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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Conquer the most essential adaptation to the knowledge economy
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth offers practical guidance for teams and organizations who are serious about success in the modern economy. With so much riding on innovation, creativity, and spark, it is essential to attract and retain quality talent—but what good does this talent do if no one is able to speak their mind? The traditional culture of "fitting in" and "going along" spells doom in the knowledge economy. Success requires a continuous influx of new ideas, new challenges, and critical thought, and the interpersonal climate must not suppress, silence, ridicule or intimidate. Not every idea is good, and yes there are stupid questions, and yes dissent can slow things down, but talking through these things is an essential part of the creative process. People must be allowed to voice half-finished thoughts, ask questions from left field, and brainstorm out loud; it creates a culture in which a minor flub or momentary lapse is no big deal, and where actual mistakes are owned and corrected, and where the next left-field idea could be the next big thing.
This book explores this culture of psychological safety, and provides a blueprint for bringing it to life. The road is sometimes bumpy, but succinct and informative scenario-based explanations provide a clear path forward to constant learning and healthy innovation.
- Explore the link between psychological safety and high performance
- Create a culture where it’s “safe” to express ideas, ask questions, and admit mistakes
- Nurture the level of engagement and candor required in today’s knowledge economy
- Follow a step-by-step framework for establishing psychological safety in your team or organization
Shed the "yes-men" approach and step into real performance. Fertilize creativity, clarify goals, achieve accountability, redefine leadership, and much more. The Fearless Organization helps you bring about this most critical transformation.
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Veröffentlichungsjahr: 2018
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Table of Contents
Cover
Introduction
What It Takes to Thrive in a Complex, Uncertain World
Discovery by Mistake
Overview of the Book
Endnotes
PART I: The Power of Psychological Safety
1 The Underpinning
Unconscious Calculators
Envisioning the Psychologically Safe Workplace
An Accidental Discovery
Standing on Giants' Shoulders
Why Fear Is Not an Effective Motivator
What Psychological Safety Is Not
Measuring Psychological Safety
Psychological Safety Is Not Enough
Endnotes
Note
2 The Paper Trail
Not a Perk
The Research
1. An Epidemic of Silence
2. A Work Environment that Supports Learning
3. Why Psychological Safety Matters for Performance
4. Psychologically Safe Employees Are Engaged Employees
5. Psychological Safety as the Extra Ingredient
Bringing Research to Practice
Endnotes
PART II: Psychological Safety at Work
3 Avoidable Failure
Exacting Standards
Stretching the Stretch Goal
Fearing the Truth
Who Regulates the Regulators?
Avoiding Avoidable Failure
Adopting an Agile Approach to Strategy
Endnotes
4 Dangerous Silence
Failing to Speak Up
What Was Not Said
Excessive Confidence in Authority
A Culture of Silence
Silence in the Noisy Age of Social Media
Endnotes
5 The Fearless Workplace
Making Candor Real
Extreme Candor
Be a Don't Knower
When Failure Works
Caring for Employees
Learning from Psychologically Safe Work Environments
Endnotes
6 Safe and Sound
Use Your Words
One for All and All for One
Speaking Up for Worker Safety
Transparency by Whiteboard
Unleashing Talent
Endnotes
PART III: Creating a Fearless Organization
7 Making it Happen
The Leader's Tool Kit
How to Set the Stage for Psychological Safety
How to Invite Participation So People Respond
How to Respond Productively to Voice – No Matter Its Quality
Leadership Self-Assessment
Endnotes
8 What's Next?
Continuous Renewal
Deliberative Decision-Making
Hearing the Sounds of Silence
When Humor Isn't Funny
Psychological Safety FAQs
Tacking Upwind
Endnotes
Appendix: Variations in survey measures to Illustrate Robustness of Psychological Safety
Endnotes
Acknowledgments
About the Author
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Taken-for-granted Rules for Voice at Work.
Table 2.2 Why Silence Wins in the Voice-Silence Calculation.
Chapter 7
Table 7.1 The Leader's Tool Kit for Building Psychological Safety.
Table 7.2 Failure Archetypes – Definitions and Implications.
16
Table 7.3 Framing the Role of the Boss.
