Strategies for Health Organizations

Empowering Worker & Learner Voice

Employee or worker voice, where individuals can and will speak up and engage on issues of patient and worker safety, relies on two key factors: 1. Psychological safety in the work and learning environment and 2. Intentional engagement of workers and learners to co-design solutions improves well-being, retention, and ultimately patient safety. These strategies must occur in concert with the Actionable Strategies across the relational and operational areas.

Psychological Safety

Psychological safety – systems in which workers and learners are protected and have a way to safely report issues - is essential to support worker voice, engagement, and trust. Key steps include: 

  • Measuring psychological safety at your organization
  • Reviewing and changing policies to support psychological safety 
  • Creating systems for confidential, anonymous reporting regarding work conditions, trust, and discrimination 


Organizations with high psychological safety were associated with better team performance, continuous quality improvement, and a learning culture, while low psychological safety was associated with employees being less likely to speak up.1 A recent systematic review identified 13 enablers of psychological safety in healthcare settings. Organizational-level factors include: safety culture (i.e., organizations actively encourage speaking up in the name of patient safety), a culture of continuous improvement (i.e., learning orientation where staff are involved in suggesting improvements to work process), organizational support (i.e., organizations that have a culture of respect and openness, where “raising concerns is a professional duty that is received positively and supported by administration and policies”), and familiarity across teams (i.e., having open communication and collaboration across different teams).2

While not focused on health or public safety workers, Mao and DeAndrea find when individuals perceive channels to voice concerns are more anonymous and when concerns were only visible to a small group of people, they believed the platform was safer and more effective for voicing concerns, and had stronger intentions to use the platform.3 


Kingston, et al.’s Annual Perspective: Psychological Safety of Healthcare Staff through the Agency for Healthcare Research and Quality’s PSNet Collection. The perspective piece provides a review of psychological safety in healthcare settings, facilitators and barriers, interventions, measurement, and potential negative consequence in psychologically safe environments.

Hadley, Mortenson, and Edmondson’s Make It Safe for Employees to Speak Up--Especially in Risky Times recommends the following steps when building a culture of psychological safety: (1) Clarify the rationale; (2) Targeted invitations (i.e., providing employees specific direction for how to speak up and on what?); (3) Ensuring no punishment or negative consequence for speaking up and training managers; and (4) Reward employees for speaking up and recognize them.

  • Amy Edmonson also designed one of the most common measures of psychological safety, the team psychological safety subscale (Appendix), which includes 7 items such as members of the team are able to bring up problems and tough issues.  

The Occupational Health and Safety Administration’s Recommended Practices for Anti-Retaliation Programs provides recommendations for employers in creating workplaces free of retaliations, including retaliation against employees engaged in activities protected under the 22 whistleblower laws OSHA enforces.

Trinity Health implemented an anonymous Web-based reporting tool, PEERs (Potential Error and Event Reporting System). The goal was to increase the reporting of actual events and near misses, facilitate the management of events, and identify potential safety problems before patients were harmed.


1 Grailey KE, Murray E, Reader T, Brett SJ. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773.

2 O’donovan R, Mcauliffe E. A systematic review of factors that enable psychological safety in healthcare teams. International Journal for Quality in Health Care. 2020;32(4):240-250.

3 Mao CM, DeAndrea DC. How anonymity and visibility affordances influence employees’ decisions about voicing workplace concerns. Management Communication Quarterly. 2019;33(2):160–188

Worker & Learner Engagement

Worker and learner engagement are core relational strategies which ensure efforts to improve well-being address organization-specific challenges that are prioritized and informed by those on the frontlines. Engaging and supporting workers and learners in advocacy further offers an opportunity to elevate voice. Organizational approaches include:  

  • Creating ongoing dialogue between organizational leadership and healthcare workers to build trust
  • Engaging workers and learners in co-developing solutions within and outside of organizations with supported/paid time to contribute


Organizational listening strategies (surveys, townhalls, stay interviews, etc.) are associated with increased trust and job satisfaction.1 COVID-19 highlighted the value of listening calls & employee surveys to create dialogue between organizational leadership and frontline workers.2 In interviews, health workers shared the importance of clear, transparent, and timely communication from the top, open communication, action based on feedback, and communicating changes back to workers in building trust.3-5 These studies suggest organizational listening followed by action and communicating change can improve trust and engagement. 

