Introduction

A resident confirms a new patient medication with the fellow because it differs from what was discussed on rounds. A fellow presents the missing data in a complex case presentation during patient care conference. A young attending disagrees with the echocardiogram interpretation of a senior Faculty member. These are examples of individuals operating within a psychologically safe system, allowing them to contribute without fear of compromising their career or experiencing ridicule or reprimand. Psychological safety was introduced in the 1990s and has since been studied by leading experts.^1-3 In psychologically unsafe spaces, individuals will choose to protect themselves from interpersonal risk by remaining silent rather than to speak up and risk personal and/or career jeopardy. In a psychologically safe organization, individuals are empowered to engage with vulnerability and feel safe to innovate. The future of pediatric cardiology requires continued innovation best achieved in psychologically safe environments. This analysis evaluates psychological safety under the umbrella of the American College of Cardiology's (ACC) core values: patient centered care, teamwork and collaboration, and professionalism and excellence.

Patient Centered Care

Somewhat unique to pediatric cardiology are the number of multi-disciplinary interactions required for patient care within a heart center. These disciplines include, but are not limited to, neonatology, critical care, cardiothoracic surgery, cardiology, interventional cardiology, echocardiography, radiology, anesthesiology, and nursing. While all members of the team presumably arrive to work with the intention to provide the best possible patient care, interpersonal risk may subconsciously inhibit open communication and lead to possible medical errors. This has been described as "discounting the future".² This concept consists of underweighting the patient's health and overweighting the potential response to an individual speaking up in a potentially compromising situation. Patient care unintentionally becomes secondary, and thus, the patient is collaterally affected by a psychologically unsafe environment. Psychologically unsafe environments are therefore a high and unnecessary risk to the patient.

Teamwork and Collaboration:

Psychological safety has been shown to increase team productivity and effectiveness and, in some analyses, has been identified as the number one characteristic of successful and high performing teams.^2-5 Psychological safety is key for all heart center members to be included in the pursuit of the common goal of improving patient care. Teams can better learn from challenging circumstances and individuals can confidently contribute their unique skillset to the team when there is shared trust and respect. Furthermore, in psychologically safe environments, team members are empowered to challenge the status quo if they believe that something has been missed, overlooked, or simply can be improved.³ A survey investigating barriers to front-line resident physicians reporting adverse events found that a decrease in perceived hierarchal power distance and an increase in leader inclusiveness significantly predicted psychological safety. This subsequently predicted an individual's likelihood to report adverse events.⁶ There is a fundamental hierarchical infrastructure within medicine allowing for learning in the context of patient care to occur safely. However, constructive communication through inclusiveness within this hierarchy is paramount for the effectiveness of psychological safety.

Open conversations amongst team members allow for the discovery of leaders who may be innovating within their sub-specialty silo such as the cardiac intensive care unit, the echocardiography or catheterization lab. Democratizing conversations allows for exchange of information which can be implemented across a heart center rather than housed within sub-specialty silos. Furthermore, psychological safety could allow for improved efficiency. If all individuals know their opinion is valued, communication can be conducted clearly and efficiently with minimal need for over-explaining one's viewpoint.² Leaders can help foster psychologically safe teams by encouraging involvement of all team members and flattening hierarchy.⁷ The leader's role is also to demonstrate vulnerability and openness which consequentially encourages contribution and participation. These intentional actions allow leaders to leverage every team member's true potential to challenge the status quo.³ A psychologically safe workplace is vital to achieve the principles of teamwork and collaboration that are integral to the ACC's core values and mission.

Professionalism and Excellence

Professionalism and excellence embody continuous improvement by holding ourselves to the highest standards while promoting a culture of balance and well-being. Pediatric cardiology programs are expected to practice evidence-based medicine while advancing the field through continuous innovation. Innovation is critical in striving towards excellence and necessary in the advancement of any organization.³ Innovation flourishes when psychological safety is abundant and diminishes in environments where it is low. Psychological safety has shown to improve productivity and the utility of peer performance reviews amongst physicians.⁸ On the contrary, lack of psychological safety can leave physicians prone to mental health issues such as depression and burnout, both of which have been associated with increased medical errors and decreased reporting of medical errors.^9-14

There is a higher rate of female physician suicide relative to the general population.¹⁵ For both genders, depression increases after starting medical school and throughout internship.^16,17 Most institutional interventions for physician well-being focus on efforts to be made by the physician themselves, such as advising exercise, good nutrition, and mindfulness. These recommendations place the burden on the physician and imply that physicians, rather than the system, are responsible for avoiding burnout. The lack of psychological safety found in medicine is not the burden of the physician, or any one individual, but rather the burden of the system.

Conclusion

Promoting psychological safety within an organization requires assessing its current state in the workplace based on established methods at an individual, team, and organizational level.¹⁸ In the book The Four Stages of Psychological Safety the ideal environment is described as one in which there is inclusion, with learner, contributor, and challenger safety.³ Achieving this requires a concerted effort by an organization under the guidance of objective experts. In recent papers, psychological safety assessment within organizations was discrepant between surveys versus observation and interview approaches. Surveys alone often over-estimate the level of psychological safety which emphasizes the additional need for on-site observation with an objective assessment and subsequent education within programs by established experts. Interventions that are rooted in education and are longitudinal, multifaceted, and involving key stakeholders and leadership are more likely to be effective.^19,20

With guidance from experts and  commitment from the pediatric cardiology community and leadership, psychological safety can and should be achieved within our institutions. It is critical for our patients, our physicians, and the continued innovation within our field.

References

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16. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA 2010;304:1181-90.
17. Guille C, Frank E, Zhao Z, et al. Work-family conflict and the sex difference in depression among training physicians. JAMA Intern Med 2017;177:1766-72.
18. Petrie K, Crawford J, Baker STE, et al. Interventions to reduce symptoms of common medical disorders and suicidal ideation in physicians: a systematic review and meta-analysis. Lancet Psychiatry 2019;6:225-34.
19. O'Donovan R, McAuliffe E. Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey, and interview data. BMC Health Serv Res 2020;20:810.
20. O'Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behavior. BMC Health Serv Res 2020;20:101.

Clinical Topics: Cardiovascular Care Team, Noninvasive Imaging, Prevention, Echocardiography/Ultrasound, Stress, Congenital Heart Disease and Pediatric Cardiology

Keywords: Professionalism, Leadership, Workplace, Intention, Anesthesiology, Goals, Respect, Trust, Mindfulness, Internship and Residency, Schools, Medical, Depression, Mental Health, Motivation, Patient Care Team, Communication, Physicians, Medical Errors, Burnout, Psychological, Patient Care, Faculty, Critical Care, Intensive Care Units, Patient-Centered Care, Evidence-Based Medicine, Catheterization, Echocardiography, Reference Standards

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