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Making It Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safety and Improvement Efforts in Health Care Teams

November 2006
27(7):941 - 966

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This paper introduces the construct of leader inclusiveness—words and deeds exhibited by leaders that invite and appreciate others' contributions. We propose that leader inclusiveness helps cross-disciplinary teams overcome the inhibiting effects of status differences, allowing members to collaborate in process improvement. The existence of a professional hierarchy in medicine and the differential status accorded to those in different disciplines is well established in the health care literature, as is the need for quality improvement. We build on this foundation to suggest that profession-derived status is positively associated with psychological safety (H1)—a key antecedent of speaking up and learning behavior—in health care teams. We hypothesize that this effect varies across teams (H2), and furthermore, that leader inclusiveness predicts psychological safety (H3) and moderates the relationship between status and psychological safety (H4). Finally, we suggest psychological safety predicts engagement in quality improvement work (H5) and mediates the relationship between leader inclusiveness and engagement (H6). Survey data collected in 23 neonatal intensive care units involved in quality improvement projects support our hypotheses. These results provide insight into antecedents of and strategies for fostering improvement efforts in health care and other sectors in which cross-disciplinary teams engage in collaborative learning to improve products or services. Copyright © 2006 John Wiley & Sons, Ltd.

A model of professional status on psychological safety as a precursor to engagement in quality improvement work: the moderating effect of leader inclusiveness and the mediating effect of psychological safety

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Psychological safety as a function of professional status and leader inclusiveness

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. Results of general linear model analysis

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Making it safe: The effects of leader

inclusiveness and professional status on

psychological safety and improvement

efforts in health care teams

INGRID M. NEMBHARD

*AND AMY C. EDMONDSON

Graduate School of Arts and Sciences, Graduate School of Business Administration, Harvard

University, Boston, Massachusetts, U.S.A

Graduate School of Business Administration, Harvard University, Boston, Massachusetts, U.S.A.

Summary This paper introduces the construct of leader inclusiveness —words and deeds exhibited by

leaders that invite and appreciate others’ contributions. We propose that leader inclusiveness

helps cross-disciplinary teams overcome the inhibiting effects of status differences, allowing

members to collaborate in process improvement. The existence of a professional hierarchy in

medicine and the differential status accorded to those in different disciplines is well

established in the health care literature, as is the need for quality improvement. We build

on this foundation to suggest that profession-derived status is positively associated with

psychological safety (H1) —a key antecedent of speaking up and learning behavior —in health

care teams. We hypothesize that this effect varies across teams (H2), and furthermore, that

leader inclusiveness predicts psychological safety (H3) and moderates the relationship

between status and psychological safety (H4). Finally, we suggest psychological safety

predicts engagement in quality improvement work (H5) and mediates the relationship between

leader inclusiveness and engagement (H6). Survey data collected in 23 neonatal intensive care

units involved in quality improvement projects support our hypotheses. These results provide

insight into antecedents of and strategies for fostering improvement efforts in health care and

other sectors in which cross-disciplinary teams engage in collaborative learning to improve

products or services. Copyright #2006 John Wiley & Sons, Ltd.

Introduction

In today’s complex organizations, teams are increasingly valued for their potential to innovate, solve

problems, and implement change. A growing literature on team learning identiﬁes factors that allow

Journal of Organizational Behaviour

J. Organiz. Behav. 27, 941–966 (2006)

Published online in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/job.413

* Correspondence to: Ingrid M. Nembhard, Graduate School of Arts and Sciences, Graduate School of Business Administration,

Harvard University, Soldiers Field Road, Boston, MA 02163 U.S.A. E-mail: inembhard@hbs.edu

Contract/grant sponsor: Harvard Business School Division of Research.

Received 28 January 2005

Revised 15 September 2005

Accepted 29 June 2006

teams to experiment, reﬂect, and improve across a range of industry settings (Bunderson, 2003a, 2003b;

Edmondson, 1999; Gibson & Vermeulen, 2003). Few industries have more at stake when teams learn —

or fail to learn—than health care. Increasingly, cross-disciplinary teams are responsible for delivering

care to patients in settings ranging from primary care to critical acute care, chronic care, geriatrics, and

end-of-life care (Institute of Medicine, 2001). These teams face not only a daunting expansion of

medical knowledge but also increasing specialization that divides critical knowledge among

individuals— knowledge that must be integrated for the delivery of quality care, as well as for

improving care.

In this environment, the combined challenges of teamwork and learning are emerging as central to

the health care delivery enterprise, in particular because research has shown that 70 to 80% of medical

errors are related to interactions within the health care team (Schaefer, Helmreich, & Scheideggar,

1994). This article seeks to advance theory in organizational behavior and health care management by

proposing and testing a model of engagement in team-based quality improvement work. In the next

section, we review critical trends in health care delivery to set the stage for our model and empirical

research.

Dynamic trends in health care

Health care professionals today face a staggering rate of change in medical knowledge. Whereas in

1966, only 100 published articles reported on randomized control trials —in medicine, the ‘‘gold

standard’’ for recognizing new knowledge—1995 brought more than 10,000 (Chassin, 1998). In terms

of sheer volume of new information, the Medline bibliographic database adds 30,000 new references

each month, and the Federal Drug Administration reviews thousands of applications for new devices

and drugs annually (Shine, 2002). No single individual can absorb all of this new knowledge in a timely

manner. Nevertheless, new knowledge must be absorbed for continued effectiveness in health care

delivery.

