Psychological Safety is the foundation for high performing teams and resilient organisations. When people on a team possess psychological safety, they feel able to ask for help, admit mistakes, raise concerns, suggest ideas, and challenge ways of working and the ideas of others on the team, including the ideas of those in authority. Via this honesty and openness, risks are reduced, new ideas are generated, the team is able to execute on those ideas and everyone feels included. Building psychological safety not only improves organisational outcomes, but it’s the right thing to do.
This is an evolving piece of work. If you spot an error, an improvement, or would like to suggest an addition, please get in touch.
In 1986, the nuclear power plant at Chernobyl in the Ukrainian SSR (the territory of modern Ukraine) suffered a major disaster that directly killed 31 people and is estimated to have indirectly killed tens of thousands. Whilst the plant itself possessed an inherently unsafe design, the wider culture in the Soviet Union at the time did not encourage raising concerns or speaking up about mistakes. A fear of authority and the need to please political masters in the communist party resulted in a fear-driven culture. During a simulated power shutdown, operators who were concerned about the safety of the process, including shutting off or ignoring safety systems, were not able to raise concerns. The test was executed, and resulted in a steam explosion, followed by a nuclear explosion. Combined with a lack of safety features such as concrete containment and water moderators, this resulted in a cloud of radiation that spread across Ukraine and Europe.
The cause of the disaster was in large part due to a lack of psychological safety resulting in operators not speaking up about their concerns. Of course, there is no root cause, but the official findings state that the RBMK-1000 reactor could *only* have been operated in an environment where there was no safety culture.
I’ve just finished reading “Chernobyl, History of a Tragedy” by Harvard University’s history professor Serhii Plokhy. This is an incredibly and meticulously researched book, describing in great detail the events leading up to the disaster at the RBMK-1000 reactor in the Ukrainian SSR, now Ukraine. Describing the sociotechnical, sociopolitical, cultural, and technological causes for the disaster and how it unfolded, it contrasts with the HBO mini-series that depicted Viktor Bryukhanov, Nikolai Fomin, and Anatoly Dyatlov as villains of the event. In fact, they were intelligent and highly skilled individuals who were at the mercy of Soviet state inefficiency, culture, and practice of severe penalties for mistakes: all three ended up in jail for years after the event, despite doing their best, and suffering radiation poisoning as a result, to protect people from the disaster.
When Paul O’Neill took over as CEO at Alcoa, an aluminium manufacturer, in 1987, he shocked board members and shareholders by pivoting the company strategy to safety and process over purely financial targets. Despite Alcoa already having a good safety record, he declared that he was aiming for zero injuries, and that unlike other manufacturing environments, he declared any level of risk to employees unacceptable. He encouraged everyone in the organisation to raise concerns, ideas, and mistakes with respect to process and safety. He even wrote to every employee, giving out his phone number, and asking them to call him if they spotted a safety issue.
Though it’s unlikely he used the word, what he was creating was an environment of psychological safety, and that psychological safety didn’t just result in fewer accidents, but in higher productivity, better quality, improved innovation and employee satisfaction. As well as fewer people suffering physical injury or death. By the time Paul left Alcoa, he’d improved the market value of Alcoa from $3 billion to over $27 billion.
The term “psychological safety” itself is believed to have been first coined in 1954 by clinical psychologist Carl Rogers in a collection of papers on Creativity, collated by P E Vernon, in the context of establishing conditions where an individual feels they possess “unconditional worth“, and fostering an environment where external evaluation is absent.
Subsequently introduced into the field of management studies by Edgar Schein and Warren Bennis in the 1960s, psychological safety was first defined as group phenomenon that reduces interpersonal risk. To quote Schein and Bennis’s book “PERSONAL AND ORGANIZATIONAL CHANGE THROUGH GROUP METHODS : THE LABORATORY APPROACH” in 1965, psychological safety reduces “a person’s anxiety about being basically accepted and worthwhile”.
