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Background: Psychological safety allows healthcare professionals to take the interpersonal risks needed to engage in effective teamwork and to maintain patient safety. In order to improve psychological safety in healthcare teams, an in-depth understanding of the complex and nuanced nature of psychological safety is needed. Psychological safety concepts, including voice, silence, learning behaviour, support and familiarity, informed the current study's investigation of psychological safety. This study aims to use a mixed-methods approach to develop an in-depth understanding of psychological safety within healthcare teams and to build on this understanding to inform the development of future interventions to improve it., Methods: Survey, observational and interview data are triangulated in order to develop an in- depth understanding of psychological safety within four healthcare teams, working within one case study hospital. The teams taking part included one multidisciplinary and three unidisciplinary teams. Observational and survey data were collected during and immediately following team meetings. Individual interviews were conducted with 31 individuals across the four teams. Thematic analysis was used to analyse these interviews., Results: Survey results indicated a high level of psychological safety. However, observations and interviews captured examples of silence and situations where participants felt less psychologically safe. Findings from across all three data sources are discussed in relation to voice and silence, learning, familiarity and support., Conclusion: The results of this study provide a detailed description and in-depth understanding of psychological safety within four healthcare teams. Based on this, recommendations are made for future research and the development of interventions to improve psychological safety.

Background: Psychological safety is a dynamic team-level phenomenon which exists when team members believe that it is safe to take interpersonal risks. In healthcare teams, the presence of psychological safety is critical to delivering safe care. Scholars have highlighted a need for alternative measures which compliment survey-based measures of psychological safety in healthcare teams., Methods: The exploratory phase of this study raised concerns about whether current survey measures could provide a sufficient understanding of psychological safety within healthcare teams to inform strategies to improve it. Thus, previously validated psychological safety surveys and a meeting observation measure were adapted for use in healthcare teams. First, two group feedback sessions were held with 22 healthcare professionals, as well as a systematic literature review. Then, the members of eleven healthcare teams in Ireland and The Netherlands (n = 135) took part in the pilot test of the adapted composite measure., Results: The final composite measure has two parts: a team meeting observation measure and an adapted survey. The observation measure has 31 observable behaviours fitting seven categories: voice, defensive voice, silence behaviours, supportive, unsupportive, learning or improvement-oriented and familiarity type behaviours. The survey part consists of 19 items in three sub-dimensions related to; the team leader, other team members and the team as a whole. Three additional items capture the perceived representativeness of the observed team meeting compared to other similar meetings. Final adaptations were made in order to integrate the observation and survey measure., Conclusions: The resulting composite measure combines the strengths of observational and survey measures and is tailored for use in healthcare teams. It is uniquely co-developed with healthcare professionals and grounded in the psychological safety and healthcare literature. This composite measure can enable longitudinal research on psychological safety and inform future research to develop and test interventions to improve psychological safety.

Background: Having psychologically safe teams can improve learning, creativity and performance within organisations. Within a healthcare context, psychological safety supports patient safety by enabling engagement in quality improvement and encouraging staff to speak up about errors. Despite the low levels of psychological safety in healthcare teams and the important role it plays in supporting patient safety, there is a dearth of research on interventions that can be used to improve psychological safety or its related constructs. This review synthesises the content, theoretical underpinnings and outcomes of interventions which have targeted psychological safety, speaking up, and voice behaviour within a healthcare setting. It aims to identify successful interventions and inform the development of more effective interventions., Methods: A key word search strategy was developed and used to search electronic databases (PsycINFO, ABI/Inform, Academic search complete and PubMed) and grey literature databases (OpenGrey, OCLC WorldCat, Espace). Covidence, an online specialised systematic review website, was used to screen records. Data extraction, quality appraisal and narrative synthesis were conducted on identified papers., Results: Fourteen interventions were reviewed. These interventions fell into five categories. Educational interventions used simulation, video presentations, case studies and workshops while interventions which did not include an educational component used holistic facilitation, forum play and action research meetings. Mixed results were found for the efficacy or effectiveness of these interventions. While some interventions showed improvement in outcomes related to psychological safety, speaking up and voice, this was not consistently demonstrated across interventions. Included interventions' ability to demonstrate improvements in these outcomes were limited by a lack of objective outcome measures and the ability of educational interventions alone to change deeply rooted speaking up behaviours., Conclusion: To improve our understanding of the efficacy or effectiveness of interventions targeting psychological safety, speaking up and voice behaviour, longitudinal and multifaceted interventions are needed. In order to understand whether these interventions are successful, more objective measures should be developed. It is recommended that future research involves end users in the design phase of interventions, target both group and organisational levels, ensure visible leader support and work across and within interdisciplinary teams., Prospero Registration Number: CRD42018100659.