It's 9 p.m. in an operating room, just before the last procedure of a long day that had been full of delays. A nurse sees that the surgeon is about to make an incision without first stopping for the expected “timeout,” a crucial step that helps the team confirm, among other things, that the correct surgery is about to be performed on the correct side of the correct patient. The nurse is also concerned they don't have enough units of blood on hand for this type of procedure.
The nurse pauses and wonders,
“Should I speak up or keep quiet?”
They must quickly balance the expected benefits of speaking up against the perceived risks. Let's say the nurse knows that the surgeon has a reputation for yelling at anybody who slows down a procedure. Perhaps the surgeon has screamed at the nurse previously for daring to question if he's doing his job properly. The nurse might have heard stories about other nurses who stopped getting choice surgical case assignments–and might fear being fired for “insubordination.” If any or all of those are true, it's understandable why the nurse might choose to keep quiet.
This isn't just a healthcare problem. Most of us have worked for a boss who either didn't listen to our ideas or bullied us into being quiet.Â
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Why Do People Choose to Stay Quiet?
In healthcare, people often say, “You should speak up” and “It's your professional obligation to say something.” Such platitudes that push employees to be brave can be counterproductive or harmful. When the prescription is courage, it assumes that people aren't speaking up because… they're cowardly. That assessment is harsh, unfair, and inaccurate.
Employees often keep quiet about problems, mistakes, and improvement ideas. They bite their tongues instead of disagreeing with the boss. They choose not to challenge the status quo even when doing so could benefit the company, customers, and everyone involved. Why might that nurse stay silent when a mistake is about to occur in the operating room?
Research by Ethan Burris, Ph.D., from the McCombs School of Business at the University of Texas at Austin, discovered two primary (and consistent) reasons why employees choose not to use their voice in the workplace:
- fear and
- futility.
Employees who fear the consequences of speaking up are more likely to keep quiet and bury mistakes. They're less likely to point out problems. People cannot solve problems in organizations where they aren't admitted and shared. With a high level of fear, the organization is more likely to struggle with half-baked products or ideas that nobody feels safe challenging. When employees fear punishment for trying something new that doesn't work out exactly as expected, they'll get cautious, and innovation will suffer.
In some organizations, leaders invite people to speak up and reward them for doing so. But when reports of problems and ideas for improvement don't lead to action, that contributes to the futility factor. Employees will often learn that speaking up, while not dangerous, just isn't worth the effort. Staying quiet due to fear or futility has the same negative effects.
How Can Leaders Help People Feel Safe to Speak Up?
Choosing to speak up isn't a matter of character or courage–it's driven by culture. Instead of asking people to be brave (or demanding courage), leaders must create conditions where people can feel safe.
Instead of blaming or, more positively, encouraging employees, leaders must create a culture that lessens, if not eliminates, both the fear factor and the futility factor. We can address futility by training and coaching people on more effective problem-solving methods. But getting better at problem-solving requires the ability to try things and learn from mistakes–which requires high levels of “psychological safety” in place of fear.
What is psychological safety? It is:
a condition where people feel safe speaking up without fearing punishment.
Leaders cannot mandate psychological safety into existence. Instead of declaring, “This is a safe space,” leaders need to consistently demonstrate it is so.
Timothy R. Clark, Ph.D., author of The 4 Stages of Psychological Safety, says two key actions cultivate the conditions for people to feel safe: modeling key behaviors (such as admitting mistakes and admitting they might be wrong) and rewarding employees when they follow their lead. Leaders, starting with the CEO, have more ability to model these behaviors because they generally face less risk of punishment. Leaders must lead the way; employees might choose to follow.
Hear my podcast with Tim (“My Favorite Mistake”)
In many workplaces, speaking up is, unfortunately, perceived to be dangerous. There will always be some people who will speak up even when it's risky to do so. But that doesn't scale well. Organizations are more effective when fear and futility are eliminated for all.
Telling employees to be more courageous doesn't begin to get to the root of the “employees aren't speaking up” problem. Stop blaming people for choosing to stay silent. And telling employees to be brave in the face of professionally dangerous situations seems ineffective, irresponsible, or downright cruel.
Surgeons and those in formal positions of power and authority must go out of their way to invite others to speak up with questions and concerns. Instead of just tolerating when people speak up, leaders need to reward them for doing so. In a safer operating room setting, the surgeon would thank the nurse for the reminder to do the timeout and for the opportunity to double-check the number of units of blood. The surgeon would remind the nurse to speak up again anytime there is a concern, especially one that risks harm to the patient and a potential lawsuit against the surgeon and hospital.
Healthcare organizations with higher levels of psychological safety are proven to be safer for patients. I know I'd feel safer, so I'd rather receive care, at a hospital that treats every staff member with respect.
It's not just a matter of being nice–lives and careers are at stake.
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To create this culture, leaders must be humble and mature to accept comments coming from their team. Thanking the team member to speak up and asking questions better understand the comment is the appropriate approach.
As for the futility factor, the leader can assign the task of correcting the issue to the team member directly. This would show empowerment of the team members. If the team member suggestion needs to be assigned to someone else or another service, the leader must follow-up and/or manage te expectations of the team member by being transparent about what can and cannot be done and when.
Great post