Psychological Safety Training in Healthcare: Transforming Care and Saving Lives
Healthcare systems are complex and demanding environments where patient safety is a top priority. Achieving this level of safety requires more than just mastering medical knowledge and technical skills ("hard skills"). Developing soft skills is also key. Among these skills, psychological safety emerges as a fundamental element for high-performing healthcare teams. It empowers each team member to speak up, take innovative risks, and admit mistakes without fear of personal attack or negative repercussions. Leaders play an important role in fostering this positive environment, which stimulates effective communication, improves teamwork and decision-making, and encourages incident reporting. The Crucial Importance of Psychological Safety for Patient Safety: Psychological safety is a fundamental concept that underpins the effectiveness of healthcare teams. It enables open communication, the ability to "speak up," and learning from mistakes. It is a crucial component of high-performing healthcare teams. Developing and maintaining psychological safety in the workplace requires a shift in culture and mindset that influences how team members interact with each other. A lack of psychological safety negatively impacts the ability to express oneself, decision-making, communication, and judgment. These dysfunctions can lead to medical errors that necessitate quality improvement. Gains in patient safety require inducing cultural and mindset changes that influence psychological safety on a large scale. Psychological safety is built on behaviors generally taught as "soft skills," defined as relational skills involved in human interactions that complement "hard" knowledge skills and technical or procedural skills. Sources emphasize that psychological safety is a concept and the foundation for safer, more effective, and more humane healthcare. The Challenges of Implementing Psychological Safety in Healthcare Systems: While the importance of psychological safety is recognized, its implementation is often hampered by significant obstacles. Sources highlight several challenges inherent in healthcare systems, particularly in large and geographically dispersed organizations. These challenges include traditional hierarchical structures, where deference prevails and superior-subordinate relationships can stifle agile decision-making and innovation. This hierarchical structure represents a barrier to agility and innovation, limiting the ability to respond quickly and effectively to emerging challenges. The pervasive influence of seniority and hierarchy in decision-making processes has been identified as a major obstacle. Cultural norms also play a significant role. Sources describe an organizational and national context where hierarchical dynamics carry considerable weight, creating cultural inertia that complicates the implementation of change initiatives aimed at improving the safety and quality of care. Anesthesia teams at the VinMec Healthcare System (VMHS) in Vietnam, for example, faced the predominance of a senior-junior relationship culture in decision-making, where deference prevailed, as well as deeply ingrained cultural norms. Introducing substantial changes to practice risked triggering a backlash, requiring careful navigation to ensure buy-in and mitigate resistance. The geographical dispersion of healthcare systems, as was the case for VMHS with its seven hospitals, also presents practical constraints. This dispersion limits direct communication and understanding of frontline staff needs, making it difficult to accurately assess and resolve safety concerns at the local level. It necessitates a strong, distributed, and organization-wide culture of quality and safety of care. Furthermore, there is often a lack of scalable and effective training models for cultivating psychological safety. Overcoming these challenges requires careful navigation and creative problem-solving. Sources emphasize that rapidly building and maintaining psychological safety to influence culture in medicine is a challenge, even for the most resourceful organizations. Leadership commitment is essential and decisive for initiating and reinforcing changes in psychological safety through educational vehicles.
The objectives of a psychological safety training initiative: the example of VMHS
Facing the challenges of In the healthcare environment, organizations can set ambitious goals to transform their healthcare system and improve safety. The initiative described in the sources within the VMHS had the overall objective of transforming the VinMec healthcare system into one of the safest in Southeast Asia for the practice of anesthesiology and pain management. This ambitious goal encompassed several key objectives. First, it aimed to demonstrate the effectiveness of a coordinated training initiative combining e-learning and simulation to improve patient safety and quality of care, and increase incident reporting. By leveraging innovative training methods, the objective was to equip healthcare professionals with the skills and knowledge necessary to improve patient safety and quality of care. Second, the objective went beyond simple procedural changes to encompass a cultural shift. The goal was to shift from a traditionally hierarchical culture to a "speaking-up" culture that fosters psychological safety and encourages proactive engagement in safety initiatives. This cultural transformation aimed to create an environment where team members feel empowered to offer and ask for help, thereby promoting a culture of safety and collaboration. Third, the objective included providing soft skills expertise to anesthesia teams at scale and within a short timeframe. This initiative sought to disrupt the traditional approach to quality and safety of care by equipping frontline healthcare professionals with the essential skills needed for optimal patient outcomes. In summary, the objective was to achieve a comprehensive transformation of the safety and quality of care delivery within the VMH system. By combining innovative training methods, fostering a culture of safety and collaboration, and providing soft skills expertise, the ambition was to position the healthcare system as a leader in patient safety in the Southeast Asia region.
