NUR 8320 Module 2 Culture and Psychological Safety Paper: Culture-Outcome Evidence, Team Learning and Inclusive Leadership Example

Afraid to Speak Up: Leading a Culture of Psychological Safety After a Safety Survey at a New Brunswick Hospital

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8320: Organizational and Systems Leadership I

Mentor Name

Month Day, Year

Afraid to Speak Up: Leading a Culture of Psychological Safety After a Safety Survey at a New Brunswick Hospital

The Survey

No real organization is described here: the hospital is a 600-bed academic medical center in New Brunswick. Its most recent safety culture survey, completed by 3,100 staff, showed strengths in teamwork within units but weaknesses in communication openness and in the response to errors. Only 41 percent of nurses agreed that they felt free to question decisions or actions of those with more authority, and 38 percent felt that their mistakes were held against them. Two serious events last year, a wrong-site procedure and a delayed response to a deteriorating patient, involved staff who saw something wrong yet stayed silent. The hospital's DNP-prepared nursing chief leads the response, with the medical chief as partner.

The two events show how silence works. In the wrong-site case, a circulating nurse noticed that the consent form and the marking did not match but assumed the surgeon had already checked. In the deterioration case, a night nurse paged the resident twice about a patient whose breathing rate was climbing, was told to keep watching, and did not call the rapid response team because she had been criticized for an unnecessary call the month before. Neither nurse broke a rule. Each made a reasonable judgment within a culture that discouraged speaking up.

Does Culture Affect Patient Outcomes?

Braithwaite et al. (2017) carried out a systematic review of research connecting culture in health care workplaces with what happens to patients. From 2,049 articles, 62 were included, mostly from North America and Europe, mostly in hospitals and mostly cross-sectional; there were four interventional studies and no randomized trials. In most of the studies, healthier cultures at work went with better results for patients, such as lower mortality, fewer falls and hospital infections and higher patient satisfaction, and none found that positive cultures were linked with worse outcomes overall. The authors judged the evidence consistent but noted that its observational design limits claims about cause.

Psychological Safety and Learning

Edmondson (1999) named team psychological safety after studying 51 teams at a manufacturer: members' common confidence that admitting an error, seeking help or voicing a concern will not be held against them. Teams with higher psychological safety engaged in more learning behavior, seeking feedback, discussing errors and testing assumptions, and learning behavior was in turn associated with better team performance. The study gave a name and a measure to what the hospital's survey describes.

Nembhard and Edmondson (2006) extended the idea to health care in a study of neonatal intensive care units. In their data, leaders who openly asked for and thanked others' input had staff who felt psychologically safer, and that safety went with more staff taking part in quality improvement. Professional status mattered: nurses and respiratory therapists reported lower psychological safety than physicians, but leader inclusiveness narrowed that gap.

Diagnosing the Culture

Before acting, the nurse executive holds listening sessions on twelve units, including night shift. Staff describe physicians who dismiss concerns, managers who respond to errors by asking who was at fault and a reporting system that seems to lead nowhere. Physicians describe nurses who wait too long to call. Both groups describe pressure to keep moving. The sessions confirm that the survey reflects real patterns, and they identify units where speaking up is already common, which become models.

The Culture Plan

The plan targets leader behaviors, team practices and system responses. Every nurse manager and physician unit leader learns to use inclusive language, such as asking "what am I missing?" at the start of rounds and thanking people who raise concerns, and their behavior is rated by staff. Units adopt a structured speaking-up phrase, agreed with physicians, that signals a safety concern and requires the receiver to stop and listen. The hospital adopts a just culture approach to errors that sorts each event as a system fault, an honest human slip, a risky shortcut or a reckless act, so that staff are not blamed for system failures. Each reported event receives feedback within two weeks, so reporters see that speaking up leads somewhere.

Training supports the change but is not the main tool. All staff complete a short simulation on speaking up, practicing the agreed phrase in realistic scenarios with physicians and nurses together. More important are the daily signals: whether a manager thanks someone who stopped a procedure, whether the resident who dismissed a concern hears about it from the chief medical officer and whether event reports lead to visible fixes. The paper argues that staff learn the real culture from what happens after they speak up, not from what the training says.

Physicians are partners rather than targets. The chief medical officer co-leads every forum, and residents learn the speaking-up phrase in their orientation alongside new nurses, so both groups hear the same expectation at the same time.

Leaders Go First

Senior leaders model the change. At a forum open to the whole hospital, both the nursing and the medical chiefs describe a mistake they made and what they learned, and they round together on units monthly, asking staff about safety concerns and reporting back what was done.

Measures

The hospital will repeat the safety culture survey yearly and track communication openness, the response to errors and the share of staff who feel free to speak up, along with event reporting rates, the time from event to feedback, serious events and staff turnover. Because culture changes slowly, the plan sets a three-year horizon.

Conclusion

A review of 62 studies links positive cultures with better patient outcomes, psychological safety enables the learning that prevents repeated errors, and inclusive leaders raise psychological safety and narrow the gap between professions. This hospital's plan builds inclusive leader behaviors, a structured way to speak up, a just culture response to errors and feedback that shows staff their concerns matter, with senior leaders going first and measures over three years.

References

Braithwaite, J., Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017). Association between organisational and workplace cultures, and patient outcomes: Systematic review. BMJ Open, 7(11), Article e017708. https://doi.org/10.1136/bmjopen-2017-017708

Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350-383. https://doi.org/10.2307/2666999

Nembhard, I. M., & Edmondson, A. C. (2006). Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior, 27(7), 941-966. https://doi.org/10.1002/job.413