Some work environments are characterised by that which is called psychological safety: a shared belief, by the people who work in the environment, that it is safe to experiment, to give voice to one’s voice, to take risks.
A Thought Experiment On Psychological Safety and Performance
A researcher is researching the link between psychological safety and the number of medication errors made in hospitals. She studies eight hospital units and finds that the hospital units characterised by psychological safety have the highest medication error rates. She reports these ‘findings’ to you.
Imagine that you are the manager responsible for reducing the number of medication errors in these hospital units. How will you determine what course of action you will take given what the researcher has ‘found’? Will your action not be determined by how you make sense of the phenomena at hand: the higher the reported psychological safety the higher the reported medication errors?
Given your management training, you say something like this to yourself: “No surprise here. Where you create an environment for people to make mistakes without fear of punishment, people make more mistakes!”
Given this ‘explanation’ what will be your course of action? Isn’t the course of action shaped, even dictated, by your explanation? Will you not reduce the psychological safety? Of course you will. You will put fear into the hospital units characterised by psychological safety. Imagine you take that course. You track medication errors by person and hospital unit. You name-shame by putting together and making visible a ‘leaderboard’ of those making the most errors. And apply sanctions to those who exceed a certain error rate.
What turns out to be the impact? You find that after a little while there is significant drop in the number of medication errors that end up on your weekly management report. You congratulate yourself: you figured out what was going on, you acted, and you generated your desired outcome.
Let’s Reconsider The Phenomena AND The Explanation
Whilst you, the manager, have been ripping out psychological safety and replacing it by fear, the researcher has been doing some more digging. She had a brain wave and decided to look at independent data.
By looking at this data, she ‘found’:
- The psychologically safe hospital units did not make more medication errors. In fact, the data showed that the higher the psychological safety within a hospital unit, the fewer the medication errors made by the people in that unit.
- The folks working within units lacking psychological safety hid their medication errors, out of fear of punishment. And as a result no learning took place regarding the causes of medication errors and thus no reduction in medication errors.
With this phenomena-explanation (the explanation and the phenomena have been merged into one here) what course of action do you the manager take? Isn’t the sound course of action dictated by the phenomena-explanation? Isn’t the sound course of action to increase psychological safety in those hospital units (under your management) where fear of retribution-punishment pervades?
Your Actions Are Shaped By The ‘Story You Construct’ To Explain The Phenomena
I draw your attention to the fact that action is the access to influencing the world and generating change-outcomes: only actions cause-shape outcomes. If you think otherwise then don’t breathe and see what shows up!
Notice that your actions are NEVER given by the phenomena itself. That which is, simply is. And is discarded by most of us if we cannot make sense of it. Why? If we cannot make sense of it then we cannot orient ourselves in relation to that which is: the phenomena.
Further, notice that your actions are ALWAYS given by the ‘story you make’, the explanation you construct, about the phenomena.
What does this mean? It means that all the power-possibility lies in the ‘story you make’, the explanation you construct. Why? Your actions are influenced-shaped, even dictated, by the explanation you construct.
What Is The Access To Generating Breakthroughs In Effectiveness-Performance?
The access to generating breakthroughs in effectiveness-performance lies in the domain of explanation: the ‘story that we construct’ around the phenomena at hand.
If we are to construct more insightful stories/explanations (on the phenomena that concern us) then we have to escape the pull of the existing ‘net of understanding’ – the paradigm that gives us being and from which we operate. Listen to Ralph Waldo Emerson:
Every nation and every man instantly surround themselves with a material apparatus which exactly corresponds to … their state of thought. Observe how every truth and every error, each a thought of some man’s mind, clothes itself with societies, houses, cities, language, ceremonies, newspapers. Observe the ideas of the present day ….. see how timber, brick, lime and stone have flown into convenient shape, obedient to the master idea reigning in the minds of many persons ….. It follows, of course, that the least enlargement of ideas …. would cause the most striking changes of external things.
I say that the job of leaders is to generate that ‘least enlargement of ideas’ that Ralph Waldo Emerson is talking about. That is to say make a shift in the dominant paradigm that shapes organisational sense making of phenomena. And thus shapes-dictates their courses of action.
If you are lamenting the state of the Customer Experience like Colin Shaw is then it is worth listening to the following words by Donella H. Meadows:
There are no cheap tickets to mastery. You have to work hard at it, whether that means rigorously analysing a system or rigorously casting off your own paradigms and throwing yourself into the humility of not knowing….