A second crucial trend is the increasing specialization of health care professionals (Hafferty & Light,

1995). Prior to 1930, there were only two boarded medical specialties (ophthalmology and

otolaryngology). Today, there are 26 specialties and 93 subspecialties within the major specialties, 8 of

which were approved during the 2002–2003 accrediting year (Accreditation Council for Graduate

Medical Education, 2004). Thus, the scope of an individual physician’s domain of expertise has

diminished, while depth of expertise has increased. At the same time, a growing number of non-

physician professions have joined the patient care enterprise. Specialists in nutrition, respiratory

therapy, physical therapy, phlebotomy, and so on, have joined nurses as non-physician caregivers,

playing vital roles in the health care system. In 1900, the ratio of physicians to non-physicians was 1 in

3; by 2000, it had exploded to 1 in 16 (Shine, 2002), implicating greater fragmentation of expertise, and

more hand-offs in the patient care process (Leape et al., 1995). Today, an increasing number of different

caregivers treat each patient at the bedside. Each brings information necessary and relevant for

development of a cohesive care plan.

A third trend—almost a necessary outcome of the ﬁrst two— is increasing interdependence. Many

new technologies and care practices involve reciprocal (as opposed to sequential) interactions.

Caregivers cannot simply do their jobs and assume others will come along at some point to do theirs.

Instead, their knowledge and efforts must be integrated to deliver quality care.

These trends—increasing knowledge, specialization, and interdependence—which are more

prominent in health care than in other industries, together imply a need for collaborative learning in

groups of professionals from different disciplines. The modern intensive care unit (ICU) is said to

DOI: 10.1002/job

942 I. M. NEMBHARD AND A. C. EDMONDSON

exemplify the conﬂuence of these factors (Wachter, 2004), but all health care settings have been

touched by these trends. Collaboration — deﬁned as ‘‘physicians and nurses [and other caregivers]

working together, sharing responsibility for solving problems, and making decisions to formulate and

carry out plans for patient care’’ (Baggs et al., 1999, p. 1991)— requires open communication and

mutual respect in addition to collective decision making (Baggs et al., 1999; Brown, Ohlinger, Rusk,

Delmore, & Ittmann, 2003; Zimmerman et al., 1993) and is critical to care delivery. Health

professionals themselves have recognized the imperative for teamwork in clinical care and quality

improvement, even suggesting that the latter needs to be based in cross-disciplinary teams (Donaldson

& Mohr, 2000), a suggestion that has been embraced by many (e.g., Berwick, Godfrey, & Roessner,

1990; Horbar, 1999).

Barriers to collaborative learning in health care

Despite the need for collaborative learning in cross-disciplinary teams in the health care setting, team-

based quality improvement efforts may stall for a number of reasons. First, the stakes are undeniably

high. Human life is at risk when processes fail, creating understandable risk aversion that can inhibit

willingness to engage in the chaos and uncertainty of team brainstorming and experimentation. It is

noteworthy that studies of other high stress environments have shown that improvement efforts tend to

be centralized and hierarchical rather than collective and democratic (Driskell & Salas, 1991; Foushee

& Helmreich, 1988; Hermann, 1963; Klein, 1976; Staw, Sandelands, & Dutton, 1981).

Second, cross-disciplinary teamwork —intended to integrate knowledge and expertise from different

sources—is difﬁcult to carry out in practice (e.g., see Edmondson, Roberto, & Watkins, 2003 for a

review). Improving the quality of care delivery processes necessarily requires different viewpoints,

each grounded in deep knowledge of a different aspect of the process. Physicians possess specialized

medical expertise, while nurses and allied health workers (e.g., respiratory therapists and dietitians)

have greater knowledge of daily patient-interaction processes. In combination, they contain a more

comprehensive information base. However, information often goes unshared. A recent study showed

that, although nurses witness and experience a variety of problems and employ a number of creative

solutions to resolve emergent issues, they generally do not communicate these to others in the hierarchy

(Tucker & Edmondson, 2003). Thus, despite its importance for improving care delivery, collaborative

learning does not occur naturally in health care.

Third, and a central focus of this paper, a well-entrenched status hierarchy exists in medicine,

making it difﬁcult to speak across professional boundaries (e.g., physician vs. nurse vs. therapists) to

collaborate for learning (Edmondson, 2003). The medical training that instills a culture of autonomy

for action can diminish professionals’ tendencies to seek opportunities to learn to communicate, share

authority, and collaborate in problem-solving and quality improvement (Institute of Medicine, 1999,

2001). Unfortunately, this reluctance can adversely affect patient care. Patient outcomes are

signiﬁcantly correlated with the degree of hierarchy in health care team interactions (Feiger & Schmitt,

1979). According to a recent report, Keeping Patients Safe:Transforming the Work Environment of

Nurses, ‘‘counterproductive hierarchical communication patterns that derive from status differences’’

are partly responsible for many medical errors (Institute of Medicine, 2003, p.361). In a content

analysis of medical malpractice cases from across the country, physicians (the high-status members of

the team) were shown to have ignored important information communicated by nurses (the low-status

members of the team), and nurses also withheld relevant information for diagnosis and treatment from

physicians (Schmitt, 1990). In this status-consciousness environment, opportunities for learning and

DOI: 10.1002/job

STATUS AND PSYCHOLOGICAL SAFETY 943

improvement can be missed because of unwillingness to engage in quality-improving communication

due to fear of reprisal by high-status others.