Table 7.4 Destigmatizing Failure for Psychological Safety.
Table 7.5 Productive Responses to Different Types of Failure.
List of Illustrations
Chapter 1
Figure 1.1 How Psychological Safety Relates to Performance Standards.
18
Figure 1.2 A Survey Measure of Psychological Safety.
20
Chapter 2
Figure 2.1 Mentions of Psychological Safety in Popular Media.
4
Figure 2.2 Citations of 1999 Article Introducing Team Psychological Safety.
12
Chapter 7
Figure 7.1 The Imperfect Relationship between Process and Outcome.
Guide
Cover
Table of Contents
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E1
the fearless organization
Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth
Amy C. Edmondson
HARVARD BUSINESS SCHOOL
Copyright © 2019 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
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Library of Congress Cataloging-in-Publication Data
Names: Edmondson, Amy C., author.
Title: The fearless organization : creating psychological safety in the workplace for learning, innovation, and growth / Amy C. Edmondson.
Description: Hoboken, New Jersey : John Wiley & Sons, Inc., [2019] | Includes index. |
Identifiers: LCCN 2018033732 (print) | LCCN 2018036160 (ebook) | ISBN 9781119477228 (Adobe PDF) | ISBN 9781119477266 (ePub) | ISBN 9781119477242 (hardcover)
Subjects: LCSH: Organizational behavior. | Organizational learning—Psychological aspects. | Psychology, Industrial.
Classification: LCC HD58.7 (ebook) | LCC HD58.7 .E287 2019 (print) | DDC 658.3/82—dc23
LC record available at https://lccn.loc.gov/2018033732
Cover Design: Wiley
To George
Whose curiosity and passion make him a great scientist and leader – and who knows all too well that fear is the enemy of flourishing.
Introduction
“No passion so effectively robs the mind of all its powers of acting and reasoning as fear.”
—Edmund Burke, 1756.1
Whether you lead a global corporation, develop software, advise clients, practice medicine, build homes, or work in one of today's state-of-the-art factories that require sophisticated computer skills to manage complex production challenges, you are a knowledge worker.2 Just as the engine of growth in the Industrial Revolution was standardization, with workers as laboring bodies confined to execute “the one best way” to get almost any task done, growth today is driven by ideas and ingenuity. People must bring their brains to work and collaborate with each other to solve problems and accomplish work that's perpetually changing. Organizations must find, and keep finding, new ways to create value to thrive over the long term. And creating value starts with putting the talent you have to its best and highest use.
What It Takes to Thrive in a Complex, Uncertain World
While it's not news that knowledge and innovation have become vital sources of competitive advantage in nearly every industry, few managers stop to really think about the implications of this new reality – particularly when it comes to what it means for the kind of work environment that would help employees thrive and organizations succeed. The goal of this book is to help you do just that – and to equip you with some new ideas and practices to make knowledge-intensive organizations work better.
For an organization to truly thrive in a world where innovation can make the difference between success and failure, it is not enough to hire smart, motivated people. Knowledgeable, skilled, well-meaning people cannot always contribute what they know at that critical moment on the job when it is needed. Sometimes this is because they fail to recognize the need for their knowledge. More often, it's because they're reluctant to stand out, be wrong, or offend the boss. For knowledge work to flourish, the workplace must be one where people feel able to share their knowledge! This means sharing concerns, questions, mistakes, and half-formed ideas. In most workplaces today, people are holding back far too often – reluctant to say or ask something that might somehow make them look bad. To complicate matters, as companies become increasingly global and complex, more and more of the work is team-based. Today's employees, at all levels, spend 50% more time collaborating than they did 20 years ago.3 Hiring talented individuals is not enough. They have to be able to work well together.
