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Stanford University School of Medicine

Countdown to Medicine X: “Speak up,” urges organizational learning expert

Amy Edmondson, PhD, considers herself lucky.

In her life, she's been hospitalized just twice, for relatively straightforward childbirths. But the memories are vivid -- and one, in particular, stands out.

Hours before the delivery of her first son, Edmondson recalls, "My husband looked at me, and said, 'Something's not right.'"

She was in so much pain, her body was essentially prohibiting the progression of labor. But she hadn't felt comfortable communicating the intensity of her experience to her care team. (Maybe what she was feeling was "normal"?)

As it happens, this general dynamic -- fear or uncertainty leading to a lack of communication -- is strikingly common in the health care delivery setting, and not just on the part of patients. The rigid hierarchy and high stakes that define the hospital environment can make employees, especially low-status ones, reluctant to speak up.

In Edmondson's case, a simple intervention by someone who knew her well prevented a potentially undesirable outcome. With better pain management, she moved on to the uncomplicated birth of a baby boy.

In other instances, and certainly in the aggregate, the consequences of not speaking up can be large and negative. And perhaps no one understands this better than Edmondson herself.

An expert in organizational learning, Edmondson, a Harvard Business School professor, has dedicated much of her career to an examination of psychological safety -- essentially, the degree to which people perceive their work environment as conducive to taking interpersonal risks -- across industries.

Humans are habitual impression managers, psychologists have shown, and we're also spontaneous temporal discounters. We worry about how others perceive us, and we give immediate consequences more weight than we do potential future ones. The result is that we often opt for silence when we have something to say.

("Don't want to look ignorant? Don't ask questions," Edmondson summed up in a 2014 TEDx talk.)

Of course, group intelligence suffers when this rational individual strategy is routinely deployed.

In one study, Edmondson showed that differences in psychological safety across units in the ICU context had an impact over time on the reduction of morbidity and mortality. In another, she found that when midlevel managers failed to display curiosity and humility, nurses in patient-care units were less willing to identify medical errors and other issues -- and that meant less opportunity for the system to learn from failure.

The everyday actors at the top of the status hierarchy -- namely, doctors -- would be important players in any effort to establish more open communication in the hospital.

"Physicians are so exclusively well-trained in knowledge and in clinical skills, they can easily be oblivious to the impact that they have, or how others see them," Edmondson said.

But ultimately, improving psychological safety in health care delivery is an organizational challenge, and one that demands a response from the top, she said.

While the factors that make hospitals challenging environments won't go away soon -- patients will continue to be complicated, shifts will be long, the need for cross-professional collaboration will only grow and status differences will continue to be "very real and very meaningful" to people -- cultures can change quickly under leadership that models curiosity, empathy and passion, Edmondson said.

Asking health care workers to build interpersonal skills might seem like "a lot to ask" given all their other responsibilities, she acknowledges. But it may be worth the effort.

Edmonson will be a speaker at the Stanford Medicine X conference, being held here next week. Registration is available online. A modified version of this originally appeared on the Medicine X site. 

Previously: Countdown to Medicine X: Advancing social causes in the face of political adversity and Registration now open for Medicine X 2017
Photo courtesy of Amy Edmondson

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