Psychological Safety in 2023: unwrapped!

Psychological Safety in 2023

Thanks so much for all your support, feedback, encouragement, ideas, insights and collaboration over 2023! It’s genuinely a privilege to be able to do this work, and I appreciate every single one of you.

I recently asked for your favourite newsletter articles of 2023 and here are the top ten. I’ve refreshed each one with updated links and new info, and below is a little précis of each article. 

1 – Types of Human Error.

The different types of human error was voted our number one article this year by a long way, with nearly 50% of all votes in our survey. 

There are many different typologies of “human error”, and these are the three types of error that I find most useful when learning from incidents. These typologies serve as a “first pass” of investigation that allow us to dive deeper into the causal factors and systemic elements that allowed the error to occur, often utilising the Local Rationality Principle as well.

• Slips and Lapses – However conscientious and expert we are, we will never execute something perfectly every time. 
• Mistakes – When presented with incomplete information, insufficient experience or knowledge, we may make a decision that turns out, after the fact, to have been incorrect.
• Violations – We may take actions or make decisions that conflict with the way we “should” do things. That might be a violation of policy, process, or the expected norms and rules of the group (which also includes unacceptable behaviour). We may do this unintentionally, or intentionally, with positive intent. Too much of this can lead to the normalisation of deviance.

These are all learning opportunities, but what we learn from each type of error is different. Human error should be the beginning of investigations, not the end.

2 – Leadership and Management

Leadership and management are not the same thing. But they’re not mutually exclusive either. We “manage things, and lead people”, as Grace Hopper would say, but in order to be a truly effective leader, we must also possess strong competency and capability in our respective domains. We don’t need to understand the details of everyone’s role or expertise in our team, but we must have a deep and comprehensive knowledge of the domain and environment that we operate in, and a clear understanding of our shared objectives.

Leadership is often framed as the sexy, high-status, aspirational role, whilst management can be framed as dull, controlling, and even shameful at times. In fact, both are crucial. Indeed, we cannot truly be great leaders without also being effective managers.

3 – Behaviours that foster psychological safety

Over my career, I’ve collected a pretty large bucket of behaviours and practices that help to foster psychological safety and team performance. This ever-growing list of 120 behaviours is a resource that I and many others come back to very often.

I have some favourites here, such as “Moving authority to where the knowledge is” and “Creating opportunities to safely fail at something.” What are yours?

4 – Cognitive load and psychological safety

There are many models of cognitive load, and the field of cognitive psychology is broad indeed. This is a simple model, but just as “all models are wrong and some are useful”, I find this really useful. It helps us understand why our cognitive load might be high when trying to execute a task well, and where we might focus our efforts to make it easier.

Framing it this way also helps us to recognise that just as psychological safety helps to reduce our cognitive load by allowing us to ask for help and worry less about the interpersonal risks we take, high cognitive load can mean we’re more likely to default to silence. When our cognitive load is high, we have less available capacity to make the constant and rapid mental cost/benefit calculations of whether it’s safe, and worth it, to speak up.

When we feel psychologically safe, we don’t need to perform the constant, small, and cognitively burdensome risk calculations and assess our vulnerability whenever we want to ask a question. 

The relationship between psychological safety and cognitive load functions as a kind of flywheel effect: higher psychological safety lowers our cognitive load, encouraging open communication and further boosting psychological safety, creating a positive feedback loop. Conversely, high cognitive load can hinder open communication and inhibit asking for help, further increasing cognitive load, reinforcing a negative feedback loop.

5 – Work as Imagined (WAI) vs Work as Done (WAD)

In order to improve the way we work, we must understand how work is actually done. But in environments of low psychological safety, the gap between how we imagine work is done, and how it’s actually done in practice, can be very large indeed. We are unlikely to be candid with others about how we actually do the work, any shortcuts we take, the steps we skip and add, or other aspects of work, if we feel there are interpersonal risks from doing so.

If we don’t close the gap between WAI and WAD in our improvement efforts, we risk improving work in theory but not in practice, and actually widening the gap between them. We only close the gap between WAI and WAD in environments of psychological safety.

6 – Speaking up at work

When creating systems to enable speaking up, we should adopt approaches and mechanisms that work best for the people speaking up, not just the people hearing the message. Some people may prefer contributing in non-verbal ways, some may have a different first language to that of the group, Some might have a stutter, some may be deaf, some prefer to think deeply and prepare a contribution before presenting it. Or we may be working with the challenges of remote and distributed work, or, heaven forbid, hybrid meetings where some people are in-person and others are remote.