Aims of the present study

The present study investigates factors that promote engagement in quality improvement work when

status differences are present in teams. We examine the relationship between status and psychological

safety, and introduce the construct of leader inclusiveness, deﬁned below, as a moderator of the status–

psychological safety relationship. We then assess whether psychological safety mediates the

relationship between leader inclusiveness and engagement in improvement efforts. At a time when

quality improvement in health care is viewed as imperative, we aim to provide insight into how to

overcome an important barrier to quality improvement learning efforts.

The implications of this study extend beyond the health care industry, however. With customer

heterogeneity, a high need for customization, and a highly specialized workforce, hospitals present a

challenging, but by no means unique, service setting. Furthermore, the use of cross-disciplinary teams

continues to rise across industries as organizations seek to learn and innovate to remain competitive

(Grifﬁn, 1997; Sarin & Mahajan, 2001; Wind & Mahajan, 1997). The salience of status in health care

though provides an opportunity to investigate its effects on team-based improvement efforts and reveal

implications for other organizations that use teams encompassing status differences to improve

products or services. Therefore, our aim is to contribute to knowledge of the role of status in shaping

perceptions of psychological safety and, more broadly, the conditions that support improvement and

learning in cross-disciplinary teams.

Collaborative Learning in Cross-Disciplinary Health Care Teams

Status in professional hierarchies as a determinant of psychological safety

Status refers to the level of prominence, respect, and inﬂuence associated with an individual as a

result of some characteristic (Anderson, John, Keltner, & Kring, 2001), such as age, education,

ethnicity, gender, organizational position, profession, wealth, etc. (Bacharach, Bamberger, &

Mundell, 1993; Benoit-Smullyan, 1944). According to status characteristics theory, personal

characteristics affect self- and other-assessments and beliefs about the individual and his or her

performance abilities (Berger, Cohen, & Zelditch, 1972; Berger, Rosenholtz, & Zelditch, 1980).

Status characteristics can be ‘‘diffuse’’ meaning they are applicable over a range of settings (e.g.,

age, gender, or ethnicity) or ‘‘speciﬁc’’ meaning they provide cues about a person’s expertise

relative to a task (e.g., education or professional training). In either case, individuals that possess

the esteemed characteristic or more of that characteristic are judged superior to those with less of

that attribute. Thus, status indicates relative position within a social hierarchy (Benoit-Smullyan,

1944).

In the United States, social status is often role- or profession-based. Status differences are thus ‘‘most

salient in the work context where they often have practical implications (e.g., education level

determining pay level)’’ (Bacharach et al., 1993, p. 24). Higher status individuals receive more tangible

DOI: 10.1002/job

944 I. M. NEMBHARD AND A. C. EDMONDSON

and intangible beneﬁts in the workplace than their lower ranked co-workers. They gain power over the

actions of others (e.g., determining co-worker schedules and tasks), prestige or the right to occupy

honorary places (e.g., a windowed corner ofﬁce), a reputation for signiﬁcant contributions leading to

greater solicitations of their opinions, the beneﬁt of the doubt in ambiguous situations, and ﬁnancial

rewards (e.g., higher salary and department budgets).

The allocation of beneﬁts which favors high-status individuals over lower status individuals

shapes the environment they share as well as interpersonal interactions (e.g., Alderfer, 1987).

Individual awareness or beliefs that membership in a particular group (e.g., profession) bestows a

certain level of status creates feelings of superiority or inferiority that consistently govern behavior

so as to preserve the hierarchy (Tajfel & Turner, 1986; Webster & Foschi, 1988). Compared to high-

status individuals, those with low status are more likely to suffer low self-efﬁcacy and

underestimate their contribution to work tasks (Berger, Fisek, Norman, & Zelditch, 1985), and

therefore withhold valid information (Argyris, 1985), defer decision rights to higher status others

(Driskell & Salas, 1991), limit their organizational citizenship behavior (Stamper & Van Dyne,

2001), and speak less (Kirchler & Davis, 1986; Pagliari & Grimshaw, 2002; Vinokur, Burnstein,

Sechrest, & Wortman, 1985; Weisband, Schneider, & Connolly, 1995). Consequently,

organizations rely heavily on high-status individuals, which is beneﬁcial when status corresponds

to the expertise required for the task. However, empirical research suggests that individuals often

fail to recognize the expertise held by multiple team members— to the detriment of group and

organizational goals (e.g., see Littlepage, Robison, & Reddington, 1997). Organizational

innovation and improvement, in particular, suffer when minority opinions are ignored (Nemeth,

1986). Nevertheless, inadequate identiﬁcation of valid contributions continues because social

hierarchy leads to the domination of high-status individuals and self-censoring by low-status

individuals. The latter relates to perceptions of risk to self and fear of negative repercussions (e.g.,

public reprimand or assignment to a ‘‘bad’’ work shift).

Research on organizational silence indicates that sense of threat and/or risk is a key determinant

of employees’ willingness to speak up freely (Ashford, Rothbard, Piderit, & Dutton, 1998; Detert

& Edmondson, 2005; Edmondson, 2003; Milliken, Morrison, & Hewlin, 2003; Morrison & Phelps,

1999; Ryan & Oestreich, 1991). Speaking up freely occurs when people are not constrained by the

possibility of others’ disapproval and/or the negative personal consequences that might accrue to

them as a result—a state of psychological safety. In most organizations, those with high status have

more control over formal appraisals and resources than those with low status, and thus may

experience a certain freedom of self-expression in front of others, that low-status individuals do not

enjoy. Research on politeness shows that those with low status employ more ‘‘facework’’ (face

saving verbal strategies) when addressing those with higher status than the other way around

(Brown & Levinson, 1987). With increased status, people exercise less concern about damaging

others’ face; opinions can be freely voiced, and requests can be made of others without verbal

compensation to convey apology, humility, or deference. This well-documented inverse

relationship between status and politeness suggests corresponding differences in psychological

safety across different status groups.