In my research over the past 20 years, I've shown that a factor I call psychological safety helps explain differences in performance in workplaces that include hospitals, factories, schools, and government agencies. Moreover, psychological safety matters for groups as disparate as those in the C-suite of a financial institution and on the front lines of the intensive care unit. My field-based research has primarily focused on groups and teams, because that's how most work gets done. Few products or services today are created by individuals acting alone. And few individuals simply do their work and then hand the output over to other people who do their work, in a linear, sequential fashion. Instead, most work requires people to talk to each other to sort out shifting interdependencies. Nearly everything we value in the modern economy is the result of decisions and actions that are interdependent and therefore benefit from effective teamwork. As I've written in prior books and articles, more and more of that teamwork is dynamic – occurring in constantly shifting configurations of people rather than in formal, clearly-bounded teams.4 This dynamic collaboration is called teaming.5 Teaming is the art of communicating and coordinating with people across boundaries of all kinds – expertise, status, and distance, to name the most important. But whether you're teaming with new colleagues all the time or working in a stable team, effective teamwork happens best in a psychologically safe workplace.
Psychological safety is not immunity from consequences, nor is it a state of high self-regard. In psychologically safe workplaces, people know they might fail, they might receive performance feedback that says they're not meeting expectations, and they might lose their jobs due to changes in the industry environment or even to a lack of competence in their role. These attributes of the modern workplace are unlikely to disappear anytime soon. But in a psychologically safe workplace, people are not hindered by interpersonal fear. They feel willing and able to take the inherent interpersonal risks of candor. They fear holding back their full participation more than they fear sharing a potentially sensitive, threatening, or wrong idea. The fearless organization is one in which interpersonal fear is minimized so that team and organizational performance can be maximized in a knowledge intensive world. It is not one devoid of anxiety about the future!
As you will learn in this book, psychological safety can make the difference between a satisfied customer and an angry, damage-causing tweet that goes viral; between nailing a complex medical diagnosis that leads to a patient's full recovery and sending a critically ill patient home too soon; between a near miss and a catastrophic industrial accident; or between strong business performance and dramatic, headline-grabbing failure. More importantly, you will learn crucial practices that help you build the psychologically safe workplaces that allow your organization to thrive in a complex, uncertain, and increasingly interdependent world.
Psychological safety is broadly defined as a climate in which people are comfortable expressing and being themselves. More specifically, when people have psychological safety at work, they feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution. They are confident that they can speak up and won't be humiliated, ignored, or blamed. They know they can ask questions when they are unsure about something. They tend to trust and respect their colleagues. When a work environment has reasonably high psychological safety, good things happen: mistakes are reported quickly so that prompt corrective action can be taken; seamless coordination across groups or departments is enabled, and potentially game-changing ideas for innovation are shared. In short, psychological safety is a crucial source of value creation in organizations operating in a complex, changing environment.
Yet a 2017 Gallup poll found that only 3 in 10 employees strongly agree with the statement that their opinions count at work.6 Gallup calculated that by “moving that ratio to six in 10 employees, organizations could realize a 27 percent reduction in turnover, a 40 percent reduction in safety incidents and a 12 percent increase in productivity.”7 That's why it's not enough for organizations to simply hire talent. If leaders want to unleash individual and collective talent, they must foster a psychologically safe climate where employees feel free to contribute ideas, share information, and report mistakes. Imagine what could be accomplished if the norm became one where employees felt their opinions counted in the workplace. I call that a fearless organization.
Discovery by Mistake
My interest in psychological safety began in the mid-1990s when I had the good fortune to join an interdisciplinary team of researchers undertaking a ground-breaking study of medication errors in hospitals. Providing patient care in hospitals presents a more extreme case of the challenges faced in other industries – notably, the challenge of ensuring teamwork in highly-technical, highly-customized, 24/7 operations. I figured that learning from an extreme case would help me develop new insights for managing people in other kinds of organizations.
As part of the study, trained nurse investigators painstakingly gathered data about these potentially devastating human errors over a six-month period, hoping to shed new light on their actual incidence in hospitals. Meanwhile, I observed how different hospital units worked, trying to understand their structures and cultures and seeking to gain insight into the conditions under which errors might happen in these busy, customized, occasionally chaotic operations, where coordination could be a matter of life-or-death. I also distributed a survey to get another view of how well the different patient care units worked as teams.
