Psychological Safety: a critical component of effective teamwork

Safe, high-quality healthcare today requires multidisciplinary teams working together effectively in complex, high-stakes situations. Psychological safety, defined as a shared understanding that interpersonal risk-taking is safe among a team, is a critical component of effective teamwork (Zajac et al., 2025).  In practice, this looks like individuals freely expressing concerns, asking questions, or sharing ideas without concern for negative consequences (Malik et.al., 2024). When frontline staff feel safe to cross-check each other, hold each other accountable, speak up about safety concerns, and report safety events and near misses, the chances of catching errors before they happen and preventing patient harm increase. These represent both real-time safety behaviors and actions that help to uncover system gaps. Based on the information gained, solutions can then be developed to prevent future recurrences. In contrast, when psychological safety is lacking, healthcare workers are less inclined to voice concerns or report safety incidents. This potentially results in critical errors, failure to report to management, and missed opportunities to improve systems of care (Zajac et al., 2025).  The following article describes a case example, factors influencing psychological safety, and strategies for improvement. 

Case example from the front lines

The following is a story about a new nurse, Jenny, who recently graduated from nursing school, and her experience working in dialysis. It demonstrates the impact of a culture lacking psychological safety. 

In this unit, nurses cared for patients in pods, small areas designated for 4-5 patients, with 2 nurses assigned to a pod. This required working closely with your colleague: setting up and breaking down the machines, including any special dialysate solutions, performing pre- and post-treatment assessments, cannulating access sites, monitoring vitals, and administering medications. 

Jenny had been working on this unit for several months. Most of the staff had longevity in the unit. Among them was a senior nurse, Sally who was known to be a bully. For an unknown reason, she did not care for Jenny and made this well-known. While working together, she would often make demeaning comments, quietly so that others could not hear and witness this behavior. Jenny became a target for her passive-aggressive actions, rude comments, and downright mean-girl behavior both at work and at any outside social functions. 

One day, before any patients had arrived, Jenny noticed Sally had set up the wrong dialysate solution. She swiftly changed it, without mentioning a word. She was afraid to point out her mistake, for fear of any subsequent backlash behaviors. This could have caused a patient safety issue and would have been a valuable learning opportunity for her and others, but she remained silent out of concern for repercussions. 

This impacted her personally and professionally. She dreaded going to work and felt an uneasiness in her gut every day before walking in- both not knowing and anticipating what she would have to endure. One day she gathered up the courage to have a conversation with her. Her goal was to try to determine the cause of this behavior and how they could move forward positively. She pulled her aside before their shift and shared her concerns professionally, apologizing for any possible misunderstanding. It only made things worse, leading to escalated behaviors. 

After months of enduring this, she eventually reported this to nursing leadership, who required that Sally participate in a communication training course. She then went on to broadcast this to the entire team. Jenny’s lesson learned was not to speak up, but rather to remain silent and endure. After a year, she left this job, in part due to this encounter, and because she knew end-of-life care was not where she wanted to specialize in nursing. As a result of this experience, Jenny developed a “thicker skin” and used it to build resilience. If she could endure this, she could endure anything. 

Factors influencing psychological safety 

This example represents the culture just beyond the bedside that impacts patient care. It exemplifies several factors influencing psychological safety: unprofessional behaviors, negative repercussions, lack of trust among team members and leaders. It also demonstrates the impact of psychological safety on individual mental health and well-being. Unprofessional behaviors include belittling comments, passive-aggressive and disrespectful actions, and purposeful efforts to create trouble for others. These contribute to a tense, uncomfortable environment. Bullying, disruptive behavior, and intimidation have been described as violence and include actions such as putdowns and insults. Violence often results in silence, also seen in the case example provided, and contributes to burnout and staff turnover (Maxfield et al., 2013). 

Negative repercussions refer to the concern that speaking up will result in dismissal, criticism, or being labeled a troublemaker or someone who is not a team player. Past experiences of feeling unsafe lead to a lack of trust among team members and leaders. Without trust, it’s more difficult to ask for help and ask questions without feeling as if one has to do or know it all. Trust is built through open and honest sharing of workplace situations by team members. Leaders facilitate trust in team members by showing up consistently, whether for frontline staff and leaders, treating everyone fairly, being open to different views, and supporting those who speak up (Zajac et al., 2025). 

Other factors influencing psychological safety in healthcare workers include: being valued, leader openness, power distance, impact on others, and communication dynamics. Being valued refers to the perception that colleagues care about you as an individual, and honor your thoughts and viewpoints. This takes into consideration both work experience and challenges that may be occurring outside of work. Leader openness is exemplified when leaders treat everyone fairly, hold people accountable, are open to others’ opinions, and exhibit vulnerability. An example of the latter is sharing similar experiences, feelings or even past failures (Zajac et al., 2025).  A power gradient exists when those high in the hierarchy are seen as holding all the power and decision-making. Typically, physicians hold positions high in the hierarchy. This contributes to conditions in which other team members’ contributions are less valued and speaking up with concerns is more difficult. 

Concerns around the impact on others from reporting mistakes or speaking up include the following potential consequences: hurting a colleague’s feelings, or getting them in trouble, perceptions of being disrespectful or being misinterpreted (Zajac et al., 2025). 