In general, high-status individuals tacitly assume that their voice is valued. People with high status —

role-based and demographic—are more likely to be asked for their opinion than those with low status.

Accustomed to having their opinions sought—often in formal capacities—they learn to offer them

freely. They thus do not perceive the same level of interpersonal risk associated with self-expression

experienced by those with low status. Qualitative evidence of this difference in psychological safety

according to status was found in Kahn’s (1990) study of an architectural ﬁrm and a summer camp;

informants described their interactions with those positioned higher in the hierarchy as more stiﬂing

and threatening than their interactions with peers. Lower status individuals in Kahn’s study reported a

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STATUS AND PSYCHOLOGICAL SAFETY 945

lack of conﬁdence that higher status individuals would not embarrass or reject them for sharing

contradictory thoughts.

Individuals in lower positions in the medical hierarchy (Helmreich, 2000) may feel a similar sense of

fear about speaking up across status boundaries, for example, to raise a concern or challenge a current

practice. The existence of a professional hierarchy in medicine and the differential status accorded to

those who occupy different positions within that hierarchy is well-known to health professionals and

well established in the health care literature (Coburn, 1992; DeSantis, 1980; Dingwall, 1974; Friedson,

1970a,b; Fuchs, 1974; Hafferty & Wolinsky, 1991; Shortell, 1974; Wolinsky, 1988). We know that

surgeons garner more prestige than other specialty physicians, that specialty physicians rank above

primary care physicians, that physicians possess more power than nurses, nurses than physical

therapists, and so on. The hierarchy and related status differences exist within professional groups (e.g.,

physicians: specialists vs. primary care) and between groups (e.g., physicians vs. non-physicians), with

between group status differences being most salient and largest. We therefore predict, based on prior

research on the behaviors of different status groups, that non-physicians, as lower status health

professionals, view the cross-disciplinary team climate as less psychologically safe than higher status

individuals such as physicians:

Hypothesis 1 (H1): In cross-disciplinary teams, higher status individuals will experience greater

psychological safety than lower status individuals. (In cross-disciplinary health care teams,

physicians will experience more psychological safety than nurses, who will experience more

psychological safety than respiratory therapists).

The proposed main effect between status and psychological safety may vary depending on how

status differences are handled in a work group. Prior research found that psychological safety can

vary signiﬁcantly across groups, even within the same strong organizational culture (Edmondson,

1996, 1999). Bringing together professionals with different backgrounds and expertise may

exacerbate this variance, if some groups handle the challenge of managing these differences more

skillfully than others (Bunderson, 2003b). When status differences are present in a team, team

members must manage a tension between the norms of collaboration that underlie the notion of

teamwork and the reality of status differences. Prior research showed that the degree of status

derived from different professions can vary across cross-disciplinary work groups (Bunderson,

2003a). Similarly, the formal status associated with a given profession in health care may be treated

differently in different work groups called ‘‘units’’ in health care. The unit is a cross-disciplinary

care team, consisting of all of the staff that participates in delivering a speciﬁc domain of clinical

care, for example, intensive care or cardiac care. Differences in status handling across work groups

in other settings suggests the effect of role-based professional status on psychological safety will

also vary across cross-disciplinary unit teams—indicating an interaction effect between status and

unit team membership on psychological safety:

Hypothesis 2 (H2): Status and unit team membership will interact to predict psychological safety.

Bunderson (2003a) identiﬁed two group attributes —average tenure and power centralization — that

helped explain differences in status effects across groups, and suggested that future research consider

alternative moderators such as task interdependence (Wageman, 1995) and task uncertainty (Van de

Ven, Delbecq, & Koenig, 1976). Other research suggests that how work is organized affects status

relationships. In their study of specialized AIDS units versus general medical units treating AIDS

patients, Aiken and Sloane (1997) found that the relative status of nurses was increased after the

conversion to specialized units. They attributed the elevation in status to an increased appreciation for

nurses’ specialized knowledge and client differentiation. We explore another possibility— that leader

DOI: 10.1002/job

946 I. M. NEMBHARD AND A. C. EDMONDSON

behavior, particularly in its level of inclusiveness, can frame the meaning of status differently across

units, even with similar structures or work design (Edmondson, 2003), helping to explain why status

effects might vary across work groups.

Leader inclusiveness

Team leader behaviors, in general, have been shown to affect the internal dynamics of a team, in

particular inﬂuencing team climate and learning orientation (Baker, Murray, & Tasa, 1995;

Edmondson, 1999; Hult, Hurley, Guinipero, & Nichols, 2000; Madhavan & Grover, 1998; Norrgren &

Schaller, 1999; Shortell, Rousseau, Gillies, Devers, & Simons, 1991; Yukl, 1994; Zimmerman et al.,

1993). Team members are highly attuned to the behavior of leaders and examine leader actions for

information about what is expected and acceptable in team interactions (Tyler & Lind, 1992). If a leader

takes an authoritarian, unsupportive, or defensive stance, team members are more likely to feel that

speaking up in the team is unsafe. In contrast, if a leader is democratic, supportive, and welcomes

questions and challenges, team members are likely to feel greater psychological safety in the team and

in their interactions with each other.

