It’s no surprise that nurses bear some of the biggest burdens in our healthcare system. Heavy workloads, time pressures, and high stress are leading to dramatically increased levels of burnout and turnover, with these effects trickling down to patient outcomes. How can their everyday tools, processes, and workflows be better designed with their needs in mind, while cutting down on red tape, freeing up time, and ultimately easing their burden?
In this episode of the In Network podcast feature Designing for Health, organizational psychologist and assistant professor at the University of Baltimore Dr. Archana Tedone sits down with Nordic Chief Medical Officer Dr. Craig Joseph and Head of Thought Leadership Dr. Jerome Pagani. She discusses her views on psychological safety and the link between worker stress and patient outcomes, the unseen emotional labor carried by healthcare workers, and how critical user buy-in is when implementing new practices.
In Network's Designing for Health podcast feature is available on all major podcasting platforms, including Apple Podcasts, Amazon Music, Google, iHeart, Pandora, Spotify, Stitcher, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Make sure to leave a 5-star rating and write a review to help others find the podcast.
[01:00] Dr. Archana Tedone’s background
[04:15] Psychological safety in healthcare
[09:13] Barriers to achieving psychological safety
[13:37] How psychological safety in the workplace affects patient care
[15:11] Nurses as masters of workarounds
[20:58] Designing tools and workflows with humans in mind
[22:53] Things outside of healthcare that are so well designed that they bring Dr. Tedone joy
Dr. Craig Joseph: Welcome, Dr. Tedone.
Dr. Archana Tedone: Thanks so much for having me.
Dr. Craig Joseph: So I wanted to start off with the fact that your father is a physician. And as young child, you watched him work and observed everything that was involved with being a physician. And that inspired you to become an organizational psychologist. Is that accurate? Did I get that right?
Dr. Archana Tedone: I know it makes total sense, right? It's a bit interesting. My story about how I ended up researching the healthcare system. Growing up, I was always surrounded by a lot of folks in healthcare. We grew up in a small town with a very large healthcare system, so we had a lot of individuals that were affiliated with the healthcare system. And so it didn't take too many eavesdropping sessions at dinner parties for me to realize a couple of things. One, I definitely was not cut out to be a healthcare worker, and I think since then I tried to avoid the space for a very long time. But, you know, as Moana, I guess, it called me. And so I ended up back in researching healthcare workers, how to make healthcare, you know, a stress free, safe environment for for everyone. And so from a young age, I definitely knew that I was interested in understanding better understanding human behavior. And now I am able to kind of understand that through the lens of healthcare, because our healthcare system is made up of a bunch of humans. It is not a machine. It is individuals that are running the system. And so really understanding things that can be stressful, things that can impact decisions, things that can change how we we feel about our jobs and our work environments, I think are all factors that I think about when we think about how to make the healthcare system units’ space a more efficient way to work.
Dr. Craig Joseph: So now you're in the wonderful world of healthcare. I want to welcome you, you know, tell you congratulations. And one of the areas that you focused in is psychological safety, specifically for the healthcare workers and even more specifically for nurses. How did you become someone who wants to study what nurses do and how they can become safer in their work environments?
Dr. Archana Tedone: Yeah, I remember one of my first research projects as a grad student. I was thrown into a focus group with a whole bunch of nurses and I was very young, didn't know what I was doing, and just chatting with the nurses, asking them questions about their day, what they do. And it was very interesting because my job was to collect information on how they practice safety for themselves. So employee safety, how do you keep yourself safe? Do you follow safety rules? Do you practice safety in your daily routines? Things like that. And the conversation always ended up at patient safety, talking about keeping patients safe, keeping them happy, keeping them healthy, making sure that they were able to meet the demands that they were experiencing on a daily basis. And I honestly just fell in love with talking to this group of individuals because, you know, we were trying to talk about their own personal safety. And the conversation always turned into this patient-first kind of conversation, which is so admirable. So from that point on, it really made me think, you know, if if our nurses are putting patients first and not their safety first, then they need some people to help them put their safety first. And so I've really been passionate about researching nurse safety, nurse stress and how we can make their jobs easier because they have so many demands thrown at them on a daily basis and they consider it to be part of their job. So it can be a stressful place to be day to day, and that has led to so many issues in our healthcare system with nurse turnover, nurse burnout and really great, awesome nurses leaving the profession because of these really huge challenges and barriers.