The Training Intervention: Innovative Pedagogical Methods
Implementing a psychological safety training initiative, such as the one described in the sources, involves a comprehensive and iterative approach. The intervention at VMHS used a combination of e-learning and immersive simulation to target soft skills and improve the safety and quality of care.
The execution strategy first required convincing management of the value of investing in large-scale training initiatives to ensure their feasibility, effectiveness, and sustainability. Once the training program was approved, an analysis of perceived and observed training needs was conducted to inform the development of targeted e-learning courses and simulation scenarios. This analysis was carried out through interviews with anesthesia teams, department heads, and VMHS management, combined with an analysis of annual quality and safety audits. The pedagogical strategy emphasized leveraging e-learning to (1) teach, (2) demonstrate soft skills ideal for crisis management, and (3) raise awareness of performance gaps among healthcare professionals. This initial phase aimed to establish a foundation for skills development and highlight areas for improvement. Simultaneously, two-day in-person courses, called DOMA (Development of Mastery in Anesthesiology), were developed. These courses blended innovative, soft-skills-focused theoretical lectures, immediately illustrated with immersive simulation scenarios. The courses aimed to provide hands-on experience and demonstrate the gap between ideal and actual performance. Participation in the educational project was mandatory as part of the continuing education process for all VMHS anesthesia staff (anesthesiologists and nurse anesthetists). By challenging professionals in simulated crises, the objective was to foster a deeper understanding of their capabilities and enhance skill acquisition in a realistic environment. The training program was designed to facilitate a progressive increase in skills, focusing on the reliability of routine practice and the management of life-threatening emergencies. Interactive debriefing sessions following the simulations allowed for an in-depth exploration of participants' understanding and mastery of their skills, while also providing opportunities for reflection and feedback. A customized program was developed by a team of experts in simulation, e-learning, and anesthesia, incorporating current and innovative soft skills concepts that positively impact the quality and safety of care (leadership, teamwork, etc.). These concepts were integrated through interactive e-learning, theoretical reviews, and full-scale simulations. The e-learning component used a progressive and gradual approach to theoretical concepts via interactive videos with multiple-choice questions and practical analyses, accessible online and at one's own pace. The two-day simulation sessions were interactive, combining brief, targeted theoretical reviews, illustrated and immediately applied in a full-scale simulation with seven scenarios per module. Specific modules focused on the use of cognitive aids and speaking-up techniques.
Over 18 months, 112 anesthesiologists and nurses completed a series of online learning modules and on-site simulation training sessions. The intervention emphasized the importance of leadership commitment, structured curriculum design, and feedback loops to ensure continuous improvement in staff competence and collaboration. The study describes this model as replicable for addressing the cultural, practical, and logistical challenges of integrating psychological safety into a large healthcare system by introducing an innovative, blended-methods training program.
The Multifaceted Team Behind the Initiative
The success of a large-scale training and change initiative depends on a diverse and well-coordinated team. In the case of the initiative at VMHS, a multifaceted team played a crucial role in advancing the project and overcoming challenges. According to sources, the team included individuals from three key components: VMHS (VinMec Healthcare System): This component included senior management, including the hospital system director, the head of the anesthesia department, and operational coordination. The health system director provided leadership in decision-making and project validation. The head of the anesthesia division led the identification of needs, the definition of objectives, and the monitoring of progress. The anesthesia coordinator oversaw operational coordination, ensuring smooth execution and alignment with organizational goals. Their commitment to driving cultural change from the top down facilitated the adoption of new practices and ensured the long-term success of the program. VV, TAL, CCPL, and PM conducted the initial situation and needs assessment. TAL and CCPL are affiliated with the CEO's office and the Department of Anesthesiology at VMHS, respectively.
