Psychological safety training in healthcare: transforming care and saving lives

Healthcare systems are complex and demanding environments, where patient safety is an absolute priority. Achieving this level of safety requires not only mastering medical knowledge and technical skills ("hard skills"). The development of non-technical skills ("soft skills") is also a key factor. Among these skills, psychological safety emerges as a fundamental element for high-performing healthcare teams. It allows each team member to express themselves, take innovative risks, and admit their mistakes without fear of personal attack or negative repercussions. Leaders play an important role in promoting this positive environment, which stimulates effective communication, improves teamwork and decision-making, and encourages incident reporting.

The Paramount Importance of Psychological Safety for Patient Safety

Psychological safety is an essential concept that underpins the effectiveness of healthcare teams. According to sources, it enables open communication, the ability to "speak up," and learning from mistakes. It is a crucial component in 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 has a negative impact on self-expression, decision-making, communication and judgment. These dysfunctions can be sources of medical errors that require quality improvement. Gains in patient safety require 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 the "hard" skills of knowledge and technical or procedural skills. The sources emphasize that psychological safety is a concept and the basis for safer, more effective and more humane healthcare.

Challenges in implementing psychological safety in healthcare systems

Although 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 where relationships between superiors and subordinates can hinder 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 an important role. The sources describe an organizational and national context where hierarchical dynamics carry considerable weight, creating a cultural inertia that complicates the implementation of change initiatives aimed at improving the safety and quality of care. The anesthesia teams of the VinMec Healthcare System (VMHS) in Vietnam, for example, faced the predominance of a senior-junior relational culture in decision-making where deference predominated, as well as cultural entrenchment. The introduction of substantial changes in practice risked triggering a reaction effect, requiring careful navigation to ensure buy-in and mitigate resistance.

The geographical dispersion of healthcare systems, as was the case for the VMHS with its seven hospitals, also poses practical constraints. This dispersion limits direct communication and understanding of the needs of frontline staff, making it difficult to accurately assess and resolve safety concerns at the local level. It requires a culture of quality and safety of care that is common to the organization, strong, and distributed.

Moreover, there is often a lack of scalable and effective training models to cultivate psychological safety. Overcoming these challenges requires careful navigation and creative problem-solving. Sources emphasize that rapidly building and maintaining psychological safety to influence the culture in medicine is a challenge, even for organizations with the best resources. Leadership engagement is essential and decisive in initiating and reinforcing changes in psychological safety through educational vehicles.

The objectives of a training initiative in psychological safety: the example of VMHS

Faced with the challenges of the healthcare environment, organizations can set ambitious goals to transform their healthcare system and improve safety. The initiative described in the sources within 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.

Firstly, 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 goal was to equip healthcare professionals with the skills and knowledge necessary to improve patient safety and quality of care.

Secondly, the objective went beyond simple procedural changes to encompass a cultural shift. It involved moving 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 fostering a culture of safety and collaboration.

Thirdly, the objective included delivering soft skills expertise to anesthesia teams on a large scale and within a short timeframe. This initiative sought to disrupt the traditional approach to quality and safety of care by equipping front-line healthcare professionals with the essential skills needed for optimal patient outcomes.

In summary, the objective was to operate a complete 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 teaching methods

The implementation of a psychological safety training initiative, such as the one described in the sources, involves a comprehensive and iterative approach. The intervention within the 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 training needs, perceived and observed, 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, coupled with analysis of annual quality and safety audits.

The pedagogical strategy emphasized the use of e-learning to (1) teach, (2) demonstrate the ideal soft skills 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.

At the same time, 2-day in-person courses called DOMA (Development of Mastery in Anesthesiology) were developed. These courses blended innovative theoretical lectures focusing on soft skills, 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 improve 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 skills, while providing opportunities for reflection and feedback.

A customized program has been developed by a team of experts in simulation, e-learning and anesthesia, including current and innovative concepts in soft skills that have a positive impact on the quality and safety of care (leadership, teamwork, etc.). These concepts are articulated through interactive e-learning, theoretical reminders and life-size simulations. The e-learning used a progressive, step-by-step approach to theoretical concepts via interactive videos with multiple-choice questions and practical analyses, accessible online and at one's own pace. The 2-day simulation sessions were interactive, combining short, targeted theoretical reminders, illustrated and put into practice immediately afterwards in a full-scale simulation with seven scenarios per module. Specific modules focused on the use of cognitive aids and speaking-up.

Over 18 months, 112 anesthesiologists and nurses completed a series of e-learning modules and on-site simulation training sessions. The intervention highlighted 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, mixed-methods training program.

The multifaceted team behind the initiative

The success of a large-scale training and change initiative relies on a diverse and well-coordinated team. In the case of the VMHS initiative, 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:

1. VMHS (VinMec Healthcare System): This component included senior management, including the hospital system director, the anesthesia department director, and operational coordination. The healthcare 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 objectives. 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 performed the initial assessment of the situation and needs. TAL and CCPL are affiliated with the CEO's office and the anesthesiology department of VMHS, respectively.
2. Safe Team Academy: This component focused on designing training courses, monitoring weekly reports, and integrating e-learning with classroom sessions. Their expertise in pedagogy and training design was essential in shaping the educational content and ensuring its effectiveness in achieving the desired results.
3. Simulation For All: This component identified training needs, articulated e-learning with classroom training, and implemented immersive simulation sessions. The team balanced theoretical contributions with practical simulation exercises, leveraging their expertise in simulation and health education to create impactful learning experiences. Guillaume Der Sahakian and François Lecomte are recognized for their contribution via Simulation For All. Clément Buléon (CB) and Rebecca Minehart (RM) are also affiliated with the Center for Medical Simulation, Harvard Medical School, and participated in the development of educational interventions and data analysis, as well as the writing of the manuscript. CB is also affiliated with the Medical Simulation Center of the University of Liège. CB and VV are the joint first authors of the article.