Along the way, I accidentally stumbled into the importance of psychological safety. As I will explain in Chapter 1, this launched me on a new research program that ultimately provided empirical evidence that validates the ideas developed and presented in this book. For now, let's just say I didn't set out to study psychological safety but rather to study teamwork and its relationship to mistakes. I thought that how people work together was an important element of what allows organizations to learn in a changing world. Psychological safety showed up unexpectedly – in what I would later describe as a blinding flash of the obvious – to explain some puzzling results in my data. Today, studies of psychological safety can be found in sectors ranging from business to healthcare to K–12 education. Over the past 20 years, a burgeoning academic literature has taken shape on the causes and consequences of psychological safety in the workplace, some of which is my own work but a great deal of which has been done by other researchers. We have learned a lot about what psychological safety is, how psychological safety works, and why psychological safety matters. I'll summarize key findings from these studies in this book.
Recently, the concept of psychological safety has taken hold among practitioners as well. Thoughtful executives, managers, consultants, and clinicians in a variety of industries are seeking to help their organizations make changes to create psychological safety as a strategy to promote learning, innovation, and employee engagement. Psychological safety received a significant boost in popularity in the managerial blogosphere after Charles Duhigg published an article in the New York Times Magazine in February 2016, reporting on a five-year study at Google that investigated what made the best teams.8 The study examined several possibilities: Did it matter if teammates have similar educational backgrounds? Was gender balance important? What about socializing outside of work? No clear set of parameters emerged. Project Aristotle, as the initiative was code-named, then turned to studying norms; that is, the behaviors and unwritten rules to which a group adheres often without much conscious attention. Eventually, as Duhigg wrote, the researchers “encountered the concept of psychological safety in academic papers [and] everything suddenly fell into place.”9 They concluded, “psychological safety was far and away the most important of the five dynamics we found.”10 Other behaviors were also important, such as setting clear goals and reinforcing mutual accountability, but unless team members felt psychologically safe, the other behaviors were insufficient. Indeed, as the study's lead researcher, Julia Rozovsky, wrote, “it's the underpinning of the other four.”11 Reflecting her wonderfully concise conclusion, Chapter 1 of this book is titled “The Underpinning.”
Overview of the Book
This book is divided into three parts. Part I: The Power of Psychological Safety consists of two chapters that introduce the concept of psychological safety and offer a brief history of the research on this important workplace phenomenon. We'll look at why psychological safety matters, as well as why it's not the norm in many organizations.
Chapter 1, “The Underpinning,” opens with a disguised true story taking place in a hospital that shows at once the ordinariness of an employee holding back at work – not sharing a concern or a question – as well as the profound implications this human reflex can have for the quality of work in almost any organization. I will also recall the story of how I stumbled into psychological safety by accident early in my academic career.
Chapter 2, “The Paper Trail,” presents key findings from a systematic review of academic research on psychological safety. I don't provide many details of individual studies but rather give an overview of how research on psychological safety has provided evidence supporting the central argument in this book – that no twenty-first century organization can afford to have a culture of fear. The Fearless Organization is not only a better place for employees, it's also a place where innovation, growth, and performance take hold. If readers want to skim this evidence and move quickly to Part II, they will be rewarded by a series of case studies that clearly illuminate first the costs of not having psychological safety and next the rewards of investing in building it.
The four chapters in Part II: Psychological Safety at Work present real-world case studies of workplaces in both private and public-sector organizations to show how psychological safety (or its absence) shapes business results and human safety performance.
Chapter 3, “Avoidable Failure,” digs into cases in which workplace fear allowed an illusion of business success, postponing inevitable discoveries of underlying problems that had gone unreported and unaddressed for a period of time. Here we will see iconic companies that appeared to be industry stars only to suffer dramatic and highly-publicized falls from grace. Chapter 4, “Dangerous Silence,” highlights workplaces where employees, customers, or communities suffered avoidable physical or emotional harm because employees, living in a culture of fear, were reluctant to speak up, ask questions, or get help.
Chapters 5 and 6 take us into organizations that have worked diligently to create an environment where speaking up is enabled and expected. These organizational portraits allow us to see what a fearless organization looks and feels like. They are strikingly different from those highlighted in Chapters 3 and 4, but importantly they are also very different from each other. There is more than one way to be fearless! Chapter 5(“The Fearless Workplace”) presents companies (like Pixar) where creative work is directly and obviously critical to business performance and where leaders understood the need to create psychological safety early in their tenure, as well as companies like Barry-Wehmilller, an industrial equipment manufacturer that underwent a transformational journey to discover that the business thrives when employees thrive. Chapter 6 (“Safe and Sound”) examines workplaces where psychological safety helps to ensure employee and client safety and dignity.
