top of page

Psychological Safety & Closed Cultures: A Discussion

Amy Edmondson coined the term "psychological safety" and has significantly raised awareness about this crucial cultural aspect. Psychological safety means that team members feel confident they can speak up, share ideas, admit mistakes, and raise concerns without fear of embarrassment, rejection, or punishment, there is more to it but that is the basic premise. This foundational concept is essential for fostering a work environment where learning, innovation, safety, and growth can thrive.

In the context of healthcare, particularly the NHS, the importance of psychological safety is evident in the numerous scandals, inquiries, and CQC special measures reports over the decades. A recurring theme in these reports is the lack of psychological safety as a major, if not root, cause of organisational failure and compromised patient safety. Common findings include statements like, “The organisation failed to listen to patients and staff,” highlighting a pervasive issue.

'For those who proactively work towards cultivating psychological safety, the organisational benefits are significant. More than 20 years of research demonstrates that organisations with higher levels of psychological safety perform better on almost any metric or key performance indicator (KPI) compared to organisations with low psychological safety.'

Professor Oliver Shanley OBE, in the Edenfield review, linked psychological safety directly to closed cultures, noting: “We found a service that had all the hallmarks of a closed culture, including an absence of psychological safety.”

Key Discussion Points

Psychological Safety for Patients: While much of the discussion around psychological safety focuses on employees, it is equally important to consider the psychological safety of patients. Patients should feel secure in voicing their concerns and experiences without fear of dismissal or facing negative repercussions.

Closed Cultures in NHS Trusts: A closed culture in an organisational context, including within NHS trusts, refers to an environment where transparency and openness are lacking, and where dissenting voices, feedback, or concerns are unwelcomed or are actively suppressed. This fits perfectly with Edmondson's model, as the absence of psychological safety can lead to damaging closed cultures. Does it therefore exist in the bottom left-hand corner?

Absence of Psychological Safety at All Levels: When examining scandals and failures, particularly in the healthcare sector, it becomes evident that the absence of psychological safety permeates all levels of an organisation. This lack of safety affects three key cohorts of people:


1.        Frontline Workers: These are the individuals directly involved in patient care. They may fail to uphold quality and patient safety due to fear of reprisal, lack of support, or overwhelming workloads. When psychological safety is absent, they may feel unable to report issues or errors, leading to compromised care.

NHS Whistleblowers, comprising healthcare professionals across the UK state, 'and the group says "a culture detrimental to patient safety" is evident across the health service'.

2.        Middle Management:

Middle managers are often responsible for acknowledging and addressing reported failures. However, if they lack psychological safety, they may ignore or dismiss concerns to avoid conflict, maintain their positions, or due to bureaucratic inertia. This can lead to systemic issues being unaddressed and perpetuated. A case in point from Dr Bill Kirkup from the 2024 Panorama:

They should be listened to, they should be taken seriously, they should get answers to their concerns, and too often that doesn’t happen, and they are treated as a troublemaker, threatened with disciplinary action or professional regulatory action.’ 

Dr Bill Kirkup, Chair, Maternity Service Review , BBC One - Panorama, Midwives under Pressure 


3.        Senior Management and Leadership:

At the top levels, senior managers and leaders might punish those who report failings. This cohort includes individuals who are under pressure from external bodies like the government, CQC, and the media. Their fear of negative publicity, regulatory repercussions, or career damage can lead to a culture of suppression and retaliation against whistleblowers. This point is aligned with the quote from Dr Bill Kirkup:

There is a widespread culture in the NHS that if you are being criticised then the right thing to do is to circle the wagons, manage your reputation, and the first stage of that is usually to do with denial and deflection and it’s masking the problems. I think that it is very difficult for trust senior management and boards to admit that they have problems that they don’t know how to fix'.

Dr Bill Kirkup, Chair, Maternity Service Review, BBC One - Panorama, Midwives under Pressure 



The absence of psychological safety at all levels - from frontline workers to senior management - creates a dysfunctional environment. This environment perpetuates failures and compromises patient safety and quality of care. Addressing psychological safety across all levels is essential for fostering a culture of openness, accountability, continuous improvement, innovation & patient safety.

We know that many NHS employees go into a career in healthcare driven by a desire to directly improve the lives of others. Caring for patients in their time of need can be incredibly rewarding. Despite a strong culture of patient care, the NHS faces immense pressure due to funding constraints, demographic shifts, and ongoing challenges since Brexit. This creates a difficult environment where closed cultures can develop even with resolute staff striving to deliver excellent service. The NHS, once a global healthcare leader, and still one of the largest employers in the world, requires innovative solutions to empower its vast workforce and ensure continued excellence.

Paul Howarth, Director of Research & Development & Founder


Rated 0 out of 5 stars.
No ratings yet

Add a rating
bottom of page