Further communication dynamics, including difficulty in going directly to individuals involved when a conflict occurs, contribute to a lack of psychological safety. It’s not unusual to avoid conflict. Instead, side conversations with others often occur, leading to potential misunderstandings, negative opinions, and gossip. Consider this perspective- when a situation is reported to leadership that could have been initially addressed with a direct conversation with the individual involved, it leaves leadership in the middle. What happens when leaders are put in the middle? It sets up an uncomfortable dynamic. If the leader goes to the respective individual with concerns, that person knows that the complaint has been taken to the leadership level and this may be hurtful to the individual involved. Most people prefer having a conversation first before an issue gets escalated to management. As a general practice, going directly to the individual is the respectful, right thing to do. If that doesn’t rectify the situation, or if guidance is needed on how to have the initial conversation, the next step is going to leadership. 

A qualitative study by Malik et al. (2024) explored obstetric and gynecologic healthcare professionals' beliefs around speaking up. They found that healthcare workers are more likely to speak up to a colleague they are fond of, due to perceived good intentions by the person receiving the information. Here are several examples from frontline staff of how relationships, good or bad, can impact speaking up. 

Well, that you feel safe to express things and not afraid of being punished or that you get hit on the head. I do not feel fear with the doctors, but I do have some fellow nurses where I do not dare to say anything because they just have very strong opinions. (...) otherwise you will have to take the bullet and you just don’t feel like doing so (Nurse). (Malik et al., 2024, p. 5)

...you know, when you’re dealing with a person with whom you don’t share a nice relationship or merely a good work relationship, then I would really watch my words carefully. And yes, that isn’t really safe of course; yet it happens a lot, I would say more than half of the time (Midwife). (Malik et al., 2024, p. 5)

Strategies for improving psychological safety 

The solution to improving psychological safety is not a one-size-fits-all approach. It must be targeted to the specific issues being experienced. The following are some practical recommendations based on the identified factors influencing psychological safety:

Leadership

• Hold staff accountable for unprofessional behavior

• Implement interdisciplinary training (ie. simulation)- to leverage separate realities as team members share and understand different perspectives, and foster an appreciation for various roles 

• Implement TeamSTEPPS® (a registered trademark of the Agency for Healthcare Research and Quality, AHRQ) programs

• Exhibit vulnerability through storytelling- sharing of one’s own mistakes and lessons learned 

• Encourage a no-blame culture focused on continuous learning and improvement 

• Conduct debriefings 

  • Solicit feedback from less experienced/new team members first, as they may be less intimidated to provide information that may be different from seasoned colleagues (Zajac et al., 2025)

• Ensure team members’ feel valued and heard, when providing input during decision making activities (Malik et al., 2024)

• Support direct communication when conflict arises:

  • Ask “how did the person respond when you shared this information with them?” 

  •  If the individual did not have a direct conversation, suggest doing so. Give suggestions if needed, and follow up to ensure the conversation has occurred. It may also be helpful to have a conversation together.

Team Members

• As a receiver, be open to those who are voicing concerns- this fosters trust and respect (Malik et al., 2024)

• Have each other’s back 

• Take the time to get to know people, especially the newbies 

• Don’t contribute, and even better, silence gossip and destructive chatter 

• Consider what it’s like to walk in someone else’s shoes 

• Acknowledge the value in all team members (new, experienced, different disciplines)

• Have direct conversations with folks when there is conflict (afterwards is ok if things are heated and allows time to think about the right approach)

  • Here’s an example from my own practice. This involved a conversation with a provider who had been called to the bedside to evaluate an abnormal fetal heart tracing that had resolved after standard, corrective measures were initiated.  An unprofessional comment was made regarding actions that should have been performed, all in front of the patient. In response, I kindly asked him to step outside the patient’s room for a word before he left. I shared that his statements felt contradictory and unprofessional, undermining the trust and relationship that I had built with the patient. I suggested that, in moving forward, if any concerns existed, unless there was an immediate safety issue, they should be kindly addressed outside of the patient’s room. It never happened again, and served to strengthen the relationship with the provider and me. 

    
    

References 

Maxfield, D. G., Lyndon, A., Kennedy, H. P., O’Keeffe, D. F., & Zlatnik, M. G. (2013). Confronting safety gaps across labor and delivery teams. American Journal of Obstetrics & Gynecology, 209(5), 402–408.

Malik, R. F., Azar, P., Taimounti, A., Buljac‑Samardžić, M., Hilders, C. G. J. M., & Scheele, F. (2024). How do cultural elements shape speak‑up behavior beyond the patient safety context? An interprofessional perspective in an obstetrics and gynecology department. Frontiers in Medicine, 11, 1345316. https://doi.org/10.3389/fmed.2024.1345316

Zajac, S. A., Williams, K. N., Patel, S. M., Lazzara, E. H., Keebler, J. R., Clemens, M. W., & Holladay, C. L. (2025). Understanding psychological safety in health care: A qualitative investigation and practical guidance. The Joint Commission Journal on Quality and Patient Safety, 51(10), 534–547.

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💡 If you appreciate this kind of simplified, bite-sized ONQS content, my book provides an expanded version of the same approach: 📘 Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses Available on Amazon: Amazon_obneonatalstudyguide

About the Author

Jeanette Zocco, MSN, RNC-OB, C-EFM, C-ONQS, is a leader in perinatal quality and safety with 28 years of experience in obstetrics. She has served as a bedside nurse, charge nurse, clinical nurse leader, perinatal safety nurse, and quality improvement specialist. Currently, she is a perinatal patient safety program manager, supporting quality and safety work for a multi-hospital healthcare system. Jeanette is recognized for developing innovative perinatal quality and safety programs in collaboration with multidisciplinary teams.

Copyright by Jeanette Zocco MSN RNC-OB, C-EFM, C-ONQS