Dr. Jerome Pagani: Archana I think that's a great place to dig in. So what is psychological safety and were these nurses even aware of that concept? And is this something that's really broadly known in healthcare?
Dr. Archana Tedone: This idea of psychological safety is a shared perception that it's okay to take interpersonal risks on a team and so when we talk about a unit in which there is high psychological safety, we think about it as a space where teammates feel comfortable raising issues, feel comfortable admitting mistakes, feel comfortable saying, hey, that task looks like it might be dangerous. How about try it this way and no one gets insulted? So having kind of that psychological freedom to be open and honest and psychologically safe work environments are really critical to getting ahead of some of these really major accidents, injuries, negative consequences from happening, right? Because having teams with low psychological safety doesn't mean that errors and mistakes, things aren't happening. It just means no one's talking about them and no one's learning about them. And so having high psychological safety really helps us get ahead of some of these issues that could turn into really big deals and put it out in the open and have that honest conversation and saying, Hey, I made this mistake today and here's how I can prevent it in the future.
Dr. Jerome Pagani: Archana, are there red flags that sort of signal that a workplace isn't psychologically safe.
Dr. Archana Tedone: There's a few red flags. I would say the biggest red flag is having a underlying tone of fear among work teams. So being scared about speaking up about something because you think you'll be retaliated against or I've spoken with nurses saying things like, you know, if I said something, then I would get the worst schedule. I know that, you know, I would really get some retaliation and you know, they might not say anything to my face, but my schedule is going to be terrible. I'm going to be put on all night shifts or something like that, right? Some of those like underlying worries. So a big red flag is having that sense of fear. You know, I'm scared that people are going to think that I'm a tattletale speaking up about all of these things. Or those negative sort of social interactions or exchanges. I don't want to be seen as that person on my work team. So work teams of low psychological safety tend to have that underlying sense of fear. And so that is a huge red flag when you're scared to speak up because you're worried about the consequences.
Dr. Craig Joseph: That seems to be like a natural thing. You're you're almost describing nursery school to me, which is kind of scary that it's also happening in the intensive care unit. But be that as it may, are there ways of kind of working that out? What kind of support do you need to make sure that nurses and all healthcare workers feel safe?
Dr. Archana Tedone: Yeah, great question. It does sound a little bit like something that happens or it doesn't, right? I'm sure we've all worked on teams where there's a natural cohesion and you're like, Oh, this is great. We're all bonding or we're all vibing, but that's not necessarily how it works. We really have to be able to design these work teams to be able to foster the sense of psychological safety. It doesn't always happen naturally. It's definitely something that is easier said than done because this is kind of a shared perception and we can't make people feel a certain way. And so really the roots of psychological safety lie in building that sense of trust. And oftentimes the leader, you know, nurse managers or team leaders, unit leaders have a large degree of power in setting the tone for a work team. So when you have a leader that is, you know, rewarding honest conversation and not only tangibly or if tangibly, but more like encouraging and recognizing some of this honest conversation around mistakes and errors and criticisms or concerns, then that kind of sets a foundation that sets the tone for behaviors that should be encouraged and expected on work teams. There's several elements of social like social exchange theory as well. If you think about individuals kind of trying to reciprocate behaviors when they feel respected and cared for. So when you're working on a team that has the foundation of mutual trust, respect, and care, then you might be more motivated to reciprocate those behaviors and voice your concerns and contribute to that.
Dr. Jerome Pagani: And your research specifically deals with some of the barriers to achieving psychological safety, right? Can you say a little bit about that?
