You’ve seen it before. A patient shows a worsening pattern. Likely, it’s subtle. Perhaps, a nursing assistant notices it first: the resident didn’t finish breakfast, a few bites of lunch, seems more confused —but the CNA hesitates to speak up, as the RN is so busy. They’re shortstaffed… again.

Possibly, the nurse doesn’t suspect anything until the I&Os are totaled at end of shift. She passes the information onto the evening shift, but the patient is sleepy and hardly touches dinner… and everyone is busy. No biggie.

However, by the next day, the situation has escalated to… (fill in the blank: extreme sudden confusion, fatigue, dizziness, oliguria). Situations like this are all too common in elder care.

Most often, the underlying issue, when vague symptoms become patterns that are missed, is assumed by management to be due to the assistant’s lack of knowledge. That may be true, but very often, the underlying problem is the staff’s reticence to ‘bother’ the RN.

In response to this hesitation to speak up, leaders should ask these questions:

• Is this a workplace of psychological safety, where all persons are treated with kindness and respect, even if they make a mistake?
• Do all employees know they will be heard because their opinions and observations matter?
• Do staff worry they’ll be shamed, made to feel stupid, or that they will face some sort of retribution, if they do speak up?

Herein lies the essence of psychological safety: the belief that anyone can raise a concern, ask a question, or admit they aren’t certain about something, without fear of dismissal or negative consequences.

Research since the turn of the century has shown that psychological safety is a critical component of effective communication and team performance, ergo patient safety (Edmondson, 1999; IOM, 2001). Nevertheless, we recognize that nursing homes and residential rehab centers have high rates of patient adverse incidents that can be directly tied to lack of effective, sustainable team communication.

Why Psychological Safety Is Hard to Maintain

In a perfect world, team communication patterns develop naturally, over time, as people get to know, like, and trust one another in the workplace. When management is open to feedback, employees of all categories know the appropriate time and method to voice concerns, and how to do so in a manner in which those concerns will be received.

However, elder care and rehab environments operate in a much more complex adaptive system. As such, inconsistency in terms of staff turnover, rotating assignments, agency personnel, skill mix, communication styles, time constraints, and variable, competing demands, pressures the best team communication mix to often morph into “the perfect storm.”

Staff may feel reluctant to speak up if they vacillate answering these internal questions:

• Is this a dumb question?
• Is the right time to speak up?
• Will I be taken seriously and supported, or ridiculed?
• If I mention this, will I have to implicate a teammate?
• Am I overstepping? What’s the policy here?

These are not individual failings; they are system-level challenges.

From Improv to Improve

Enter applied improvisation, which is not about comedy! Instead, it is an evidence-based communication method based on principles from all the arts that emphasizes small, repeatable behaviors. These principles can be utilized in healthcare to strengthen communication and teamwork in dynamic environments, even within one shift (Crossan, 1998; Vera & Crossan, 2005; Campbell, 2014; Campbell, 2022). Here are three basic principles to begin the process of creating a psychologically safe culture.

1. “Yes, and…” instead of “Yes, but…”

At its core, the “Yes, and…” philosophy presupposes your acknowledgment of another  

person’s idea before you add to it.

Instead of:

• “…But, that’s not what’s happening.” or “…But we’ve never done it that way.” Try:
• “Yes, I see what you’re noticing—and I’m also wondering if we should check…”This simple shift reduces the risk of shutting someone down and encourages continued communication. It signals: Your voice is welcome here. Let’s work together.

2. Listen to Understand

Improvisation requires deep, active listening—not simply waiting to respond, but focusing on what is being communicated.

In practice, this means:

• Take breath, pause, and think before responding.
• Ask clarifying questions rather than assuming.
• Don’t interrupt or redirect the conversation prematurely.

Listening, in this sense, is not passive—it is a core mechanism for creating psychological safety.

3. Make Your Partner Look Good

This phrase is something we improv-ers say to remind each other that whatever the goal is, we’re a team, i.e., “It’s not all about me.”

In practice, this means:

• Encourage and validate a colleague’s observation or action.
• When chaos reigns, ask: “How can I help” or “What do you need now?”
• Offer a quick update or share information that could prevent a problem

When staff feel supported rather than judged, they are more likely to contribute openly.

A Practical Path Forward

Never fear! Creating psychological safety in elder care does not require perfect conditions or having the same team every day. It begins with small, consistent actions that signal respect, curiosity, and shared responsibility.

The results, when staff feel able to speak up:

• Concerns are raised earlier.
• Changes in patient condition are communicated sooner.
• Teams adapt more spontaneously and effectively, in real time.
• Key metrics for patient care, patient outcomes, and patient satisfaction are all improved.Psychological safety is not simply a cultural ideal. It is a daily practice—one that can be supported through simple, practical behaviors that fit within the realities of andy complex adaptive system – even elder care.

References

Campbell, C. A., (2014). Improv to Improve Interprofessional Communication, Team Building, Patient Safety, and Patient Satisfaction. Doctor of Nursing Practice (DNP) Projects. 27. https://repository.usfca.edu/dnp/2

Campbell, C. (2022). Improv to Improve Healthcare: A System for Creative Problem-Solving (2nd ed.). Business Expert Press.  https://www.businessexpertpress.com/books/improv–toimprove–healthcare–a–system–for–creative–problem–solving/

Edmondson, A. (1999). Psychological safety and learning behavior in work teams.

Administrative Science Quarterly, 44(2), 350–383.

https://web.mit.edu/curhan/www/docs/Articles/15341_Readings/Group_Performance/Edmondson%20Psychological%20safety.pdf

Institute of Medicine, National (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Academy Press.

https://www.ncbi.nlm.nih.gov/books/NBK22832/pdf/Bookshelf_NBK22832.pdf

Vera, D., & Crossan, M. (2005). Improvisation and innovative performance in teams. Organization Science, 16(3), 203–224. https://doi.org/10.1287/orsc.1050.0126

Candy Campbell, DNP, RN, CNL, CVP, CEP, LNC, FNAP

Is an award-winning author, actor, filmmaker, keynote speaker, and applied improvisation specialist who helps organizations build resilient, high-performing teams. With a clinical background in high-acuity healthcare and doctoral research conducted at Stanford’s Lucile Packard Children’s Hospital, she has firsthand experience working in environments where communication breakdowns can carry serious consequences.

Dr. Campbell integrates principles from multiple performance disciplines—including theater, music, writing, fine art, and aviation—into evidence-informed leadership and team development programs. She is the author of Improv to Improve Your Leadership Team: Tear Down Walls and Build Bridges and Improv to Improve Healthcare: A System for Creative Problem-Solving. Her work has been used to strengthen collaboration, psychological safety, and adaptability in corporate, healthcare, and professional association settings.

Her engaging, highly interactive sessions translate complex behavioral science into practical tools leaders can apply immediately to improve team performance and organizational culture.

For more: https://candycampbell.com or candy@candycampbell.com