Deming, in his 14 Points for Management, also raises the point of reducing fear of interpersonal risk taking in point 8: “Drive out fear, so that everyone may work effectively for the company”. This highlights a growing change in sentiment at the time, away from reductionist and Taylorist views of workers towards more a progressive paradigm of empowerment and engagement to improve business outcomes.
“Wherever there is fear, there will be wrong figures.”
– W E Deming, The New Economics.
William Kahn, in 1990, renewed interest in psychological safety with his paper “Psychological Conditions of Personal Engagement and Disengagement at Work” where he described psychological safety as:
“the sense of being able to show and employ one’s self without fear of negative consequences to self-image, status or career.” (p.705, Kahn, W.A., 1990. Psychological conditions of personal engagement and disengagement at work. Academy of management journal, 33(4), pp.692-724.) Kahn in this respect refers to an individual sense of safety, with the implication of a group dynamic that could result in negative consequences. As we’ll see, the concept has since expanded to explicitly describe a group phenomenon, under Amy Edmondson.
At the same time, progressive management paradigms such as safety culture, Deming’s System of Profound Knowledge and his 14 Points of Management, and the Toyota Production System (TPS) were emerging that introduced concepts such as the the Andon Cord, which empowers employees to raise issues or concerns around safety and process (which is exactly what Paul O’Neill did at Alcoa).
Subsequently, in 1999, Dr Amy Edmondson was studying clinical teams and the number of mistakes that different teams made. During her research she was surprised to find that the teams with a higher number of good outcomes actually made more mistakes than teams with fewer good outcomes. It was a surprising result, but after further investigation, Dr Edmondson discovered that in fact those teams with better outcomes were admitting more mistakes, whilst the teams with fewer good outcomes were more likely to hide theirs. As a result, Dr Edmondson codified the concept of psychological safety, namely: the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes, and the team is safe for interpersonal risk taking.
Dr Edmondson showed that psychological safety was a key factor in team performance, and continues to lead the field in expounding the importance of psychological safety in all fields of work and life, and literally wrote the book on psychological safety as well as a great deal of ongoing research.
This research built on the previous work by Schein, Bennis, Kahn and others to codify psychological safety and provide us with a more practical, actionable definition that aids practitioners (that is, me and you) to actually understand, foster and maintain psychological safety by asking:
Is it safe to speak up with ideas, questions, concerns, and mistakes in this group?
Think about the best team you’ve been a member of. It could be a sports team, a business team, or some other group of people with a shared goal. Being a member of that team probably felt good, it may have even been energising and inspiring. Whilst the members of that team may well have been experts in their field, it’s likely that being a member of that team felt good because that team felt safe to be themselves. They, and you, likely felt free to admit mistakes, ask for help, and even challenge ideas from other team members without fear of humiliation or embarrassment.
Now think about one of the worst teams you’ve been a member of. Perhaps you felt that you had to put on a metaphorical “mask”, and be a different version of yourself in order to fit in. You may not have been able to admit mistakes, or ask for help, in case members of the team saw it as a weakness and used it against you. Chances are, you didn’t feel very “safe” in this team.
Think of these two teams when thinking about levels of psychological safety. Psychological safety isn’t a binary “on or off” factor, it’s a sliding scale. Teams (and members of those teams) possess it to varying degrees. The best team you’ve been on probably possessed a lot, whilst the worst probably did not possess much at all.
Of course, there should be consequences for intentional violations, and we should hold ourselves and others accountable to high standards of professionalism. But one thing we know for sure is that if we punish people for slips, lapses, and mistakes rather than trying to improve the system around them, we don’t end up with fewer errors, we just stop hearing about them until they’re too big to hide.
In order to improve the work, and make work safer, we must understand how it’s actually done, not just how we think it’s done, or how we’d like it to be done.
In order to improve quality, outcomes, and the safety of work, we need to maximise the overlap between work as imagined, and work as done – to close the gap between perception and reality. We can only do this by fostering psychological safety, so that people closest to the work can be honest and candid about how work is actually done in the real world.