Worker engagement through quality improvement has also been demonstrated to improve mental health and burnout. A recent systematic review6 of enablers of psychological safety in healthcare settings identified a culture of continuous improvement as a key enabler. Physicians and nurses have rated interventions that improve care delivery and patient safety as more important than interventions specifically aimed toward improving their mental health.7 “Zero-burnout” primary care practices are using more quality improvement strategies8 and quality improvement projects targeting clinician concerns are associated with reduced burnout in randomized trials conducted in primary care settings.9

Studies of shared governance among nurses found that dedicated time with compensation were important elements of shared governance work.10,11 A systematic review & meta-analysis of interventions to reduce physician burnout also noted some interventions include a component of covering physicians’ time for participating in the interventions.12 These studies indicate that protecting compensation will allow for participation in organizational change interventions. 


The Nurse Staffing Think Tank: Priority Topic and Recommendations prioritizes innovative care delivery models and provides recommendations for organizational assessment, resource allocation and defining success, inclusion of nurses for implementation, and PDSA. Their Gap Analysis Tool helps organizations evaluate their own readiness under each of these areas, as well as in the other five identified priority topics.

The American Board of Internal Medicine (ABIM) Foundation’s Building Trust initiative promotes trustworthiness between systems and clinicians, clinicians and patients, and the communities they serve. Resources include:

  • Webinars exploring various aspects of this process 
  • A resource repository of relevant peer-reviewed literature
  • Stories describing how other organizations have built better trust with and among health workers, patients, and communities. 

The American Medical Association (AMA) provides resources to engage physicians in addressing burnout and rebuilding trust, including:

  • Building Bridges Between Practicing Physicians and Administrators module describes the drivers of physician-administrator distrust and discusses strategies to improve trust between physicians and administrators.
  • The Listening Campaign Toolkit describes how to engage physicians to uncover and address sources of burnout. The Toolkit has three main objectives: 1) Outlines how to design a structured Listening Campaign; 2) Provides a framework to prioritize and implement improvement work; and 3) Describes ways to overcome common obstacles to engaging both leaders and physicians in improvement work.

Successful Engagement Begins with Listening: This blog post from the Cleveland Clinic discusses their four-part strategy to engage their employees. A key strategy recommended is to end any listening strategy with an affirmation of accountability and action. 


Virginia Mason Medical Center (VMMC) created the Respect for People program, which is designed to build trust by “by fostering an inclusive, psychologically safe workplace climate in which all team members foster respectful behavior during interactions with patients and each other, and where individuals feel safe to ask for help, discuss problems and admit errors as we work together toward our vision to be the quality leader and transform health care.”

Norton Medical Group adapted the Stanford Medicine WellMD approach into a multi-component strategy including: 1) provider engagement & growth; 2) workflow/office efficiencies; 3) relationship building; and 4) communication to building trust between clinicians and administrators and address workplace stressors.

Cleveland Clinic has multiple public webpages dedicated to Caregiver Engagement and Safety. During the earlier part of the COVID-19 pandemic, the Cleveland Clinic had a focus on ensuring “transparent, frequent and empathetic communication” to their workforce of over 70,000. They also have a podcast episode discussing how healthcare organizations can care for caregivers.


1 Qin YS, Men LR. Why does listening matter inside the organization? The impact of internal listening on employee-organization relationships. Journal of Public Relations Research. 2021;33(5):365-386.

2 Cumberland DM, Ellinger AD, Deckard TG. Listening and learning from the COVID-19 frontline in one US healthcare system. IJWHM. 2022;15(3):410-426. 

3 Smallwood N, Bismark M, Willis K. Burn-out in the health workforce during the COVID-19 pandemic: opportunities for workplace and leadership approaches to improve well-being. BMJ Lead. 2023;7(3):178-181.

4 Smallwood N, Pascoe A, Karimi L, Bismark M, Willis K. Occupational Disruptions during the COVID-19 Pandemic and Their Association with Healthcare Workers’ Mental Health. IJERPH. 2021;18(17):9263.

5 Neill MS, Bowen SA. Ethical listening to employees during a pandemic: new approaches, barriers and lessons. JCOM. 2021;25(3):276-297. 

6 O’donovan R, Mcauliffe E. A systematic review of factors that enable psychological safety in healthcare teams. International Journal for Quality in Health Care. 2020;32(4):240-250. 

7 Aiken LH, Lasater KB, Sloane DM, et al. Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety. JAMA Health Forum. 2023;4(7).

8 Edwards ST, Marino M, Solberg LI, et al. Cultural And Structural Features Of Zero-Burnout Primary Care Practices. Health Affairs. 2021;40(6):928-936.

9 Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30(8):1105-1111.

10 Wilson J, Gabel Speroni K, Jones RA, Daniel MG. Exploring how nurses and managers perceive shared governance. Nursing. 2014;44(7):19-22. 

11 Giambra B, Kneflin N, Morath H, et al. Meaningful participation and effective communication in shared governance. Nurse Lead. 2018;16(1):48-53.

12 West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet. 2016;388(10057):2272-2281.