Following on from the powerful blog “After the speeches…” that outlined actions needed to reduce discrimination, we are delighted to publish part seven of a ten part blog series by Roger Kline with suggestions on how to tackle structural racism in the NHS.

In 2012 Google set out to answer a simple question “What makes a Google team effective?” After hundreds of interviews and scrutiny of 180 different teams, they found, contrary to what they expected to find, that “Who is on a team matters less than how the team members interact, structure their work, and view their contributions”

They found that when individual members attached low interpersonal risk to voicing their ideas or making mistakes, they were more likely to share novel information or challenge the status quo. In turn, the group was able to access and integrate a greater diversity of thought to drive innovation and to improve judgment and decision-making. They found that employees in psychologically safe teams were also less likely to want to leave Google, brought in more revenue, and were rated as effective twice as often.

Research on psychological safety confirms a strong association with learning and performance in teams and organisations. West and colleagues found that “evidence of the links between psychological safety, supportiveness, positivity, empathy, leadership and innovation is deep and convincing”

Creating a safe place can nurture a work environment where staff can share novel ideas and perspectives or raise concerns free from the risking ridicule or adverse consequences. Psychological safety isn’t about being nice. Rather as Edmondson put it, “it’s about giving candid feedback, openly admitting mistakes, and learning from each other.” When that happens, employees are more likely to make use of their differences for good than to “mask” them.

Inclusion is the extent to which staff believe they are a valued member of the work group, in which they receive fair and equitable treatment, and believe they are encouraged to contribute to the effectiveness of that group. Such teams value the difference and uniqueness that staff bring and seek to create a sense of belonging, with equitable access to resources, opportunities and outcomes for all, regardless of demographic differences. Such teams and organisations are more likely to be ‘psychologically safe’ workplaces where staff feel confident in expressing their true selves, raising concerns and admitting mistakes without fear of being unfairly judged.

Whilst COVID-19 prompted fantastic teamwork in health and social care, it also highlighted how substantial groups of staff, especially from Black and Minority Ethnic (BME) backgrounds, felt unable to raise concerns and were largely absent from decision making, despite being at higher risk. This fault line had fatal consequences. At the start of COVID-19, failure to recognise this even led NHS England and NHS Improvement to temporarily park the collection of race equality data (and then hastily reinstate it).

The impact of COVID-19 and Black Lives Matter has now led to a renewed focus on career progression and improved representation of BME staff especially in more senior grades. Such goals will not be sustained unless the teams they join become inclusive and psychologically safe so they can leverage the benefits of diversity. More diverse representation alone – more BME staff in more senior positions – neither necessarily leads to a sense of belonging nor guarantees that everyone in your organisation feels a sense of belonging, feels respected, listened to and that their difference is valued and welcomed.

Leaders who understand the necessity for inclusive teams promote psychological safety. Such leaders “walk the walk” and demonstrate this in their day to day interactions not just their public statements. They understand Unwin’s focus on embedding relational intelligence (kindness, emotional intelligence) as powerfully as rational intelligence (regulation, measurement and efficiency). They model, promote and reward behaviours that promote a safe work environment.

This is not a cuddly optional extra. It may involve difficult direct conversations. But it is intrinsic to good team building focussed on learning not blame, and underpinned by the evidence that such teams are safer both for staff, patients and service users. Amy Edmondson’s suggestions for a 5 minute psychological audit might be a good starting point for reflection.

Inclusive teams which are psychologically safe are likely to be better at tackling the “protective hesitancy” which results in some managers being reluctant to have honest conversations when “critical” issues arise – and staff not feeling it is safe to say what they really think. This applies especially to BME staff but also to how disabled staff, women and LGBT+ staff may be treated. Inclusive teams built on psychological safety are also likely to be less tolerant of those who may enable “testimonial injustice” which can so easily undermine staff with protected characteristics.

Psychologically safe and inclusive teams are an antidote to the bullying, rife in the NHS, which ‘inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale and inhibits compliance with and implementation of new practices’. Such teams and workplaces do not miraculously emerge. They are created by leaders who actively promote inclusion and a culture where speaking up is valued and encouraged. Such leaders (at team level not just Board level):

• pay deep attention to the contributions and culture of others
• pay attention to others’ cultures and adapt as required.
• make diversity and inclusion a personal priority
• speak out and do not leave it to those subjected to poor behaviours to do so
• admit mistakes, enable others to flourish and are modest about their own achievements, using “we” not “I”
• are aware of their own biases and openly seek to mitigate them: 
• are curious about others and their experience, seeking to “walk in their shoes”
• constantly seek to enable and polish the skills of others, creating space for others to shine

Improved demographic diversity at more senior levels is a precondition for improving health care and achieving social justice. But, unless the teams those newly recruited staff join are also characterised by inclusion and psychological safety, that diversity will neither be sustainable nor add the value it can and should.

Roger Kline

Roger Kline is Research Fellow at Middlesex University Business School. He authored “The Snowy White Peaks of the NHS” (2014), designed the Workforce Race Equality Standard (WRES) and was then appointed as the joint national director of the WRES team 2015-17. Recent publications include) the recent report Fair to Refer (2019) to the General Medical Council on the disproportionate referrals of some groups of doctors (co-authored with Dr Doyin Atewologun) and The Price of Fear (2018), the first detailed estimate of the cost of bullying in the NHS, co-authored with Prof Duncan Lewis.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.