Shifting the Culture in Healthcare From Silence to Empowerment

We’ve all faced moments where we’ve hesitated to speak up. Worried about how others will perceive us, we wonder: Will I sound unintelligent? Does everyone else already know this? Will I be seen as troublesome for bringing it up? Consciously or not, the weight of our peers’ and superiors’ judgments is there.

This weight is particularly prevalent in healthcare, and my conversations with friends in the industry—nurses, residents, doctors—reveal a resigned acceptance of this status quo. Sentiments like “There’s no point in speaking up. Nothing happens,” and “It’s a rite of passage,” are heard often.

culture in healthcare

And yet, in a field where continuous feedback, learning, and innovation are critical to improving patient outcomes and quality of care, this culture of silence in healthcare is concerning. What are the impacts of this environment, and should it—can it—change?

The effect of strict structures and culture on healthcare

The stakes are high in healthcare. With people’s lives and well-being on the line, the pressure to perform flawlessly is ever-present. As a result, a zero-tolerance attitude has taken root, where mistakes are seen as unacceptable, even punishable. Some call it a culture of blame—a pervasive mindset in which nobody wants to be at fault.

Adding to this pressure is the rigid hierarchy that defines the healthcare landscape. From top to bottom, there’s a clear chain of command that’s strictly followed. This hierarchy dictates who is heard, blamed, and protected.

This dynamic can lead to fear and stifle open communication at every level:

  • Professionals, regardless of experience, often hesitate to admit their own mistakes for fear of reprisal.
  • Those at the top, possessing the most authority, may dismiss criticism and have the power to deflect blame onto their subordinates.
  • Junior team members regularly find themselves voiceless, afraid to challenge their superiors for fear of alienation or being labeled as incompetent or troublemakers.

Unfortunately, this dynamic breeds stagnation within organizations. The resultant environment is often one where feedback processes are weak, with team members lacking the confidence or opportunity to offer constructive criticism or innovative ideas that could lead to better processes and outcomes.

For instance, a survey of junior doctors in specialist training spoke about their fear of speaking up and challenging senior doctors. Many expressed a sense of powerlessness, which led to feelings of anger, resentment, and disillusionment. They even recounted instances of intimidation, bullying, and humiliation by senior staff, which often went unchallenged and unquestioned.

Healthcare’s perfectionist approach doesn’t necessarily lead to greater performance.

Another study discovered that hierarchy played a significant role in why nurses find it difficult to report child abuse. Scared of making mistakes and feeling stuck because of strict rules and unclear procedures, the nurses would hesitate or be confused when it came to reporting possible instances of abuse.

The reality is that healthcare’s perfectionist approach doesn’t necessarily lead to greater performance. In fact, fostering fear, stifling communication, and inhibiting innovation can actually hinder progress and compromise patient care.

The need for psychological safety and a just culture

The nature of healthcare means that we never want to encourage mistakes or failure. The issue here is when all errors are treated as equally shameful despite some being beyond control.

Take, for instance, a routine procedure executed incorrectly versus an unexpected reaction to medication. While the circumstances surrounding them differ vastly, both are reported as errors. This lack of differentiation makes it challenging for healthcare professionals to discuss and learn from mistakes openly.

As Harvard professor and author Amy Edmonson asserts, expecting flawless performance in a system as inherently prone to errors as healthcare sets an unrealistic standard. Mistakes will inevitably happen. What truly matters is how we respond to them and what we learn from them.

As Amy Edmonson asserts, expecting flawless performance in a system as inherently prone to errors as healthcare sets an unrealistic standard.

Edmondson’s research into error-making and teamwork in hospitals backs this up.
Initially expecting high-performing teams to make fewer mistakes, she discovered the opposite. The best teams, as indicated by diagnostic surveys, actually reported higher error rates. This discovery challenged conventional wisdom. Perhaps it’s not that better teams make more mistakes but that “they’re more willing and able to talk about them.”

Indeed, the most successful teams foster an environment where “everyone, from the lowest ranking employee to the highest, felt empowered to speak up.” Termed “psychological safety” by Edmondson, this climate encourages learning and improvement and has since been shown to be a “critical component of successful teams.”

What’s a just culture?

In parallel with the concept of psychological safety, some healthcare organizations have embraced a similar framework known as a “just culture.”

A just culture in healthcare seeks to step away from blame and punishment, with researchers arguing that “the use of retributive justice mechanisms, focusing on punishment, hinders the ability of an organization to learn from mistakes.”

Instead of pointing fingers, just culture focuses on collective responsibility and improvement.

Instead of pointing fingers, just culture focuses on collective responsibility and improvement. When an error occurs, the priority is understanding what went wrong and how to prevent it from happening again. Team members are encouraged to speak up and voice concerns, not just when mistakes occur but to enhance overall healthcare practices.