- Satisfaction (Kirkpatrick Level 1): Satisfaction was assessed through anonymous digital satisfaction surveys conducted at the end of each 2-day in-person simulation training session. The overall results of the satisfaction surveys were very positive, with 100% of participants recommending the training and 100% believing it would change their practice. Knowledge Improvement (Kirkpatrick Level 2): Knowledge improvement was assessed using anonymized results from the e-learning platform's pre- and post-tests (success rate). For each participant, data were collected on the number of learning modules started, the number of modules completed, pre- and post-test results, and total time spent on the platform. The pre- and post-tests consisted of single- and multiple-choice questions, similar but presented in a different order. Over 18 months, 112 participants completed 4,870 hours of e-learning, demonstrating strong engagement (average of 43 hours and 29 minutes per participant). 91% of the 3213 modules started were completed 100%, with a significant improvement in results between pre-tests and post-tests (41% vs. 89% success rate, p<0.001). Level 2 demonstrates the effectiveness of the e-learning tool and its value for pre-activation, aiming to maximize the benefits of full-scale, in-person simulation sessions. Behavioral Changes (Reported and Observed) (Kirkpatrick Level 3): Reported and observed behavioral changes were assessed through anonymous digital impact surveys conducted with anesthesia teams prior to each 2-day in-person simulation training session. The training impact surveys were conducted before each new course and focused on observed or non-observed changes regarding topics covered in all previous courses. The questions focused on behavior, communication, leadership, teamwork, the use of cognitive aids, briefing and debriefing practices, and speaking up. Participants were asked to describe significant changes and indicate whether the change was perceived as lasting. Three surveys conducted before each of the four simulation sessions assessed the perceived impact of the training on behaviors applied and observed in everyday clinical situations. These changes were significant and stable over 18 months. More than 93% of participants perceived the changes as lasting. Among the most effective changes reported in the 6-, 12-, and 18-month surveys, the three most frequently cited were communication (including speaking up; 46% to 63% of respondents), teamwork (including task allocation and coordination; 35% to 57% of respondents), and the use of cognitive aids (20% to 57% of respondents). Level 3 reports on both reported and observed behavioral changes.
- Impacts on Organization, Quality, and Safety (Kirkpatrick Level 4): The impacts on organization, quality, and safety were assessed using the results of the VMHS annual quality and safety audits and the trend in reported events for the VMHS Department of Anesthesia. The VMHS annual safety audits are based on 124 indicators (rated from 1 to 10) collected through inspection visits, interviews, and analyses of operating room records and data related to technical devices, safety practices, organizational structures, and the management of postoperative and delivery room pain. To assess the cultural shift regarding safety and quality of care, and the willingness to speak up/report an adverse event, the number of adverse events reported in the various VMHS hospitals before and after the start of the procedure was collected and compared to data from a North American database. The results of the annual operating room safety audits showed an improvement in the overall safety score and a reduction in the dispersion of scores between 2021 (baseline year) and 2022 and 2023. The reduction in dispersion can be interpreted as a harmonization of practices toward greater safety. The assessment of a safe culture within the VMHS anesthesia department using the SOPS Hospital Survey V.2.0 questionnaire showed an increase in the reporting of adverse events and errors. The number of individuals reporting no events was halved compared to the previous year (nine times less than the data from the North American database). Level 4 is significant because it shows objective changes in practice, indicating an improvement in the quality and safety of care: an increase in reported events and a consistent improvement in quality audits over time. The reported educational intervention is the only implementation in the VMHS Anesthesia Department during the observed period that could have influenced the objective criteria described, thus supporting the hypothesis of a causal link. Overall, the results are very positive, demonstrating strong adherence to e-learning, a significant improvement in knowledge acquisition, a perceived impact on clinical behaviors, and an overall improvement in safety scores across the healthcare system. Obstacles Encountered and How to Overcome Them: Implementing a large-scale training and change initiative is not without its challenges. Sources describe several significant obstacles encountered during the initiative at