This is a great concept analysis of psychological safety by Ito et al, 2022. A concept analysis can clarify the structures of a concept and its relationships to other concepts. It also highlights implications for future scale development and clinical practices. This study aimed to identify the concept of psychological safety in a healthcare context through a Rodgers’ concept analysis and provide the first theoretical foundations for how such an understanding may improve interpersonal relationships and patient care. The research question was “What are the attributes, antecedents and consequences of psychological safety in the context of health care?”
It’s important to recognise the difference between these two practices. The indubitable Grace Hopper once stated that “You manage things, you lead people.” What she meant is that management consists of all the processes, tools, and controls that need to exist in order for people to work effectively, whilst leadership is far larger in scope and consists of, for example, setting direction, making strategic decisions, supporting and motivating people, and elevating people in order to reach their highest potential.
In practice, this means that neither management nor leadership can be neglected.
In order for people to perform well and possess psychological safety, they need to operate in environments where safety, costs, tools and processes are managed effectively. A team cannot deliver if they do not know how, or indeed what to deliver. Management is therefore part of leadership, and contributes to the “structure and clarity” that Google’s Project Aristotle led by Julia Rozovsky in 2013 defined as the third most important factor in high performing teams. The Project Aristotle team uncovered four key factors (Dependability, Structure and Clarity, Meaning, and Impact) that are essential to team performance, but it was clear during the research that there remained one or more missing elements. The team discovered Edmondson’s 1999 research and applied the paper’s methodology to measure psychological safety. The results showed that “even the extremely smart, high-powered employees at Google needed a psychologically safe work environment to contribute the talents they had to offer”.
Google’s Project Aristotle was a turning point for psychological safety. It was enough proof for what we all intrinsically know – that feeling safe to be yourself as part of a team, where you’re able to contribute your ideas, admit mistakes, challenge others respectably, and try without fear of failure, is one of the most powerful aspects of human performance.
Similarly, the 2019 and 2021 “State of DevOps” reports consistently show that psychological safety is an essential and foundational factor in software delivery team performance, and also to organisational performance more widely.
Dr. Ron Westrum wrote in 2003 about “The Typologies of Organisational Cultures” that reflect how information flows through an organisation. He wrote: “organisational culture bears a predictive relationship with safety and that particular kinds of organisational culture improve safety…” That is: because the flow of information is influential and indicative of other aspects of culture, it can also be used to predict how organisations or parts of them will behave when problems arise.
Westrum was focussed on real-world physical safety measures in the realm of healthcare and aviation, but in our organisations we should also strive to adopt the same diligent approach to psychological safety for the sake not just of the products we build but for the humans on our teams as well.
See the table below for Westrum’s organisational typology model. Each column describes a broad cultural typology: Pathological, Bureaucratic, or Generative, and six aspects of those cultures. It is clear from the table that the Generative culture that Westrum describes is a broadly psychologically safe culture where team members cooperate, share their fears, admit failure and continually improve.
|Power oriented||Rule oriented||Performance oriented|
|Low cooperation||Modest cooperation||High cooperation|
|Messengers “shot”||Messengers neglected||Messengers trained|
|Responsibilities shirked||Narrow responsibilities||Risks are shared|
|Bridging discouraged||Bridging tolerated||Bridging encouraged|
|Failure leads to scapegoating||Failure leads to justice||Failure leads to inquiry|
|Novelty crushed||Novelty leads to problems||Novelty implemented|
The Westrum organisational typology model: How organizations process information ( Ron Westrum, “A typology of organisation culture),” BMJ Quality & Safety 13, no. 2 (2004), doi:10.1136/qshc.2003.009522.)
Timothy R Clarke in his book “The Four Stages Of Psychological Safety” described a model of four “stages” of psychological safety that teams can move through, progressing from stage 1 to stage 4. These are:
Members feel safe to belong to the team
Members are able to learn through asking questions
Members feel safe to contribute their own ideas
Members can question others’ ideas or suggest significant changes
Whilst “all models are wrong, and some are useful” applies in this case (people do not move linearly through stages 1-4, nor do the stages exist in discrete reality, The “four stages”can be a useful model to reinforce the point that psychological safety is not a binary “on/off” phenomenon: we all move through different degrees of psychological safety in different teams, contexts, times of day, etc.