Undoubtedly, the ethos of a just culture aligns closely with the concept of psychological safety. Both emphasize an environment where people feel safe to speak up, finding that openness is crucial not just for ensuring that errors are acknowledged but that they become opportunities for learning and improving patient care and safety.

Encouraging an innovative culture in healthcare

Creating an environment where people feel comfortable speaking up is crucial not only for improving performance but also for fostering innovation. In contrast to healthcare’s traditional focus on “conformity, consistency, efficiency, and survival,” climates of psychological safety and just cultures naturally promote a culture of innovation.

Healthcare organizations are frequently seen as less innovative compared to other sectors because the culture often emphasizes adherence to established protocols and procedures. This focus, while essential for ensuring patient safety and operational efficiency, can inadvertently stifle creative thinking and the exploration of new ideas. But it doesn’t have to.

The same principles that underpin high performance—psychological safety, just culture, and continuous learning—are also the foundation for a culture of innovation in healthcare.

Innovation is not something to be achieved at the expense of safety and organizational stability. In fact, it can and should be directed towards enhancing both ideals. However, in addition to the established safety protocols and procedures, true innovation requires a safe and supportive environment where employees feel comfortable sharing their ideas and taking measured risks. Additionally, when innovation efforts don’t go as planned, it’s crucial for leaders to encourage their teams to learn from these experiences.

In other words, the same principles that underpin high performance—psychological safety, just culture, and continuous learning—are also the foundation for a culture of innovation in healthcare.

Concerns and criticisms

While striving for an open and supportive environment in healthcare has many positives, it also brings up legitimate concerns, particularly regarding the balance of hierarchy and accountability.

One common argument is that a strict hierarchy is essential for directing care delivery, setting priorities, and impacting how healthcare workers communicate and collaborate. However, as Edmondson clarifies, hierarchy in itself isn’t the issue — it’s how those with higher status handle their roles. Teams with similar hierarchical structures can experience vastly different levels of psychological safety based on the behavior of their leaders.

True accountability is achieved by conveying, motivating, and inspiring high standards while fostering psychological safety.

Concerns about holding individuals accountable for poor performance are also common. However, accountability through fear and punishment often becomes a barrier to continuous learning and innovation. Instead, true accountability is achieved by “conveying, motivating, and inspiring high standards” while fostering psychological safety.

The difference is an emphasis on shared accountability and problem-solving. Rather than being punished, team members are expected to share their mistakes with the team and uncover solutions. As Anthony Warmuth, an Executive Director at Cleveland Clinic, explains, “Just culture is about accountability for underlying systemic problems to improve safety and prevent harm. It’s also about people feeling safe saying, ‘I made this mistake. Let’s find out why.’”

The road to empowerment in healthcare organizations

So, how can organizations encourage a more just and psychologically safe environment? A paper by Dr. Mina Sarofim recommends a multi-prong approach which includes 1) implementing change at an institutional level, 2) creating an atmosphere of open communication, and 3) providing regular training and simulation education. Some additional practical advice drawn from experts and successful healthcare organizations include:

  1. Clarifying Shared Goals and Perspectives: Edmondson encourages explicitly defining the shared goal of providing excellent patient care and recognizing the diverse perspectives and skills of each team member. After all, understanding medicine doesn’t equate to identical approaches, so discussions on objectives, challenges, and individual contributions are necessary.
  2. Fostering Psychological Safety: In addition to ensuring everyone is on the same page, leaders should lead by example by proactively “acknowledging their own fallibility,” inviting engagement by “asking good questions,” and actually acting on employee’s input.
  3. Normalize Feedback: Make giving and receiving feedback a core competency for all team members. Leaders should model effective feedback practices, empowering employees to provide constructive feedback to peers and superiors alike. Normalize feedback as an “act of caring,” shifting the mindset from criticism to constructive support for continuous improvement.
  4. Provide Training and Education: As recommended above, teams need to be supported and provided resources throughout this change. Role-playing exercises have been recommended to help team members practice effective communication and reporting mechanisms, shifting the focus from individual blame to systemic improvement.

All in all, it’s clear that conscious and intentional effort is required to foster a culture in healthcare where continuous improvement thrives alongside high performance. At UCLA Health, for instance, a strategic approach began with a formal assessment of cultural perceptions followed by the development of 40 “culture champions” who would facilitate change and introduce just-culture principles in their units.

Similarly, Cincinnati Children’s Hospital underwent a culture refresh focused on psychological safety in 2019, which included training for “all 15,000 leaders and staff on empowering front-line employees to voice safety concerns during active events.”

In his interview with Healthcare Executive, Chief Quality Officer Stephen Muething, MD, proudly described the effect: “When people visit to learn from us, they’re struck by how openly and actively we learn from events every day. Everybody’s talking about what they can do better and what they learned. They don’t take joy in not finding problems; they take joy in finding them.”

For more insights on achieving organizational change and alignment, reach out to us here at Tronvig.

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