Dr. Archana Tedone: Yeah. So I've worked with some researchers at the University of Nebraska, Kearney, Dr. Julie Landes, and we're working on a project right now that's looking at barriers to this kind of communication about stressors or safety. We call that voice. So having, you know, being comfortable raising your voice when you need a break at work or, you know, when you're having a heavy workload. We've done a lot of interviews with nurses, and in our conversations we've been finding that there is a lot of stigma associated with saying that I need help in healthcare workers a little bit because a lot of healthcare workers do think that some of these stressors that eventually cause them to exit their job sometimes are part of the job. Things like having heavy time pressures, things like having heavy workload, things like not having a minute to go to the bathroom or take a break. They're like, Oh, I signed up for this. I knew that I was getting into this. And these are the things that if they don't get better, then the only option is really to experience heavy burnout and leave or change what you're doing. And so in our research, we found that several barriers to this kind of voice and healthy psychological safety on a work team across a few levels at the individual team and organizational level. And just to give you a quick summary of some of these barriers, you know, at the individual level, we found the fear of retaliation and sort of that social risk to be one of the most common reasons. So nurses saying things like, I don't want to speak up or I don't want to say anything because I feel like I'll be treated less favorably or I'll be viewed negatively on my team. I don't want to be labeled as that person sort of thing. Things also like fatigue. Sometimes nurses are just saying like, I don't have the time. I'm super busy already and this is just another element to my job that I can't engage in right now. I can't go out of my way to to fix systems and speak up about concerns because I have heavy workload, time pressures already, as I mentioned, things like expectations, right? I knew that I was going to be bombarded with these types of jobs and demands going into this whole profession. And so this sense of speaking up makes me look like I can't do my job is also a driving factor behind kind of staying silent about some of these things.
Dr. Craig Joseph: So this reminds me a little bit of of being on an airplane and being told before I help others, I need to help myself. So it's really kind of a self-preservation and I think what I'm hearing is nurses and other healthcare workers really do need to care for themselves and think about themselves. And and by thinking of the patients solely and primarily they're burning out and then they can't save themselves, nor can they help patients.
Dr. Archana Tedone: Absolutely. I remember chatting with someone about patient safety versus personal safety, employee safety and healthcare. And I remember a nurse saying, you know, if there's a patient falling off of a bed, I'm not going to say, hey, wait, stop falling. I'm going to go run and get my gate built. I'm going to go make sure that patient is okay and that is such an admirable attitude to have. And nurses are amazing and they definitely prioritize patients and that's all great. Back injuries and nurses are out the roof, right? And so there can be some really long term consequences for not paying attention to personal safety as well. And so it is kind of like that airplane, put your mask on first because, you know, if we can protect the backs of our nurses, then we'll be able to deliver better patient care in the long run, we'll be able to treat more efficiently. We'll be able to make sure our patients are getting what they need and manage the heavy patient demands at times.
Dr. Jerome Pagani: So Archana, do psychologically safe environments actually end up affecting patient outcomes, patient care?
Dr. Archana Tedone: Absolutely. There's tons of research that supports this link between nurse, healthcare worker, safety, stress, and patient outcomes. We definitely can see a clear link between that in the research. And so oftentimes, it isn't something that is at the top of mind for us, right? Because we think that improving patient safety and putting the patient first, you can see more immediate benefits of that, right? But if you think long term, if you look at these data over time, then you can definitely see a clear link between quality of care and nurse efficiency, safety, health, stress, right? If we're burning out our nurses, then just that cost of kind of hiring and filling staffing, those all affect the quality of care we're able to deliver. So being able to retain good nurses and make sure they're happy, healthy, and safe is really the best long-term strategy for patient care as well.
Dr. Craig Joseph: So, Archana, you've mentioned several times about how there are stressors and other kinds of organizational blocks that can be there and that we know also from your research that that can affect patient outcome. Are there any ways that nurses deal with some of these things that are either positive or negative on them or their patients?