By creating an environment where everyone feels safe to express themselves in a manner that suits them best, we pave the way for richer, more meaningful, and truly collaborative dialogues, leading to better outcome as well as improved equity.

7 – Psychological Safety and High Performing Teams

Whilst high performance isn’t the only reason we foster psychological safety, it’s certainly one good reason to. This piece summarises the essential dynamics in relation to psychological safety and team performance, covering the dynamics of suggesting ideas, asking questions, raising concerns, and admitting mistakes. It also makes a few key points:

• Psychological safety is the foundation for team performance, via a number of mechanisms.
• Psychological safety is not enough to foster team performance on its own.
• In respect to speaking up, the stakes are higher for some than others.
• A team is only as safe as the least safe member.
• A team cannot be “too” psychologically safe. But once we remove the constraint of interpersonal risk, other constraints become evident. 
• Team performance isn’t the only reason for us to foster psychological safety.

Even if psychological safety had zero effect on team performance, it would still be the right thing to do.

8 – The Theory of Constraints

Maybe there’s a little recency bias emerging here, as this issue was just last week, but in any case, I received a lot of positive feedback for this piece on Eli Goldratt’s Theory of Constraints (ToC). 

ToC states that “improvements made anywhere besides the bottleneck are an illusion”, and I tried to show in this article how that works in practice. 

Crucially, ToC also provides us with a lens through which to observe and improve organisational value flow – it’s no good one team being really psychologically safe and high performing if they’re simply piling work on top of another team who are drowning. We therefore need to think about a fabric of psychological safety across organisations, rather than high-performing bubbles, because it’s this fabric of psychological safety that will allow us to have the powerful conversations about how work and value flows between teams, not just within them.

9 – Burnout and psychological safety. 

This piece dives into the relationship between burnout and psychological safety. There are many causes of burnout, both systemic and individual, but we know that low psychological safety means we’re unlikely to be able to ask for help or raise concerns, which increases the likelihood of employee burnout. In an environment of higher psychological safety, we feel more able to speak up and say to our friends and colleagues things such as:

• I made a mistake.
• I need some help.
• I can’t take on any more work right now.
• I’ve got stuff going on outside work that’s affecting my ability to work effectively.
• I’m feeling overwhelmed.
• Please be patient with me.

And in groups that possess the dynamics that foster psychological safety, team members are much more likely to actually step in, support, help and discuss these issues with us, which helps both to prevent, and recover from, burnout.

Burnout is preventable, and it is not an employee’s responsibility to simply be more resilient.

10 – Normalisation of Deviance

Every time that we deviate or fail to follow protocol, we skip a checklist or turn an alarm off, it becomes easier to do it again next time – because it was fine last time. This piece dives into the example of the Challenger disaster, Normalisation of Deviance, and Diane Vaughan’s concept of “production pressure”, and the reasons why deviance from standards or process can become accepted as normal in an organisation:

• Rules are seen as “stupid”, inefficient, or irrational. Of course, sometimes this is true.
• Knowledge about the rules is not uniformly distributed. People might be unaware of a rule’s existence or might have been incorrectly taught the deviation from the rule as standard practice.
• People intentionally break rules to achieve what they believe is a better outcome. In some cases, the rule might appear to hinder success, and again, sometimes this might actually be the case.
• A lack of psychological safety means that people who observe or become aware of the violations don’t speak up or intervene. 
  

As Feynman said: “Try playing Russian roulette that way: you pull the trigger and the gun doesn’t go off, so it must be safe to pull the trigger again.”

And for the rest of the survey – I really deeply appreciate all your feedback! I’ve highlighted some of the insights below.

Future content suggestions:

There were so many awesome ideas for future issues, ranging from inspections in healthcare and education, to how psychological safety occurs and builds in different organisation typologies and sizes. Plus suggestions on sporting performance, different industries, cultural differences and more – look out for these over 2024!

There were also some fantastic suggestions for the weekly poem, so I’ll be including those as we go along and thanking the folks that suggested them 🙂 

And finally, thanks so much for your positive words of encouragement and thanks. The little bits of positive feedback really make this worth doing, and I’m overjoyed to hear the positive impact that our 8,000+ strong community is having around the world!  

