The majority of infection preventionists (IPs) surveyed in a new study1 reported the lack of a strong “psychological safety” culture in their hospitals, meaning workers may be less likely to point out breaks in aseptic technique and other incidents that could undermine patient safety.
In contrast, the 38% of responding hospitals reporting a strong climate of psychological safety had infection control practices that reflected this work culture. For example, IPs in these hospitals regularly use urinary catheter reminders, stop-orders, and nurse-initiated catheter discontinuation to prevent urinary tract infections. Similarly, IPs in cultures of psychological safety frequently used “sedation vacation” approaches to prevent ventilator-associated pneumonia.
Another classic example from the medical literature is the dramatic reduction in central-line bloodstream infections after nurses and other team members were given the power to “stop the line” if they saw a break in technique during insertion.2
“Our finding that the large majority of responding hospitals did not report high psychological safety is concerning, but not unexpected,” the authors of the current study conclude. “Much of the literature on psychological safety provides little insight into how psychological safety unfolds and builds, or lessens, or even is destroyed. What is known is that an environment that supports psychological safety does not emerge naturally.”
That begs the question of how IPs can strengthen this sense of safety and empowerment.
“The best way to start building a culture of psychological safety is to ask people if they feel safe to speak up if they see an issue, mistake, or have an idea for improvement,’” says lead author Todd Greene, PhD, MPH, an epidemiologist and research scientist at the University of Michigan. “Another approach is to include in rounds the question, ‘Is everything as safe as you wanted it to be?’ Then follow up with, ‘What do you need?’”
Of course, needed changes may not be addressed without the involvement and support of administration.
“The culture of any healthcare organization is heavily shaped by the worst behavior that the leaders knowingly tolerate,” Greene says. “As leaders within their organizations, IPs help shape that culture.”
A ‘Shared Belief’
Greene and colleagues surveyed IPs in a random sample of some 900 U.S. acute care hospitals in 2017. They sought input on hospital and infection control program characteristics, organizational factors, and the use of practices to prevent common healthcare-associated infections (HAIs).
On a five-point scale, IPs that gave their hospital a 4 or 5 ranking on seven key questions were classified as having a work culture with high psychological safety.
“Psychological safety is a shared belief that team members will not be reprimanded, punished, or embarrassed for speaking up, sharing ideas, posing questions, raising concerns, or making mistakes,” the researchers report.
The overall survey response rate was 59% (528 of 897).
“Although nearly 80% of hospitals were involved in collaborative efforts to reduce HAIs, only 53% of hospitals reported receiving strong to very strong support for infection control programs from hospital leadership,” the authors found. “Over 41% of hospitals reported they had a hospital epidemiologist, and 62% had a lead infection preventionist certified in infection control. Less than half (47%) of hospitals had a program engaging patients and families in infection prevention.”
The overall results for the psychological safety questions were as follows:
- Do you assert your views on important issues, even though your supervisor may disagree? (88%)
- I personally feel comfortable speaking up when I see a physician not clean his or her hands. (81%)
- When a medical error occurs at this hospital, healthcare workers are encouraged to discuss mistakes in order to learn how to prevent similar future errors. (91%)
- If you make a mistake at this hospital, it is often held against you. (5%)
- Staff members at this hospital are able to bring up problems and tough issues. (77%)
- It is safe to try something new at this hospital. (66%)
- At this hospital, people are too busy to invest time in improvement. (15%)
“It is not surprising that high levels of psychological safety are associated with frequent use of socioadaptive safety interventions, such as nurse-initiated urinary catheter discontinuation or ventilator sedation vacation,” the authors conclude. “These practices require communication between nurses, respiratory therapists, and physicians, efforts by bedside staff to engage with patient and family requests, and the willingness to speak up and challenge entrenched customs and practices.”
Speaking a Truth
Lakshman Swamy, MD, MPH, a critical care clinician at Boston Medical Center, has been involved in efforts to improve psychological safety at the facility. He was not involved in the study but has witnessed firsthand how the fear of repercussions impair infection control efforts.
Part of improving a culture of safety is for those in power to show “situational humility,” Swamy noted recently in Orlando at the Institute for Healthcare Improvement’s 2019 forum, held Dec. 8-11. Swamy recalled a surgeon at a meeting with members of nursing and other disciplines who asked for input on a case, saying — quite unexpectedly — that he was not sure he made the right decision.
“That one statement changed everything. Suddenly, you had the interns, the nurses, everyone in the room was asking questions,” he said. “If [the surgeon] could say that, then the rest of us could ask the questions that otherwise we might not have the psychological safety to ask.”
In a follow-up email exchange, Hospital Infection Control & Prevention asked Swamy for further comment on psychological safety.
“In almost all cases, front-line clinicians care deeply about the patient’s well-being and put the care of the patient first,” he replied. “But the truth is that the environments we work in can actively work against that very ideal. We’re recognizing that more and more clinical environments — especially learning environments — are toxic in one respect or another.”
This toxicity can be manifested in “aggressive hierarchies” that exhaust clinicians and contribute to burnout, Swamy says. “This certainly is a major barrier to psychological safety and it relates directly to infection prevention and is evident in my work in the intensive care unit,” he says.
Swamy relayed the following vignettes from other institutions where he previously worked, with details slightly altered to preserve anonymity:
- Dr. S. is the resident on an intensive care unit. She knows Rob, the nurse taking care of Mr. C., has been rough with her and other residents in the past, openly ridiculing residents on rounds in front of the team. He also has made a number of comments to the families about waiting to speak to the doctor, referring to her attending and bypassing her entirely. Dr. S.’s patient, Mr. C., has had a central line in place for several days, and from her perspective, it is time to take it out. She knows Rob is going to get upset by this — he wants the line for blood draws. Dr. S. knows bringing it up will lead to an argument — she probably will be mocked and belittled on rounds again. The checkbox “remove CVC” has been on her to-do list for two days now.
- Amy is a floor nurse on a med-surg unit. Her patient is on C. diff precautions because of persistent diarrhea. The attending is notoriously grumpy and chews out nurses for things entirely out of their control. She notices, day after day, that the doctor is not properly washing his hands with soap and water after he leaves the patient’s room. She is not sure if he is unaware that the alcohol-based hand sanitizer is inadequate for C. diff, or if he just does not care. Amy does not know how to approach him about this, and she is feeling torn between her desire to do what is right and the risk of being attacked for speaking up.
“Both of the cases reflect a lack of psychological safety,” he says. “It isn’t about being coddled, and it isn’t utopian. Far from it; it is extremely practical, even gritty. It is all about hearing what you may not want to hear, and the ability of others to speak that truth.”
- Green MT, Gilmartin HM, Saint S. Psychological safety and infection prevention practices: Results from a national survey. Am J Infect Control 2020;48:2-6.
- Centers for Disease Control and Prevention. Vital signs: Central line-associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011;60:243-248.