Psychological safety; but how?

The concept of psychological safety has become increasingly prominent across healthcare, education, business, and public service organisations. It is frequently presented as a critical ingredient for learning, innovation, wellbeing, and safety. Within healthcare particularly, psychological safety has become closely associated with patient safety, organisational learning, and the ability of staff to raise concerns before harm occurs.

At a recent Royal Society of Medicine conference on psychological safety, speakers highlighted the importance of creating environments in which individuals feel able to speak openly, challenge assumptions, share concerns, admit mistakes, and contribute to learning without fear of embarrassment, punishment, or negative interpersonal consequences. The discussions reflected a growing recognition that safety is not solely dependent upon policies, procedures, or governance systems. Rather, safety is influenced significantly by organisational culture and leadership behaviour.

This perspective aligns closely with the work of Amy Edmondson, whose research has been instrumental in establishing psychological safety as a distinct organisational construct. Edmondson describes psychological safety as a shared belief that a team is safe for interpersonal risk-taking. Importantly, psychological safety is not about comfort, consensus, or simply being nice. Instead, it concerns the confidence that individuals can raise concerns, ask questions, challenge assumptions, and admit mistakes without fear of humiliation or reprisal.

The significance of psychological safety becomes particularly apparent within high-consequence environments. Healthcare, aviation, emergency services, and military organisations all operate within contexts where mistakes can have serious consequences. In such settings, silence can be dangerous. The willingness of individuals to speak up, challenge decisions, report concerns, and share information often represents a critical defence against organisational failure.

While the importance of psychological safety is increasingly recognised, a fundamental question often receives less attention:

How is psychological safety actually created?

Much of the literature identifies psychological safety as an outcome. Less attention is given to the everyday leadership practices that produce the conditions in which psychological safety can emerge.

This question became particularly relevant during my research examining leadership practice within British Army command environments. Although conducted within a military setting, many of the challenges faced by the participants mirrored those discussed during the Royal Society of Medicine conference. The participants described operating within hierarchical structures characterised by accountability, risk, uncertainty, and competing priorities. Yet despite these constraints, some leaders were consistently able to create environments in which individuals felt able to contribute, challenge, participate, and engage openly.

The findings suggested that psychological safety does not emerge simply because leaders tell people to speak up. Rather, it develops through a series of leadership practices that demonstrate responsibility, fairness, trustworthiness, and concern for others.

The participants frequently described leaders who protected welfare, redistributed workloads, advocated for subordinates, provided mentorship, created opportunities for participation, and exercised discretion when balancing competing demands. These actions were often small and largely invisible. However, collectively they contributed to the development of trust and leadership legitimacy.

This finding is particularly important because psychological safety appears to be closely linked to perceptions of leadership legitimacy. Individuals are more likely to raise concerns, share information, and participate openly when they believe leaders are acting fairly, responsibly, and in the interests of the team rather than solely in pursuit of organisational outcomes.

Within healthcare settings, this observation may have significant implications. Organisations often focus considerable effort on encouraging speaking-up behaviours through reporting systems, policies, and formal mechanisms. While these interventions remain important, they may be insufficient if the underlying leadership environment does not support genuine psychological safety.

The conference discussions repeatedly highlighted the importance of learning cultures, openness, and reducing fear within healthcare systems. My research suggests that achieving these outcomes requires more than procedural change. It requires leaders who actively cultivate the conditions in which trust, participation, and psychological safety can flourish.

When leaders consistently demonstrate fairness, responsibility, advocacy, and sound judgement, they create conditions in which individuals are more likely to speak up, contribute, learn, and engage constructively with uncertainty.

As healthcare systems continue to pursue improvements in patient safety, culture, and organisational learning, psychological safety will undoubtedly remain a central concern. However, the challenge is not simply convincing people to speak up. The deeper challenge is creating environments in which speaking up feels both safe and worthwhile.

Ultimately, psychological safety is not created by policy alone. It is created through leadership.