Here’s a little word cloud of the feedback from the survey.

Have a wonderful end to 2023, and I look forward to seeing what we can achieve together in 2024!

P.S. We’re a small business and rely almost entirely on your recommendations, and you promoting us online. So, if you can, and you want to, please:

Share this newsletter! Forward it to friends and colleagues, and share it online. This link: https://psychsafety.co.uk/newsletter/  takes you to all the past issues and has a sign up form.

Write nice things about us online and in print. And if you do, let me know, because I’ll send some stickers as a thank you!

Cite our articles, research and content in your own research, books and articles.

Buy some psych safety stickers and stick them in strategic places, such as on your laptop, in the office kitchen or the back of the CEO’s office door. Tell us if you’ve stuck them in particularly interesting or cool places and we’ll share your photo in the newsletter!

Psychological Safety at Work

Check out this piece of heavy duty work from community member Dan Rust. In the vein of the Github “Awesome Lists”, Dan’s put together a huge resource at https://safetypsy.ch/, containing loads of resources and links from around the world, including business, academia, military, podcasts, quotes from key figures, and more. You can read it and use it, fork it (which means make a copy and adapt it) and/or create pull requests (which means you can suggest additions and changes that make it into the main resource). Kudos Dan, amazing work!

Thanks to James Pomeroy for sharing this article, “Seduced by the Machine” in The Ruffian by Ian Leslie. Leslie references philosopher C. Thi Nguyen’s pre-print paper, “Value Capture” which focuses on how people’s core values are being overtaken by quantifiable metrics imposed by apps, organisations in the form of KPIs, and modern bureaucratic systems. This phenomenon shifts our focus from personal aspirations and individuality to standardised, pre-fabricated goals.

“metrics do more than give us a way to monitor the progress of our own intrinsic values; they become our values. We internalise them. The metrics become what we care about, what we dream of.”

I had such a great time on this episode of The Healthcare Leadership Experience with Jim, and really appreciate the opportunity for the chat! We discussed why workplaces are only as safe as the experience of the least safe person, the evolution of psychological safety, why diversity will remain ‘’on paper’’ without inclusion, and why high-performing teams possess high degrees of psychological safety. We also got into the Andon Cord and how it can be used in healthcare teams.

And thanks also to Christopher Habig for inviting me on to the Healthcare Americana podcast, where we discussed psychological safety, failing and learning, and drew on parallels from aviation, manufacturing, and other industries. We also got into disasters such as Chernobyl, and particularly the impact of the case of Dr Bawa-Garba.

I love the folks at GFDA (Good F*cking Design Advice). I have a framed print of theirs in my office:

And this from the GFDA instagram is f*cking spot on:

Some good social media news in contrast to what I’ve heard called “the descent of twitter”. Discord, with an estimated 350 million users, has updated its Hateful Conduct Policy to explicitly forbid misgendering and deadnaming of transgender people. Crucially, users who violate the policy receive direct communication about it, offering a chance for learning and improvement. This approach is intended to be more constructive than punitive measures, as it aims to educate people about the impact of their actions. Using someone’s correct pronouns demonstrates respect and acknowledgment of their identity, and sets a positive example to others, contributing significantly to psychological safety.

Finally, let’s end the year on more positive notes, in fact, let’s end on 25 positive notes. Here are the top 25 good news stories from this year, from Positive News. Including progress in protecting the natural world, LGBTQ rights, the 4-day working week, renewable energy, indigenous rights, and medicine.

This week’s poem:

This was the most requested poem in our survey – Ozymandias, by Percy Bysshe Shelley. 

I met a traveller from an antique land,
Who said—“Two vast and trunkless legs of stone
Stand in the desert. . . . Near them, on the sand,
Half sunk a shattered visage lies, whose frown,
And wrinkled lip, and sneer of cold command,
Tell that its sculptor well those passions read
Which yet survive, stamped on these lifeless things,
The hand that mocked them, and the heart that fed;
And on the pedestal, these words appear:
My name is Ozymandias, King of Kings;
Look on my Works, ye Mighty, and despair!
Nothing beside remains. Round the decay
Of that colossal Wreck, boundless and bare
The lone and level sands stretch far away.”


Shelley wrote this in friendly competition with his friend Horace Smith, who also wrote a sonnet called Ozymandias on the same topic. We’ll share Smith’s in a future issue 🙂