Dr. Archana Tedone: Great question. And in this really speaks to this idea that nurses we think of as the masters of workarounds, that's what they've been called in the research on healthcare space and what that means is that nurses have, as I mentioned, so many different demands, right, time pressures, patient loads and things along those lines. So nurses often think that they're not able to follow every single safety policy, abide by every single rule, and also meet the demands that are being put on them and deliver quality patient care. And so, as I mentioned many times, oftentimes nurses do prioritize patient care and sometimes they feel that they have to sacrifice either their own safety or some of the red tape, I guess you could say, around policies, practices, and systems in order to make it work, in order to be able to deliver the care that they want to deliver. And so nurses have been titled in the literature the masters of workarounds, because they've really turned this into a science. They know exactly what they need to do to meet their demands, and they've kind of made it into an art form to figure out what roles they can work around to meet the demands that are being put on them.
Dr. Craig Joseph: So this is interesting from the perspective of someone like me who has designed workflows for physicians and nurses and often wondering why specific steps are being missed. And to your point, it's it's the workaround, hey, I've found another way to do this thing faster and sometimes that's great. That was a bad design decision that we made when we created that tool. Sometimes, though, when you do a workaround, you're skipping a couple of steps and that's information that we might need for patient care down the line. And without thinking about that and making sure that that's, you know, top of mind for the healthcare worker, we get suboptimal outcomes. Have you seen anything like that where where there are kind of skipped steps where these workarounds do lead to problems either with tech or outside?
Dr. Archana Tedone: Absolutely. And I think the nature of a workaround is that, A, it doesn't always have to be a bad thing, right? Sometimes it can be a more efficient way to do something. However, especially in terms of, you know, safety and things like that, these rules and these workflows are developed in order to make a process more efficient, in order to make the workplace safer, in order to solve a problem that's being experienced. However, if your work team is not bought in to this whole idea of the workflow you're presenting or the piece of technology that you're introducing, then they're going to view it as a barrier to their workflow and they're going to figure out how to work around that barrier to get their job done. So when it comes to introducing new policies, workflows, techniques, technologies, it's critical to invest time, effort, energy into getting that buy in from your work team, because without that buy in, then you could have a harder time getting your workflow, your technology integrated into the system. And so spending that time upfront is really going to save you the headache down the road of trying to convince people why this thing is important, why this thing should be working properly. You know, it's better to spend that time upfront to make sure that people are bought in.
Dr. Jerome Pagani: So it sounds like you're talking about doing change management properly and really designing that whole process for the end user, in this case the nursing staff.
Dr. Archana Tedone: Exactly. I think there needs to be that kind of upfront thought of how to roll something out, how to, you know, perhaps roll it out in batches, do a test case, right, roll it out to a work team, get feedback, really thinking about the steps that you're going to take to disseminate your system idea, so on and so forth. I think collecting the most valuable data is data from employees, their reactions, their experiences, their thoughts, and using that feedback to better improve your system or workflow or technology rollout, I think would be ideal in helping to get that buy in in the beginning.
Dr. Craig Joseph: I agree with you 100%. Often, it's not just the how and that's where people focus on workflows or other things that folks have to do. This is how you do it. What they don't mention and you've kind of referenced, is the why
Dr. Archana Tedone: Exactly.
Dr. Craig Joseph: Why should I be doing this? Who benefits? Is it good for me? Is it good for my patient? Is it good for the bottom line of the hospital so we can, you know, follow the rule of no margin, no mission? It's that why that often makes the difference with changes.
Dr. Archana Tedone: Absolutely. I totally agree with that. And it's especially the case when it comes to introducing new, you know, processes, technologies, for example. I think technology has been one of the most commonly cited workarounds. You know, when someone just plops a new technology and says, hey, use this now, that's it, of course we're going to question it, right? Like, Hey, I've been doing my job this way for so long and it's been going great. Why do I have to do it this other way now? And I think without having that why, it's really hard for any human to buy into anything, right? Because we don't know why we're being asked to do something. So yes, absolutely right.
Dr. Craig Joseph: So as an organizational psychologist, are there any tips or ideas that you can throw out to us where you see people designing tools, designing workflows that just don't take into account some areas of being a human that they're not aware of but really should be?