The collaborative efforts of these various team members, each bringing unique expertise and perspectives, have been essential in overcoming challenges and achieving the initiative's goals. Their collective dedication and collaboration illustrate the importance of a well-coordinated and diverse team in driving innovation and change in healthcare education and practice.

Training impact assessment

Evaluating the impact of the training intervention is a crucial step in measuring its effectiveness and success. In the study described, the impact of the intervention was evaluated according to the Kirkpatrick model. The four dimensions of this model were documented: satisfaction, knowledge improvement, behavioral changes (reported and observed), and impacts on the organization, quality, and safety.

1. Satisfaction (Kirkpatrick's 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.
2. Amélioration des connaissances (Niveau 2 de Kirkpatrick): L'amélioration des connaissances a été évaluée à l'aide des résultats anonymes des pré-tests et post-tests de la plateforme d'e-learning (pourcentage de réussite). Pour chaque participant, des données ont été collectées sur le nombre de modules d'enseignement commencés, le nombre de modules terminés, les résultats des pré-tests et post-tests, et le temps total passé sur la plateforme. Les pré-tests et post-tests consistaient en des questions à choix unique et à choix multiples, similaires mais présentées dans un ordre différent. Sur 18 mois, 112 participants ont complété 4870 heures d'e-learning, ce qui a montré une forte adhésion (moyenne de 43h29/participant). 91% des 3213 modules commencés ont été complétés à 100%, avec une amélioration significative des résultats entre les pré-tests et post-tests (41% contre 89% de taux de réussite, p<0.001). Le niveau 2 démontre l'efficacité de l'outil d'e-learning et sa valeur pour la pré-activation, visant à maximiser les bénéfices des sessions de simulation en personne grandeur nature.
3. Behavioral changes (reported and observed) (Kirkpatrick Level 3): Reported and observed behavioral changes were evaluated through anonymous digital impact surveys conducted among anesthesia teams before each 2-day in-person simulation training session. Training impact surveys were conducted before each new course and focused on observed or non-observed changes regarding the topics covered in all previous courses. Questions concerned behavior, communication, leadership, teamwork, the use of cognitive aids, the practice of briefing and debriefing, and "speaking up". Participants were invited to describe significant changes and to indicate whether the change was perceived as lasting. The 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 are 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 declared and observed behavioral changes.
4. Impacts on organization, quality and safety (Kirkpatrick Level 4): The impacts on the organization, quality, and safety were estimated by the results of the VMHS's annual quality and safety audits and the evolution of reported events for the VMHS's anesthesia department. The VMHS's annual safety audits are based on 124 indicators (rated from 1 to 10) collected during inspection visits, interviews, and analyses of operating room records and data relating to technical devices, safety practices, organizations, and the management of postoperative pain and pain in the delivery room. To assess the cultural change in safety and quality of care and the ability 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 intervention 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 score dispersion between 2021 (reference year) and 2022 and 2023. The reduction in dispersion can be interpreted as a homogenization of practices towards greater safety. The evaluation 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 people reporting no events was halved compared to the previous year (nine times less than the data in 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 one implemented 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

The implementation of a large-scale training and change initiative is not without challenges. The sources describe several significant obstacles encountered during the initiative at the VMHS, which required careful navigation and creative problem-solving.

One of the main challenges was obtaining funding for the project. Convincing medical and financial leaders of the importance of the program proved to be a lengthy process, taking nearly a year to overcome this obstacle. In addition, we had to face skepticism and challenges to the authority of certain senior stakeholders, which required delicate management.

Language barriers presented another substantial obstacle. English served as the common communication language, although it was the native language of only one expert. To mitigate comprehension issues, Vietnamese assistance was available for e-learning, and simultaneous Vietnamese translation was offered for all lectures and simulations. However, the cultural and linguistic divide posed ongoing challenges in comprehension and communication.

Cultural norms and hierarchical structures within the healthcare system have considerably hampered efforts to encourage safer practices and promote horizontal communication and leadership. As mentioned previously, the predominance of a senior-junior relational culture where deference prevailed has made it difficult to encourage "speaking up" and establish a culture of psychological safety.

The logistical complexities associated with conducting training sessions with large groups have also complicated matters. Managing multiple languages and coordinating simultaneous translation during in-person training (simulation) required intense cognitive effort on the part of translators and trainers. In addition, a limited knowledge of local anesthesia practices and interprofessional relational 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 in-depth 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, ensuring alignment with organizational needs and expectations, securing full commitment, and effectively coordinating online and face-to-face training are essential. This requires mobilizing resources and expertise, and anticipating and proactively resolving potential challenges. The role of leadership has 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 such as 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" behaviors, the increase in safety incident reports, and the cultural change observed within the VMHS suggest that psychological safety is not an abstract ideal - it is a concrete skill that can be trained, with 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.

Although 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 in all healthcare settings. The results suggest that integrating psychological safety through structured training is not only possible but essential for reducing medical errors, improving patient care, and promoting a collaborative work environment.

If knowledge alone is not enough to change behavior, then healthcare systems should prioritize active, immersive learning experiences that link theory to practice. The DOMA (Development of Mastery in Anesthesiology) model provides a replicable and scalable framework for institutions worldwide aiming 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 apply it, but how quickly we can achieve it. Investment in structured psychological safety training 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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