VMHS, which required careful navigation and creative problem-solving. One of the main challenges was securing project funding. Convincing medical and financial leaders of the program's importance proved to be a lengthy process, taking nearly a year to overcome this obstacle. Furthermore, the project had to deal with skepticism and challenges to the authority of some senior stakeholders, which required delicate management. Language barriers presented another substantial obstacle. English served as the common language of communication, even though it was the native language of only one expert. To mitigate comprehension issues, Vietnamese support was available for e-learning, and simultaneous Vietnamese translation was provided for all lectures and simulations. However, the cultural and linguistic divide has posed ongoing challenges to understanding and communication. Cultural norms and hierarchical structures within the healthcare system have significantly hampered efforts to encourage safer practices and promote horizontal communication and leadership. As previously mentioned, the prevalence of a senior-junior relationship culture where deference prevailed made it difficult to encourage speaking up and establish a culture of psychological safety. Logistical complexities in conducting training sessions with large groups have also complicated matters. Managing multiple languages and coordinating simultaneous translation during face-to-face (simulated) training has required intense cognitive effort from both translators and trainers. Furthermore, limited knowledge of local anesthesia practices and interprofessional relationship dynamics within the healthcare system, compounded by the distance between trainers and the training site, posed significant logistical and preparatory challenges. Overcoming these obstacles required extensive preparatory discussions and adaptations to training methodologies to align with the cultural and contextual realities of the healthcare environment. For those seeking to implement similar initiatives, it is essential to ensure alignment with the organization's needs and expectations, secure full commitment, and effectively coordinate online and in-person training. This requires the mobilization of resources and expertise, as well as the anticipation and proactive resolution of potential challenges. The role of leadership emerged as a decisive factor in overcoming these obstacles.
- Conclusion and Future Implications
- The reported study demonstrates that targeted training programs combining e-learning and immersive simulation can effectively transform the culture of psychological safety in healthcare, even in hierarchical and geographically dispersed systems like the VMHS. Over an 18-month period, the structured intervention not only improved communication and teamwork but also increased incident reporting and improved patient safety outcomes.
- It is important to note that this transformation was not only the result of knowledge acquisition but also the result of behavioral change, supported by leadership commitment and organizational alignment. The notable increase in "speaking up" behavior, the rise in security incident reports, and the observed cultural shift within the VMHS suggest that psychological safety is not an abstract ideal—it is a concrete skill that can be trained and has a measurable impact. However, the findings also highlight significant barriers that must be addressed for large-scale implementation, including financial constraints, cultural resistance, and logistical complexities. The role of leadership emerged as a critical factor in overcoming these obstacles—without institutional buy-in, even the best-designed training interventions risk limited adoption and sustainability. While this study focused on a specific healthcare system, its implications extend far beyond Vietnam. The challenges related to hierarchical culture, psychological safety, and soft skills training are universal across all healthcare settings. The results suggest that integrating psychological safety through structured training is not only possible—it is essential for reducing medical errors, improving patient care, and fostering a collaborative work environment. If knowledge alone is insufficient to change behavior, then healthcare systems should prioritize active and immersive learning experiences that connect theory to practice. The DOMA (Development of Mastery in Anesthesiology) model provides a reproducible and scalable framework for institutions worldwide that aim to place psychological safety at the heart of their patient safety strategies. Psychological safety is not just a concept; it is the foundation of safer, more effective, and more humane healthcare. The question is no longer whether we should implement it, but how quickly we can do so. Investing in structured training in psychological safety must become a global imperative for healthcare leaders committed to reducing medical errors and improving patient outcomes.
- Source :
- https://bmjopenquality.bmj.com/content/14/2/e003186
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