Preliminary evidence of leadership effects on psychological safety emerged in a study of medication

errors in nursing teams (Edmondson, 1996). In some units, nurses described nurse managers as

authoritarian and also expressed deep fears about being reprimanded for revealing mistakes. In

contrast, nurses in other units felt safe speaking up about errors because their nurse manager had

stressed the importance of using this information as a learning tool for the unit. In a later study of

cardiac surgery teams, qualitative data suggested that teams with leaders who actively invited others’

input had higher psychological safety than those in which this behavior was absent. Qualitative data

suggested that surgeon team leaders handled status differences within their teams differently

(Edmondson, 2003). Although all teams comprised four professional roles, with clear traditional status

differences, in some, the surgeons (those with the highest status) made an explicit effort to invite others’

input to help the team implement a new technology. In other teams, the leaders were not similarly

proactive.

Building on these qualitative insights, we propose the construct of leader inclusiveness, deﬁned as

words and deeds by a leader or leaders that indicate an invitation and appreciation for others’

contributions. Leader inclusiveness captures attempts by leaders to include others in discussions and

decisions in which their voices and perspectives might otherwise be absent. It is related to team leader

coaching behavior, which describes team leader behaviors that facilitate group process and provide

clariﬁcation and feedback (Baron, 1990; Edmondson, 1999), and to participative leadership, which

describes leaders that consult with workers, participate in shared decision-making and delegate

decision-making authority to subordinates (Bass, 1990; McGregor, 1960; Yukl, 1994). Leader

inclusiveness differs from these constructs in that it directly pertains to situations characterized by

status or power differences and pertains more narrowly to behaviors that invite and acknowledge

others’ views. The established constructs did not capture sufﬁciently the difﬁculty of lower social

position, nor the behavior of explicit invitation designed to overcome communication boundaries.

Leader inclusiveness describes behavior that, through direct invitation, should create psychological

safety for speaking up. We suggest that both invitation and appreciation are needed to convey the

More speciﬁcally, team leader coaching describes the leader as an operational facilitator; participative leadership emphasizes

harnessing employee motivation to maximize productivity. Thus, neither construct is intended— as is leader inclusiveness— to

address status salient environments, nor to identify the two-pronged strategy of invitation and appreciation.

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STATUS AND PSYCHOLOGICAL SAFETY 947

inclusiveness that helps people believe that their voices are genuinely valued. Without a recognizable

invitation, impressions derived from the historic lack of invitation will prevail. And without

appreciation (i.e., a positive, constructive response), the initial positive impact of being invited to

provide input will be insufﬁcient to overcome the subsequent hurdle presented by status boundaries.

Deﬁning leader inclusiveness in this way, we hypothesize that:

Hypothesis 3 (H3): Leader inclusiveness is positively associated with psychological safety.

Finally, we predict that leader inclusiveness will alter the status–psychological safety relationship as

follows. When leaders demonstrate inclusiveness, lower status others are likely to feel supported and to

believe the leaders see them as important members of the team. An atmosphere of mutual respect across

the different professions may develop, in which the specialized expertise held by those with low status

is seen as valuable to the team’s shared task. This helps to equalize the value associated with all

members’ contributions, promoting an egalitarian context. These efforts may increase the level of

psychological safety felt by everyone in the team, but the effect is likely to be greater for low-status

individuals who have less prior experience with others expressing interest in their input than it will be

for those with high status. In contrast, when leader inclusiveness is low, a lack of opportunity to

overcome traditional status barriers allows them to prevail, such that low-status individuals fail to

experience an elevation in psychological safety, leaving high-status individuals more advantaged in this

respect. Thus, we hypothesize:

Hypothesis 4 (H4): Leader inclusiveness moderates the relationship between status and

psychological safety.

Engagement in quality improvement

The need for active quality improvement in health care has been widely recognized since the Institute

of Medicine released its 1999 report documenting rampant failures in the health care system.

Improving the quality of work processes and outcomes requires effort and engagement—which we

deﬁne, drawing on Kahn (1990) as being physically, cognitively, and/or emotionally connected to the

improvement work. Engagement is essential for overcoming powerful barriers to quality improvement

that exist in the health care setting, as well as in other busy and chaotic service contexts. Health care

professionals are often stretched thin, barely able to complete their required tasks in the workday, let

alone devote time to improving the system (Tucker & Edmondson, 2003). Participating in quality

improvement efforts thus requires deliberate and effortful allocation of time. Yet, despite time and

resource constraints, many in health care are embracing quality improvement projects, because of what

is at stake when systems fail. The construct of engagement captures the commitment and effort these

individuals devote to quality improvement.

We argue that engagement in quality improvement in health care is likely to be enabled by

psychological safety. First, engaging in quality improvement requires team members to be willing to try

new technologies and procedures, remaining cognitively ‘‘mindful’’ of relationships between tasks and

team members (Weick, 2002) and emotionally open to giving and receiving feedback in these states of

transition. These behaviors can be interpersonally risky and thus more likely to be found when

psychological safety is present. In a psychologically safe environment, team members do not feel they

must be guarded in their behavior, instead feeling encouraged to question current practices and to share

what may be regarded as provocative ideas, challenging the group to develop more innovative

solutions. Without psychological safety, suggesting new procedures, overstepping professional status

boundaries (Kahn, 1990), or offering unsolicited feedback would seem overly risky.