Part III: Creating a Fearless Organization presents two chapters that build on the stories and research presented so far to focus on the question of what leaders must do to create a fearless organization – an organization where everyone can bring his or her full self to work, contribute, grow, thrive, and team up to produce remarkable results.
Chapter 7, “Making It Happen,” tackles the question of what you need to do to build psychological safety – and how to get it back if it's lost. It contains the leader's tool kit. I present a framework with three simple (but not always easy) activities that leaders – at the top and throughout an organization – can use to create a more engaged and vital workforce. We'll see that creating psychological safety takes effort and skill, but the effort pays off when expertise or collaboration matter to the quality of the work. We will also see that the leader's work is never done. It's not a matter of checking the psychological safety box and moving on. Building and reinforcing the work environment where people can learn, innovate, and grow is a never-ending job, but a deeply meaningful one. Chapter 8, “What's Next,” concludes the book, updates a few stories, and offers answers to some of the questions I am most frequently asked by people in companies around the world.
*****
In an era when no individual can know or do everything needed to carry out the work that serves customers, it's more important than ever for people to speak up, share information, contribute expertise, take risks, and work with each other to create lasting value. Yet, as Edmund Burke wrote more than 250 years ago, fear limits our ability for effective thought and action – even for the most talented of employees. Today's leaders must be willing to take on the job of driving fear out of the organization to create the conditions for learning, innovation, and growth. I hope this book will help you do just that.
Endnotes
1
. Burke, E.
A Philosophical Inquiry into the Origin of Our Ideas of the Sublime and Beautiful
. Dancing Unicorn Books, 2016. Print.
2
. Selingo, J.J. “Wanted: Factory Workers, Degree Required.”
The New York Times
. January 30, 2017.
https://www.nytimes.com/2017/01/30/education/edlife/factory-workers-college-degree-apprenticeships.html
Accessed June 13, 2018.
3
. Cross, R., Rebele, R., & Grant, A. “Collaborative Overload.”
Harvard Business Review
. January 1, 2016.
https://hbr.org/2016/01/collaborative-overload
Accessed June 13, 2018.
4
. Edmondson, A.C. “Teamwork on the fly.”
Harvard Business Review 90
.4, April 2012. 72–80. Print.
5
. Edmondson, A.C.
Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy
. San Francisco: Jossey-Bass, 2012. Print.
6
. Gallup.
State of the American Workplace Report
. Gallup: Washington, D.C, 2017.
http://news.gallup.com/reports/199961/state-american-workplace-report-2017.aspx
Accessed June 13, 2018.
7
. Gallup,
State of the American Workplace Report
. 2012: 112
8
. Duhigg, C. “What Google Learned From Its Quest to Build the Perfect Team”
The New York Times Magazine
. February 25, 2016.
https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html
Accessed June 13, 2018.
9
.
Ibid
.
10
. Rozovsky, J. “The five keys to a successful Google team.”
re:Work Blog
. November 17, 2015.
https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/
Accessed June 13, 2018.
11
.
Ibid
.
PART IThe Power of Psychological Safety
1The Underpinning
“Psychological safety was by far the most important of the five key dynamics we found. It's the underpinning of the other four.”
—Julia Rozovsky, “The five keys to a successful Google team.”1
The tiny newborn twins seemed healthy enough, but their early arrival at only 27 weeks' gestation meant they were considered “high risk.” Fortunately, the medical team at the busy urban hospital where the babies were delivered included staff from the Neonatal Intensive Care Unit (NICU): a young Neonatal Nurse Practitioner named Christina Price* and a silver-haired neonatologist named Dr. Drake. As Christina looked at the babies, she was concerned. Her recent training had included, as newly established best practice, administering a medicine that promoted lung development as soon as possible for a high-risk baby. Babies born very prematurely often arrive with lungs not quite ready for fully independent breathing outside the womb. But the neonatologist had not issued an order for the medicine, called a prophylactic surfactant. Christina stepped forward to remind Dr. Drake about the surfactant and then caught herself. Last week she'd overheard him publicly berate another nurse for questioning one of his orders. She told herself that the twins would probably be fine – after all, the doctor probably had a reason for avoiding the surfactant, still considered a judgment call – and she dismissed the idea of bringing it up. Besides, he'd already turned on his heel, off for his morning rounds, white coat billowing.