Dr. Archana Tedone: Yeah, there's there's a couple of that come to mind, and I think one is that, as I mentioned before, that we're all human, right? We're all humans interacting with one another. And in the workplace we need to take into account the social environment in which one is working. And so things like your behavior and decisions are in part, if not majorly, driven by perceptions of others. Your peer group, your leaders. And so really thinking about how these social exchanges can influence behavior and decisions is something that we should keep in mind when we're designing tools and workflows. And another is these cognitive factors that we should be thinking about. Things like the cognitive load that's being placed on nurses when they are managing multiple demands, when they have heavy pressures. The emotional labor as well. You know, healthcare is very emotionally charged at times. There's some really big things happening. A lot of times, you know, our healthcare workers are making really emotional decisions and sometimes they have to kind of turn that off and move on to the next one, right? And so suppressing emotions like that can also play a really big role in kind of your long term mental health, right? And so really thinking about how the cognitive load in these cognitive factors, the emotional labor that our healthcare workers are engaging in and how that can also affect the tools, workflows, processes, things like that is also critical.
Dr. Jerome Pagani: Archana, that was fantastic. So we like to end the podcast asking everyone pretty much the same question and it's basically this: what are up to about three things that you've interacted with in your everyday life, and they could be outside of healthcare, but that are so well-designed that they bring you joy to interact with.
Dr. Archana Tedone: Great question. And thinking about this makes me think that well-designed things tend to be very simple solutions to really complex problems. I would say that some of the moments in my life where I've been like, Wow, this is great. Why haven't I thought of this? Have been all of the awesome kids stuff these days. So I'm a mom and I've interacted with a lot of new kids gadgets and things like that. And I would say simple things like a bib that catches food so the clothes don't get all dirty or a, this inflatable footrest that kind of turns a plane seat into a little bed.
Dr. Jerome Pagani: What?!
Dr. Archana Tedone: I know, they have that now. Why didn't we think of that? Or this, it's a pacifier that is also a medication delivery system. You just insert the medication into the pacifier. Like, genius inventions. And these are all from parents who, I feel like, a lot like healthcare workers, try to make do with what they have and they're like, okay, how do I solve this little problem? My kid is not taking their medication. How can we make it happen? And so it's almost like they're creating their own systems and ways to to get things done efficiently with little resources. And they're like, we're going to put the medicine in a pacifier, genius. And so it's these little things I feel like are so simple fixes to some of the most complicated issues, right? Like my kid won't take their medicine, but here is a very easy way to make that work. Or or my child is spilling all over themselves. Let's create a bib that just catches all the food. And so I think that the most amazingly designed products are kind of when you're in that desperate space and you're trying to figure out how to how to solve this this problem. And it's often the simplest solutions, I think, that happen to be the best.
Dr. Craig Joseph: You know, as a pediatrician, I'm offended by some of those things. I feel like some of them might decrease my business and I, you know, we need the business.
Dr. Archana Tedone: So, do not prescribe your own medication. Go to a doctor and get the medication, but then use the medication pacifier.
Dr. Jerome Pagani: Archana, I love those examples because having, there are things that I banged my head against the wall, and they feel so frustrating and unsolvable, and just the genius of having a simple solution at hand is …
Dr. Archana Tedone: Yes.
Dr. Jerome Pagani: … incredibly joyful.
Dr. Archana Tedone: Exactly. Talking to my parents and how they didn't have some of these things growing up. I'm like, wow, how did you manage? We have so many cool gadgets and tools and sleep sacks and pacifier clips, like back in the day, if a baby dropped their pacifier, that, it was, that was it.
Dr. Jerome Pagani: You boiled it.
Dr. Archana Tedone: Yeah, exactly.
Dr. Jerome Pagani: If you could.
Dr. Archana Tedone: And now you know, bungee cords for pacifiers.
Dr. Jerome Pagani: Well, Archana, thanks so much this has just been a fantastic conversation. We really appreciate you joining us.
Dr. Archana Tedone: Thanks so much for having me. It's been a pleasure.