DOI: 10.1002/job

948 I. M. NEMBHARD AND A. C. EDMONDSON

Second, in a related vein, researchers have argued and shown that individuals’ willingness to

participate in problem-solving activities diminishes signiﬁcantly when they view the team as hostile

(e.g., Dutton, 1993; MacDufﬁe, 1997). In fact, they are more likely to act in ways that diminish learning

behavior (Argyris & Scho

¨n, 1978). One such way is to withdraw from the team and its work. Kahn

(1990) described this as personal disengagement. We thus expect an association between psychological

safety and engagement in quality improvement work in health care. Psychological safety creates the

willingness to change personal habits (Schein & Bennis, 1965), and should allow team members to be

enthusiastic about improvement and their role in that process.

Hypothesis 5 (H5): Psychological safety is positively associated with engagement in quality

improvement work.

Combining Hypotheses 5 and 3, we predict that psychological safety will mediate a relationship

between leader inclusiveness and engagement:

Hypothesis 6 (H6): Psychological safety mediates a relationship between leader inclusiveness and

engagement in quality improvement work.

Together our hypotheses comprise a model of engagement in quality improvement work that

includes antecedents and consequences of psychological safety for health care improvement teams

(See Figure 1). We hypothesize that professional status (H1) and its interaction with unit team

membership (H2) explain variance in psychological safety. Moreover, the magnitude of the status

inﬂuence is moderated by leader inclusiveness (H4), an additional predictor of psychological safety

(H3). Finally, psychological safety enables engagement in quality improvement work (H5), and

mediates between leader inclusiveness and engagement (H6).

Figure 1. A model of professional status on psychological safety as a precursor to engagement in quality

improvement work: the moderating effect of leader inclusiveness and the mediating effect of psychological safety

DOI: 10.1002/job

STATUS AND PSYCHOLOGICAL SAFETY 949

Organizational Context

The Quality Improvement Imperative in Health Care

In 1998, the National Roundtable on Health Care Quality issued a statement, The Urgent Need

to Improve Quality of Care, which documented signiﬁcant quality problems in the American

health care system, problems ranging from overuse of antibiotics to underuse of beta blockers

following heart attack to misuse inherent in medical error (Chassin, Galvin, & The National

Roundtable on Health Care Quality, 1998). Shortly thereafter, the Institute of Medicine

published ToErrisHuman(1999) and Crossing the Quality Chasm (2001), which further

quantiﬁed the extent of preventable medical error and identiﬁed the systemic nature of quality

problems. In response to these reports, health care organizations across the country from

individual providers to community health centers to hospital systems bolstered their efforts to

improve the quality of care they delivered (Wachter, 2004). Continuous quality improvement

became a community ideal, to which every organization strove to achieve. The health care

organizations we studied were no different.

Proﬁle of Participating Unit Teams

We collected data for this study from NICUs in the United States and Canada. NICUs provide

care for premature infants, infants weighing less than 1500 g and infants born with complications.

All of the NICUs studied were members of the 2-year, 44-member Neonatal Intensive Care Quality

Improvement Collaborative (NIC/Q 2002). Collaboratives such as this, which are intended to

facilitate improvement by facilitating the transfer of knowledge across health care organizations

(Kilo, 1999), are a growing phenomenon in health care (Mittman, 2004). In the one we studied,

cross-disciplinary teams were encouraged to work together on speciﬁed improvement areas (e.g.,

infection control, respiratory care management, or discharge planning) to develop and test clinical,

organizational, and operational changes for improving neonatal care. As such, this setting was

particularly attractive for our study of how status relationships that exist between professional

disciplines relate to psychological safety and engagement in quality improvement in cross-

disciplinary teams. To craft and execute their quality improvement projects in-house, team members

from different disciplines had to work together. Development of a new or better delivery room

plan for infant resuscitation, for example, required physicians, nurses, and respiratory therapists

to share their expertise and recommendations with one another to ensure that the developed

plan included accurate and up-to-date practices from each group, and accounted for their

interactions.

Methods

Sample and procedure

We conducted data collection in three phases. First, we visited 4 of the 44 neonatal intensive care

units (NICUs) in the collaborative. We toured the units, observed unit functioning and interviewed

DOI: 10.1002/job

950 I. M. NEMBHARD AND A. C. EDMONDSON

23 staff members (5–7 members per NICU) for 30 to 90 minutes using open-ended questions about

the NICU work climate and quality improvement efforts. We selected the four NICUs to include

differences in demographic variables (e.g., teaching status, size, etc.) and improvement efforts

(e.g., improvement focus areas and prior collaborative participation) and selected interviewees

to capture multiple professional groups (i.e., physicians, nurses, and respiratory therapists).

This increased our understanding of NICUs and facilitated the design of a meaningful survey

for this population. In the second phase, we developed and pilot tested a survey with these four

NICUs. Descriptive statistics and psychometric tests indicated no need to alter the survey. Further,

the survey results accorded with our site visit observations, supporting the validity of the

instrument.

