Table 3 Interview results from the post-interviews
From: Psychological safety during the test of new work processes in an emergency department
Deductively coded material | |
Team leader The team leader can support psychological safety by: • supporting workers in case of challenges • providing sufficient information (keeping in mind that not all information delivered is actually received, understood, accepted, or acted upon) • planning the tasks as well as possible • empowering workers to make the necessary changes to make a change work • communicating own expectations • identifying key change enablers • being present during the change period or by delegating the support of the change clearly | Feedback seeking • The close physical proximity and cooperation during the test allowed for an easy dialogue and collaboration • If the people working in this constellation are not collaborating, it can be difficult to seek feedback from each other |
Informal group dynamics • The close contact to a single physician increased the pressure on the nurse to complete tasks immediately • People react differently to the test process • Close working conditions meant people got to know each other better, but it can also generate feelings of being observed • The contributions of the individuals involved become more visible, one cannot hide behind other group members • Personal differences have stronger impact | Help seeking • It was easier to discuss with more experienced colleagues |
Trust and respect • In close contact, it is important to manage conflicts as early as possible, but this also generates insights into the other person’s perspective, generating more mutual understanding • Process challenges can be interpreted differently by those involved: some see them as rooted in the subject matter, others as rooted in personal issues • The professions are perceived differently: Physicians are considered as more independent and willing to work independently • People vary in how willingly they work with people who are different or unknown • The culture in the department has a big impact on how the test progresses | Speaking up • The close contact between the colleagues and the reduced number of patients increased the coupling between the work of those involved and increased the interdependency, requiring more co-ordination and agreements about how to do that • Those involved need to find the matching level of explicitness in the communication |
Use of practice fields • Having an opportunity to practice helped increase a sense of safety. Plus, having people who are willing to try new ideas, helps to see how those ideas can evolve and can be implemented • People are different in terms of their support for new ideas | Innovation • Known procedures felt safe, which makes the work easier • Quality and safety are higher, when the contact between the nurse and the physician is so close • The change is not unequivocally positive, e.g., reduced opportunities for reflection. Telephone-based discussions with colleagues, for example, are more difficult, as they are ideally done away from the patient • The expected effect of more patients being treated was not achieved • Some change ideas are not tested, as those involved do not see them as promising • Not all were convinced of the sense of the trial |
Supportive Organisational Context • The change (patient pathway) needs to be discussed and agreed upon across the department, and the arrangements put into practice. In particular, co-ordinating nurses have an important role to ensure patients are directed to the new treatment pathway • The co-ordinating nurse is under pressure to send enough patients to the clinical pathway • Physicians and nurses may initially engage with the patient at different points in their care pathway • The dependency between the staff involved increases, e.g., if the one clinician is busy, the other may need to wait. This may contribute to slower task completion • The number of interruptions to clinical work varied throughout the test process • An additional colleague with a flexible role would increase overall task completion • The system was faster for the individual patient, as less patients went through it, but the overall capacity was reduced • The physical resources in terms of room and equipment did not match the tasks. The room was considered too small, the equipment too widely distributed across different locations. This is particularly relevant at the start of test, although adaptations over time reduced this challenge • There is an expectation that some of these challenges could be solved, when the system is established, and the necessary equipment placed in the optimal location • Changes in personnel during the test period required additional time to be spent on introductions and orientation | Boundary Spanning • The official task distribution was not questioned, e.g., physicians were not asked to do “nursing” tasks • Adjustments of resources were required, if colleagues had idle time, they offered help in a different task • Only those directly involved in the test mentally engaged in it. This is mainly due to them being so busy that they do not have much capacity to think beyond their immediate jobs • Co-ordination of work is not perceived as an interruption and accepted as a necessary component of collaboration |
Inductively coded material beyond the Edmondson model | |
Physical characteristics • The physical context should be optimized in terms of the rooms and the equipment • The room tested was: • Too small • Had no windows • Not temperature regulated • Did not allow access to fresh air to alleviate challenges from smell (especially relevant with the infection patient) • Was perceived as uncomfortable (e.g., because you needed to move equipment to actually exit the room) • Made people feel isolated • Located away from necessary materials • Considered impractical for safe patient care, e.g., patients too close together and confidentially was difficult • Had blue light that over time was perceived as uncomfortable • To consider and discuss patient diagnosis and treatment plan, a separate room (without patients) is necessary • Opinions varied regarding the advantages of such close contact to the patients • For the co-ordinating nurses, the room was far away, making it difficult to keep an overview, e.g., whether the patient was accompanied by a nurse. As an adaptation, often the most unwell patients would be placed closer to the co-ordinating nurse | |
Perceived quality of treatment • When patients with critical conditions have to wait too long because of delays in the new care pathway, the treating clinicians can feel anxious, due to concerns for the patient’s well-being. This makes made participants feel insecure about the new pathway, as their priority was to treat their patients – consequently, decreasing the perception of psychological safety • The individual perceptions of care quality had a direct impact on how safe participants felt the process was | |