Another useful model for team development is Tuckman’s Model of Team Development, where teams “Form”, “Storm”, “Norm”, and finally, “Perform”. It is only in psychologically safe teams that true performance will be reached, since this stage requires the ability for team members to admit and learn from mistakes, and to contribute and challenge ideas. Reaching this stage, as a leader of a team, is one of your goals.
It’s really important, and fortunately, really easy to measure psychological safety. You can do this in your team or across an entire organisation: one way to do it is via a survey, which asks for agreement with multiple statements that reflect the degree of psychological safety on a team. This provides quantitative metrics that are really powerful in building psychological safety and ensuring momentum is maintained. Another way, particularly useful for short lived teams, is to use a more discursive method such as the psychological safety matrix, which encourages people to describe where they are and how they feel. If you’re interested in measuring psychological safety, you can attend one of our psychological safety workshops to learn more and put it into practice.
There are some important considerations to make before measuring psychological safety, however.
In short, no. However, it’s important to distinguish psychological safety from existential or other kinds of safety. A mountaineering team climbing K2 require very high degrees of psychological safety in order to know that their teammates will support each other, and make it safe to raise concerns, however small. Their existential safety is very low, and they’re in real danger of dying on the mountain: but their high psychological safety aids in maximising their chance of success, and not dying on the mountain. Read more about whether a team can be “too safe” here. Where research suggests that psychologically safe teams exhibit unwanted behaviours and dynamics, it is not psychological safety that is the problem – it is the lack of agreed standards and expectations of behaviour.
The lesson: maximise the psychological safety of your teams, but do not shelter them from the real world. Building psychological safety doesn’t mean hiding the challenges ahead; quite the opposite.
There are three core leadership behaviours which support psychological safety in teams. These may seem simple, but in practice they extend to every single leadership behaviour and every single aspect of communication. Those three core behaviours (thanks to Amy Edmondson for codifying these) are:
Dr Amy Edmondson elucidates these core principles in The Fearless Organization.
Psychological safety and inclusion efforts not only go hand-in-hand, they are fundamentally inseparable. A team is only as psychologically safe as the least safe person on the team, and those with least safety tend to be those who are already minoritised, disadvantaged, or under-represented. If we disregard people’s lived experiences, identities, pronouns, past trauma and existing structural inequities, we aren’t fostering psychological safety for everyone: only for those who are already privileged enough to not have to worry about those things.
We must recognise that it is not (yet) a level playing field, and it is not only morally right for us to address existing inequities, but it’s also the only way that we will truly realise the benefits of psychological safety in our organisations. We cannot disentangle work on psychological safety from work on inclusion: and that means acknowledging and addressing the challenges faced by minoritised and disadvantaged people.
Research has also shown that psychological safety moderates the relationship between team diversity and team innovation and performance by making it easier for teams to leverage the benefits of diversity through more open conversations and more respectful, engaged interactions. (Caruso and Woolley, 2008, in Edmondson and Lei, 2014.) – not only is psychological safety the right thing to do, but it also mediates the performance aspects of diversity in teams.
Over the years, I have used and evolved this interpretation of the interrelationship between psychological safety, inclusion, diversity and performance. Please consider this image open source – feel free to adapt, recreate, modify and use as you wish.
Here is an excellent piece on diversity, psychological safety and performance, from Amy Edmondson and Henrik Bresman. The authors show, through research in pharmaceutical teams, that diversity enables performance, but only if combined with psychological safety. You can see in this chart below the relation between performance and diversity, mediated by psychological safety (red dots).
Fundamentally, building psychological safety is not only the right thing to do for members of your teams, but it’s the right thing to do for your business or your organisation.
Download your Psychological Safety Toolkit to measure, build and maintain psychological safety in your teams.