Unconscious Calculators
In hesitating and then choosing not to speak up, Christina was making a quick, not entirely conscious, risk calculation – the kind of micro-assessment most of us make numerous times a day. Most likely she was not even aware that she had weighed the risk of being belittled or berated against the risk that the babies might in fact need the medication to thrive. She told herself the doctor knew better than she did, and she was not confident he would welcome her input. Inadvertently, she had done something psychologists call discounting the future – underweighting the more important issue of the patients' health, which would take some time to play out, and overweighting the importance of the doctor's possible response, which would happen immediately. Our spontaneous tendency to discount the future explains the prevalence of many unhelpful or unhealthy behaviors – whether eating that extra piece of chocolate cake or procrastinating on a challenging assignment – and the failure to speak up at work is an important and often overlooked example of this problematic tendency.
Like most people, Christina was spontaneously managing her image at work. As noted sociologist Erving Goffman argued in his seminal 1957 book, The Presentation of the Self in Everyday Life, as humans, we are constantly attempting to influence others' perceptions of us by regulating and controlling information in social interactions.2 We do this both consciously and subconsciously.
Put another way, no one wakes up in the morning excited to go to work and look ignorant, incompetent, or disruptive. These are called interpersonal risks, and they are what nearly everyone seeks to avoid, not always consciously.3 In fact, most of us want to look smart, capable, or helpful in the eyes of others. No matter what our line of work, status, or gender, all of us learn how to manage interpersonal risk relatively early in life. At some point during elementary school, children start to recognize that what others think of them matters, and they learn how to lower the risk of rejection or scorn. By the time we're adults, we're usually really good at it! So good, we do it without conscious thought. Don't want to look ignorant? Don't ask questions. Don't want to look incompetent? Don't admit to mistakes or weaknesses. Don't want to be called disruptive? Don't make suggestions. While it might be acceptable at a social event to privilege looking good over making a difference, at work this tendency can lead to significant problems – ranging from thwarted innovation to poor service to, at the extreme, loss of human life. Yet avoiding behaviors that might lead others to think less of us is pretty much second nature in most workplaces.
As influential management thinker Nilofer Merchant said about her early days as an administrator at Apple, “I used to go to meetings and see the problem so clearly, when others could not.” But worrying about being “wrong,” she “kept quiet and learned to sit on my hands lest they rise up and betray me. I would rather keep my job by staying within the lines than say something and risk looking stupid.”4 In one study investigating employee experiences with speaking up, 85% of respondents reported at least one occasion when they felt unable to raise a concern with their bosses, even though they believed the issue was important.5
If you think this behavior is limited to those lower in the organization, consider the chief financial officer recruited to join the senior team of a large electronics company. Despite grave reservations about a planned acquisition of another company, the new executive said nothing. His colleagues seemed uniformly enthusiastic, and he went along with the decision. Later, when the takeover had clearly failed, the executives gathered with a consultant for a post-mortem. Each was asked to reflect on what he or she might have done to contribute to or avert the failure. The CFO, now less of an outsider, shared his earlier concerns, acknowledging that he had let the team down by not speaking up. Openly apologetic and emotional, he lamented that the others' enthusiasm had left him afraid to be “the skunk at the picnic.”
The problem with sitting on our hands and staying within the lines rather than speaking up is that although these behaviors keep us personally safe, they can make us underperform and become dissatisfied. They can also put the organization at risk. In the case of Christina and the newborns, fortunately, no immediate damage was done, but as we will see in later chapters, the fear of speaking up can lead to accidents that were in fact avoidable. Remaining silent due to fear of interpersonal risk can make the difference between life and death. Airplanes have crashed, financial institutions have fallen, and hospital patients have died unnecessarily because individuals were, for reasons having to do with the climate in which they worked, afraid to speak up. Fortunately, it doesn't have to happen.
