The Psychologically Safe Environment and Professional Silence

The eminence in the media of critical cases of events involving health professionals, such as the reopening of the Ian Paterson case, despite well-established and well-founded practices aimed at the quality of care, brought the need to rediscuss this system. This model proves to be ineffective, as the practice based on “camaraderie, trust and hierarchy” is still established and has space. Silence under the aspect of loyalty is still complicit in unsafe practices perpetuated over the years.

The error in healthcare practice has already been discussed for some decades, and one of the major milestones was published “To err is human: building a safer health system”, in 2000. At this moment, there is already a discussion about the predictability of error and the occurrence of fragile systems at these barriers needs to be put in place so that they do not occur.

Concerns about patient safety, together with the increasing complexity of care delivery processes, require organizational efforts to detect and prevent problems of this nature.

Ensuring the quality of care, especially for patients with multiple health conditions, implies coordinating decisions and treatments, coupled with the constant pressure to reduce costs without sacrificing quality of care.

In some countries, whose health care value is a frequent target of research, the cost of the error reaches values between 17 and 29 billion dollars, reaching 44 thousand to 98 thousand people a year.

Given the evidence of the error, for individuals, society, in the social and economic spheres; on the other hand, the existence of ample resources in communication, such as the use of highly technological programs or even the use of electronic medical records, thus questioning the power relations exercised in professional practice, causing professionals to be silent in the face of error. In the health area, at the top of the hierarchy, there is the figure of the doctor, the greatest technical-scientific authority. The legitimacy of this authority is dependent on individuals in relation to this knowledge since health has an immeasurable value of importance for individuals and society.

Authority is a skill that generates trust in others and voluntary obedience. The trust about legitimacy of an authority when broken gives way to violence to maintain obedience. Thus, there is a depersonalization of health care, weakening of bonds, with the absence of reflection on practice, where technical and scientific knowledge is no longer valued. This is a loss of human ethical values as well as a loss of technical importance in the character of relationships.

Technical and practical failure favors violence by transforming subjects into objects. The speeches or behaviors thus become coarse, disrespectful, and discriminatory. Fear or “false camaraderie”, in this way, gains its place in different professional relationships in health practice and among peers. Thus, health errors partially find their cause in these hierarchical patterns built over decades, whose medical autonomy abstains many professionals from criticizing the care practice, as well as the identification of dangerous conditions and the dissemination of best practices.

As a mirror of these conditions, there are the “front line” professionals, living with pressures, anxieties, and uncertainties; highly unfavorable conditions for a psychologically safe work environment that promotes learning.

On the other hand, when these work relationships are characterized by respect, affection, transparency and autonomy, it brings a high level of understanding and tolerance; not with the aim of consenting to error, but bringing discussions to an open dialogue that does not consent to failures, but understands them. This is one of the main points and perhaps one of the most sought-after regarding patient safety, after decades of unsuccessful attempts to guarantee minimum working conditions.

So, it is said, in a psychologically safe climate for work, that promotes the reduction of safety and productivity incidents. Thus, psychological security is understood as the environment conducive to interpersonal behaviors such as speaking or asking for help. Contemporary leaders in this context allow the release of individual and collective talents, in which employees feel free to contribute ideas, share information, and report errors. Taking risks is not a threat to professionals as work is built for safety, in an open environment for learning.

Since these professionals graduated, it is necessary to rediscuss these themes, stimulating the reflection of the various values involved, in an attempt to introduce the essential principles for an adequate professional conduct, with emphasis on the model of ethical practice given by the masters; while returning to the hypocratic “primum non nocere” model of medical education, based on the “critical, democratic and disalienating” problematization.

After years of work and actions aimed at patient safety, we are still facing a fragile system designed for the cyclical repetition of cases like Ian Paterson’s. The improvement of the adequate assessment of the work environment, and concrete analysis of the conditions that favor health events and, finally, the associated human factors are essential points for changing the current health context. It is necessary to develop intervention techniques that provide psychologically safe work environments to support adult learning.

Negligence, malpractice, and recklessness happen daily, but they also need to find their discussion forum in the institutions. Bioethics, Compliance, and integrity in care practices are still little discussed points that signal a reality seen under the veil of established security protocols and indicators.

Thus, the urgent and essential redesign of care practices is sought, which denotes the absence of powers or hierarchies, in addition to allowing practices that favor communication, not only the free sharing of knowledge between the team, but also the error, making their broad, understandable and non-judgmental approach.

The effectiveness of leadership interventions to provide support associated with psychological safety must be designed as a strategic action and deployed by all institutional hierarchical levels. Psychological safety is promoted by the explicit recognition of the complex and interdependent nature of health work and aims to meet the current organizational demands for the detection and prevention of problems related to patient safety.

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