In the third and ﬁnal phase, we invited the 40 remaining, non-pilot site NICUs in the

collaborative to participate in the survey via phone and electronic mail directed to the leader of

each NICU’s collaborative improvement team. Twenty-three NICUs agreed, for a NICU response

rate of 58%. When we compared participating sites to non-participating sites, we found no

signiﬁcant differences between the two groups on avariety of structural, clinical, and patient acuity

measures. For example, there were no signiﬁcant differences based on hospital ownership type

(not-for-proﬁt, for-proﬁt, government), teaching status, level of severity of the care provided in the

NICU, volume of extremely low birth weight babies (ELBW, less than or equal to 1000 g), number

of times the site participated in prior collaboratives (0, 1, or 2), length of stay, percentage of ELBW

babies with Apgar scores 3 one minute after birth, percentage of babies transported from another

hospital (‘‘outborn’’), average birth weight, and gestational age (see Tucker, Nembhard, &

Edmondson, 2006).

As soon as a NICU received the permission of its hospital Institutional Review Board (IRB), its

team leader provided us with a count of the number of staff and patient beds in the unit. We then

invited all team members in the NICU to participate in our survey via an invitational letter distributed

in accordance with the procedures outlined in the hospital IRB approval. In 18 NICUs, the

collaborative team leader electronically mailed or placed in team mailboxes our letter to team

members, which provided instructions on where to retrieve a paper copy of the survey in the unit, if

interested. In the remaining ﬁve NICUs, the team leader distributed our letter along with a paper copy

of the survey to team mailboxes. The invitational letter described the purpose of the study, assured

respondents’ anonymity and included instructions for completion of the paper as well as an online

version of the survey. We offered two versions to allow participants to choose their preferred format.

All individuals returned the survey directly to us via self-addressed stamped envelope or online

submission.

In all, 1440 health care professionals (46% of team members contacted) from 23 NICUs in the

United States and Canada completed the survey between July 2003 and May 2004. Of the

respondents, 1375 persons declared their profession: 100 as physicians (83 neonatologists, 13

attending physicians, and 4 neonatology fellows), 998 as nurses (65 neonatal nurse practitioners, 16

Master’s prepared nurses, 8 clinical nurses specialists, 867 registered nurses, 14 licensed

nurse practitioners, and 28 other nursing functions), 131 as respiratory therapists, and 146 as

other types of health care professionals (e.g., social worker, dietitians, etc.). Excluding individuals in

the latter group (because the presence and recognition of their discipline as part of the NICU

team varied across units), NICUs averaged 60 respondents, ranging from 10 to 164. The

average number of respondents per NICU was 3 physicians, 15 nurses, and 5 respiratory

therapists.

We regarded the professionals in each NICU from medicine, nursing, and respiratory therapy as the

‘‘unit team’’ because these interdependent professionals unquestionably work together in the unit on a

daily basis. Their patients generally stay in the NICU for an extended period of time, often months, to

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STATUS AND PSYCHOLOGICAL SAFETY 951

receive the care that only a team of neonatal-trained practitioners can deliver. These teams and

members are so specialized that they work exclusively in the NICU.

Measures

Professional status

Professional status was inferred from occupational category because prior research had demonstrated

that status in the medical ﬁeld derives from role or position in the professional hierarchy (Friedson,

1970a,b, 1994; Mechanic, 1991; Wolinsky, 1988). The numerous professional roles reported in the

survey were combined into three major categories for the purposes of these analyses: (1) physicians

(neonatologists, other attending physicians and neonatal fellows); (2) nurses; and (3) respiratory

therapists. Further, because physicians—as ‘‘captains of the health care team’’ (Fuchs, 1974)— garner

higher status than all other health care professionals (Hafferty & Light, 1995), an additional

dichotomous professional status variable was created to reﬂect that (0 ¼low-status ¼nurses and

respiratory therapists, 1 ¼high status ¼physicians).

Unit team membership

Unit team membership, a categorical variable, refers to the speciﬁc NICU in which an individual

respondent worked (N¼23).

Psychological safety

Four items from Edmondson’s (1999) psychological safety scale adapted to this context were used to

assess the extent to which respondents felt safe to speak up about issues or ideas regarding the NICU.

Examples of these items are: ‘‘Members of this NICU are able to bring up problems and tough issues’’

and ‘‘People in this unit are comfortable checking with each other if they have questions about the right

way to do something.’’ Respondents’ agreement (1 ¼strongly disagree, 7 ¼strongly agree) with these

items formed a single scale (Chronbach alpha ¼0.73).

Leader inclusiveness

In the hospital context, physicians are both high-status technical experts and leaders who are

responsible for directing the efforts of others in delivering care to patients. Thus, although the construct

of leader inclusiveness is more general, in this setting, it refers to behaviors and attitudes of the

physicians-in-charge. A three-item scale assessed the extent to which NICU leaders’ words and deeds

indicated an invitation and appreciation for others as contributing members in a team endeavor. The

ﬁrst two items, ‘‘NICU physician leadership encourages nurses to take initiative’’ and ‘‘Physicians ask

for the input of team members that belong to other professional groups,’’ were adapted from Shortell

et al.’s (1991) physician leadership scale. The third item, ‘‘Physicians do not value the opinion of others

equally’’ (reversed scored), was developed by us for this research. The level of agreement with each

statement (1 ¼strongly disagree, 7 ¼strong agree) was averaged to provide a single perception for

each respondent (Chronbach alpha ¼0.75).

In this study, we assessed leader inclusiveness with data from non-physicians only, for two reasons.

First, prior research suggested that nurses provide a more accurate assessment of organizational culture

There is one possible exception to the exclusivity of the NICU teams. Some hospitals do use ‘‘rotating’’ respiratory therapists,

who work exclusively on the unit for a deﬁned period of time periodically (e.g., 2 months every 2 months), then rotate to other

units when not assigned to the NICU. That said, we believe that ‘‘unit teams’’ are accurately represented in our sample since we

asked team leaders to distribute the survey to NICU staff. We abided by team leader judgment of team membership.