Envisioning the Psychologically Safe Workplace
Had Christina worked in a hospital unit where she felt psychologically safe, she would not have hesitated to ask the neonatologist whether or not he thought treating the newborns with prophylactic lung medicine was warranted. Here too, she might not even be aware of making a conscious decision to speak up; it would simply seem natural to check. She would take for granted that her voice was appreciated, even if what she said didn't lead to a change in the patient's care. In a climate characterized by psychological safety – which blends trust and respect – the neonatologist might quickly agree with Christina and call the pharmacy to put in a request, or he might have explained why he thought it wasn't warranted in this case. Either way, the unit would be better off as a result. The patients would have received life-saving medication, or the team would have learned more about the subtleties of neonatal medicine. Before leaving the room, the doctor might thank Christina for her intervention. He'd be glad he could rely on her to speak up in case he slipped up, missed a detail, or was simply distracted.
Finally, as she gave the medicine to the babies, Christina might come up with the idea that the NICU could institute a protocol to make sure that that all babies who need a surfactant would get it. She might seek out her manager to make this suggestion during a break in the action. And because psychological safety exists in work groups, rather than between specific individuals (such as Christina and Dr. Drake), it's likely her nurse manager would be receptive to her suggestion.
Speaking up describes back-and-forth exchanges people have at work – from volunteering a concern in a meeting to giving feedback to a colleague. It also includes electronic communication (for example, sending an extra email to ask a coworker to clarify a particular point or seek help with a project). Valuable forms of speaking up include raising a different point of view in a conference call, asking a colleague for feedback on a report, admitting that a project is over budget or behind schedule, and so on – the myriad verbal interactions that make up the world of twenty-first century work.
There is, of course, a range of interpersonal riskiness involved in speaking up. Some cases of speaking up occur after significant trepidation; others feel reasonably straightforward and feasible. Still others simply don't occur – as in the case of Christina in the NICU – because one has weighed the risk (consciously or not) and come out on the side of silence. The free exchange of ideas, concerns or questions is routinely hindered by interpersonal fear far more often than most managers realize. This kind of fear cannot be directly seen. Silence – when voice was possible – rarely announces itself! The moment passes, and no one is the wiser except the person who held back.
I have defined psychological safety as the belief that the work environment is safe for interpersonal risk taking.6 The concept refers to the experience of feeling able to speak up with relevant ideas, questions, or concerns. Psychological safety is present when colleagues trust and respect each other and feel able – even obligated – to be candid.
In workplaces with psychological safety, the kinds of small and potentially consequential moments of silence experienced by Christina are far less likely. Speaking up occurs instead, facilitating the open and authentic communication that shines the light on problems, mistakes, and opportunities for improvement and increases the sharing of knowledge and ideas.
As you will see, our understanding of interpersonal risk management at work has advanced since Goffman studied the fascinating micro-dynamics of face-saving. We now know that psychological safety emerges as a property of a group, and that groups in organizations tend to have very interpersonal climates. Even in a company with a strong corporate culture, you will find pockets of both high and low psychological safety. Take, for instance, the hospital where Christina works. One patient care unit might be a place where nurses readily speak up to challenge or inquire about care decisions, while in another it feels downright impossible. These differences in workplace climate shape behavior in subtle but powerful ways.
An Accidental Discovery
As much as I'm passionate about the ideas in this book, I didn't set out to study psychological safety on purpose. As a first-year doctoral student in the process of clarifying my research interests for my eventual dissertation, I had been fortunate to join a large team studying medical error in several hospitals. This was a great way to gain research experience and to sharpen my general interest in how organizations can learn and succeed in an increasingly challenging, fast-paced world. I had long been interested in the idea of learning from mistakes for achieving excellence.
My role in the research team was to examine the effects of teamwork on medical error rates. The team had numerous experts, including physicians who could judge whether human error had occurred and trained nurse investigators who would review medical charts and interview frontline caregivers in patient care units in two hospitals to obtain error rates for each of these teams. These experts were, in effect, getting the data for what would be the dependent variable in my study – the team-level error rates. This was a great arrangement for me, for at least two reasons. First, I lacked the medical expertise to identify medical errors on my own. Second, from a research methods perspective, it meant that my survey measures of team effectiveness would not be subject to experimenter bias – the cognitive tendency for a researcher to see what she wants to see rather than what is actually there. So the independence of our data collection activities was an important strength of the study.7
The nurse investigators collected error data over a six-month period. During the first month, I distributed a validated instrument called the team diagnostic survey to everyone working in the study units – doctors, nurses, and clerks – slightly altering the language of the survey items to make sure they would make sense to people working in a hospital, and adding a few new items to assess people's views about making mistakes. I also spent time on the floor (in the patient care units) observing how each of the teams worked.