The reason that organisations have not made a success of Customer Experience. And are in the process of killing it, is that the Tops in these organisations have not made the requisite ‘least enlargement of ideas The have not put aside their existing ‘net of understanding’ and so are go about the new in the same old way. Thus, I say that many, if not almost all, Customer Experience initiatives start stillborn.
To conclude: the challenge of leadership is to cast off the already existing ‘net of understanding’ and thus creating a space from which to construct more insightful stories-explanations of phenomena. And thus opening up new courses of action. Course of action that carry risk and also the promise of breakthroughs in effectiveness-performance.
If you found this ‘conversation’ one that resonates with you then I invite you to watch the following video:
The Customer Blog 
Great post, Maz, as always. Clearly the human tendency is to find simple explanations for phenomena and once these have settled the tenor is: ‘I have made up my mind so don’t confuse me with facts!’ The main problem is that we have no means to distinguish causes from consequences and so we so often if not primarily try to treat symptoms. Clearly we measure the symptom a´to see if it works and not the real cause as we don’t know it. Systems thinking can help to avoid that trap but many system thinkers fall into it again because they think that they are now immune to that mistake. So they start to take their models as reality and not just as interpretations. The biggest issue with that has Big Data. All results from Big Data are pure interpretations and have no causal connection with the real world and most of all they do not predict what will happen, not even in the average.
Security in the sense that failures are allowed is essential for a human work environment. I have pointed to my post before but it fits this subject as well: The Value of Failure – Not failure is the outlier, success is! Today’s executives have absolutely no ‘humility in not knowing’. They know it all and they want to be certain in their predictions, even if it is all fake and an illusion they create.
http://isismjpucher.wordpress.com/2011/10/24/the-value-of-failure/
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Hello Max,
Thank you. I appreciate you taking the time to share that which you share. I find myself delighted that you find that which I write worth reading. Why? I value you. You show up for me as one who thinks for himself.
What more can I say? I thoroughly enjoyed reading your post. It showed up for me as insightful and deeply persona//human at the same time. It occurs to me that you and I are in agreement on the matter of knowing, of humility, and the importance of inviting-allowing failure. When one eliminates the space for failure to show up one in the very same action eliminates the space for creativity and innovation to show up.
I hope all is great with you Max. And thank you for being willing to enter into a conversation with me. And for creating an opening through these conversations for learning to show up for me.
At your service
maz
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Hi Maz, thanks for a thought-provoking post and to you, Max, for your reply.
I agree that many of ‘Today’s executives have absolutely no ‘humility in not knowing’.They know it all and they want to be certain in their predictions,…’
However, do you not think that to address this issue we also have to address how we describe, identify and recruit executives?
Adrian
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Hello Adrian,
It occurs to me that we, as in you and i, do not recruit executives nor is our opinion asked for by those who do recruit. So who does recruit executives? Executives (or ex Executives) recruit Executives. If you get that then you get the challenge that lies ahead.
Furthermore, our way of life puts huge emphasis on knowing. Especially, ‘knowing’ opinions, beliefs, facts: the know what. What do schools, universities and MBA programmes teach: know what.
Who teaches or calls for the the humility of simply saying ‘I don’t know’? The higher up you are, status-power wise, the more you are expected to know even if you don’t know. If you don’t know you are expected to know.
So the challenge is much broader than ‘changing’ executives.
And here, I wish to point out that neither you, nor Max, nor I have shown the kind of behaviour we want others to practice. Each of us has rushed forth to put forward our ‘knowledge’ and as such suggest a path-solution. What we have not done is to say/stand in the place of ‘not knowing’. And asking the question: how do I go about generate ‘not knowing’ in my own way of showing up in the world.
All the best
maz
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Maz, interesting post, particularly the start about the hospital. Is there a background story there or is it simply an example? If there is a reference I’d love to know what it is.
Thank you
James
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Hello James,
In reading Adam Grant’s book ‘Give and Take’ I came across Amy Edmondson and her research on psychological safety and its relationship to facilitating learning and innovation. Amy Edmondson is a Harvard Business School Professor.
If you want to read about the research she conducted on hospitals and which I refer to then please click the following link:
Click to access v013p00ii3.pdf
Enjoy. And thank you for taking an interest in that which I share.
I hope all is great with you.
Maz
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Thank you
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