible, provide a return to work plan that takes into account the contributions to absence

Specific training that focuses on psychologically safe behaviours enabling collaborative discussion about the current absence, broader influences, and candidly discussing next steps

Exit interviews

Exit interviews create an invaluable opportunity to find out whether any of the reasons staff leave is attributable to the organisation. On a population level, they also offer opportunities to recognise trends and areas that may be improved to increase staff retention and engagement

Even when leaving, employees may feel like they are unable to speak freely about the reasons they are leaving—fear of not receiving a good reference further influences whether people speak up. Individuals high in psychological safety are likely to speak more frankly about their experience and can offer critical insights for an organisation. Like PDRs, an exit interview should seek to serve the individual, first and foremost, and to provide open opportunities for organisational learning

Develop and implement a process to thematically analyse patterns for people leaving and how this is fed back into the organisation—alongside this, messaging that feedback received is valuable and actioned