Going into the study, I hypothesized, not surprisingly, that the most effective teams would make the fewest errors. Of course, I had to wait six months for the data on the dependent variable (the error rates) to be fully collected. And here is where the story took an unexpected turn.
First, the good news (from a research perspective anyway). There was variance! Error rates across teams were strikingly different; indeed, there was a 10-fold difference in the number of human errors per thousand patient days (a standard measure) from the best to the worst unit on what I sincerely believed was an important performance measure. A wrong medicine dosage, for example, might be reported every three weeks on one ward but every other day on another. Likewise, the team survey data also showed significant variance. Some teams were much stronger – their members reported more mutual respect, more collaboration, more confidence in their ability to deliver great results, more satisfaction, and so on – than others.
When all of the error and survey data were compiled, I was at first thrilled. Running the statistical analysis, I immediately saw that there was a significant correlation between the independently collected error rates and the measures of team effectiveness from my survey. But then I looked closely and noticed something wrong. The direction of the correlation was exactly the opposite of what I had predicted. Better teams were apparently making more – not fewer – mistakes than less strong teams. Worse, the correlation was statistically significant. I briefly wondered how I could tell my dissertation chair the bad news. This was a problem.
No, it was a puzzle.
Did better teams really make more mistakes? I thought about the need for communication between doctors and nurses to produce safe, error-free care. The need to ask for help, to double-check each other's work to make sure, in this complex and customized work environment, that patients received the best care. I knew that great care meant that clinicians had to team up effectively. It just didn't make sense that good teamwork would lead to more errors. I wondered for a moment whether better teams got overconfident over time and then became sloppy. That might explain my perplexing result. But why else might better teams have higher error rates?
And then came the eureka moment. What if the better teams had a climate of openness that made it easier to report and discuss error? The good teams, I suddenly thought, don't make more mistakes; they report more. But having this insight was a far cry from proving it.
I decided to hire a research assistant to go out and study these patient care teams carefully, with no preconceptions. He didn't know which units had made more mistakes, or which ones scored better on the team survey. He didn't even know my new hypothesis. In research terms, he was “blind” to both the hypothesis and the previously collected data.8
Here is what he found. Through quiet observation and open-ended interviews about all aspects of the work environment, he discovered that the teams varied wildly in whether people felt able to talk about mistakes. And these differences were almost perfectly correlated with the detected error rates. In short, people in the better teams (as measured by my survey, but unbeknownst to the research assistant) talked openly about the risks of errors, often trying to find new ways to catch and prevent them. It would take another couple of years before I labeled this climate difference psychological safety. But the accidental finding set me off on a new and fruitful research direction: to find out how interpersonal climate might vary across groups in other workplaces, and whether it might matter for learning and speaking up in other industries – not just in healthcare.
Over the years, in studies in companies, hospitals, and even government agencies, my doctoral students and I have found that psychological safety does indeed vary, and that it matters very much for predicting both learning behavior and objective measures of performance. Today, researchers like me have conducted dozens of studies showing greater learning, performance, and even lower mortality as a result of psychological safety. In Chapter 2, I will tell you about some of the studies.
In that initial study over two decades ago, I learned that psychological safety varies across groups within hospitals. Since that time, I have replicated this finding in many industry settings. The data are consistent in this simple but interesting finding: psychological safety seems to “live” at the level of the group. In other words, in the organization where you work, it's likely that different groups have different interpersonal experiences; in some, it may be easy to speak up and bring your full self to work. In others, speaking up might be experienced as a last resort – as it did in some of the patient-care teams I studied. That's because psychological safety is very much shaped by local leaders. As I will elaborate later in this book, subsequent research has borne out my initial, accidental discovery.