DOI: 10.1002/job

952 I. M. NEMBHARD AND A. C. EDMONDSON

and leadership practices than physicians. One study showed that while nurses’ reports of the culture

showed appropriate variance, physicians’ reports were more uniform across different contexts, as well

as more positive; further, only the nurse data predicted performance outcomes (Leonard, Frankel,

Simmonds, & Vega, 2004), afﬁrming earlier studies’ ﬁndings that nurses’ perceptions of the work

environment are more predictive of the risk of adverse outcomes (e.g., Baggs et al., 1999) and quality of

care (e.g., Shortell et al., 1991) than physicians. Second, and more important, conceptually, those with

low status are in a better position to assess the degree to which high-status leaders are including them

than are those with high status— who may rate themselves as inclusive even when others would not do

so. More simply, physician ratings of their own inclusiveness toward others are unlikely to be as

externally valid as the ratings of those others will be.

Engagement in quality improvement work

Engagement in quality improvement work was measured using a four-item scale adapted from Baker,

King, MacDonald, & Horbar (2003). Sample items are: ‘‘A growing number of staff in this NICU are

participating in improvement efforts’’ and ‘‘In the coming year, I would like to be very involved in our

NICU’s quality improvement efforts.’’ Respondents rated their agreement with these statements on a

seven-point scale (1 ¼strongly disagree to 7 ¼strongly agree). Chronbach’s alpha was 0.79.

Control variables

We included gender, years working in any NICU, years as an employee of the hospital, years working in

the current NICU, and hours per week in the NICU as control variables since these demographic

variables are potential predictors of psychological safety at the individual level. These control variables

were excluded from the group-level analyses performed to test psychological safety as a mediator

between leader inclusiveness and engagement in quality improvement work (H6).

Table 1 provides the means, standard deviations, and intercorrelations between the variables. We

assessed the adequacy of our survey measures through tests of internal consistency reliability and

discriminant validity. The results supported the use of these measures for analysis. Chronbach’s alpha

for all survey scales exceeded the 0.70 threshold proposed by Nunnally (1978) for internal consistency,

and factor analysis, in which the planned constructs emerged, conﬁrmed discriminant validity.

Analysis and Results

To test Hypotheses 1and 2, that status and its interaction with unit team membership explain variance

in psychological safety; we used a univariate general linear model (GLM) with professional status

(three groups: physicians, nurses, and respiratory therapists) and unit team membership as independent

variables and the reﬂected, logarithmic transformation of psychological safety as the dependent

variable.

We also included the above mentioned control variables. Results shown in the upper portion

of Table 2 indicate that two of the ﬁve control variables were signiﬁcant and that our ﬁrst two

hypotheses were supported. The number of years spent working in any NICU and the number of years

The reﬂected, logarithmic transformation corrected for heterogeneity of variance and non-normality (i.e., negative skewness) in

the dataset (Tabachnick & Fidell, 2001).

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STATUS AND PSYCHOLOGICAL SAFETY 953

Table 1. Summary statistics and intercorrelations for individual-level data

Variable Mean SD 1 2 3 4 5 6 7 8 9

1. Professional status—3 groups:

Physicians versus

nurses versus therapists

2.03 0.43

2. Professional status—2 groups:

High versus

low status

0.08 0.27 0.71



3. Psychological safety 5.31 1.08 0.15



0.14



4. Leader inclusiveness 4.62 0.55 <0.01 0.01 0.29



5. Engagement in quality improvement work 5.45 1.06 0.12



0.17



0.48



0.21



6. Gender 1.10 0.30 0.23



0.56



0.05 0.04 0.02

7. Years in any NICU

4.17 1.19 0.08



0.10



0.05 0.09



0.03 0.08



8. Years as hospital employee

3.97 1.26 0.03 0.01 0.04 0.02 0.02 0.07



0.73



9. Years in current NICU

3.84 1.31 0.05 0.03 0.04 0.02 0.02 0.08



0.81



0.94



10. Hours per week in NICU 33.84 13.46 0.35



0.38



0.05 0.03 0.10



0.12



0.06



0.08



0.08



This is a categorical variable: 1 ¼less than 1 year, 2 ¼1 to less than 2 years, 3 ¼2 to less than 5 years, 4 ¼5 to less than 10 years, 5 ¼10 or more years.



p<0.05.



p<0.01.

DOI: 10.1002/job

954 I. M. NEMBHARD AND A. C. EDMONDSON

spent working in the current NICU signiﬁcantly predicted psychological safety (F(4,1111) ¼3.54,

p¼0.01 and F(4,1111) ¼3.09, p¼0.02): More time spent in NICUs in general as well as an

intermediate amount of time spent in the current NICU (5 to less than 10 years) both were associated

with higher psychological safety. The number of years as an employee of the current hospital was only

marginally predictive (F(4,1111) ¼2.09, p¼0.08), and gender and hours worked per week not at all

(F(1,1111) ¼0.01, p¼0.93 and F(1, 1111) ¼0.24, p¼0.62).

Consistent with Hypothesis 1, professional status was positively associated with psychological

safety (F(2,67) ¼8.46; p¼0.001). Physicians felt signiﬁcantly more psychological safety than

nurses (t(1111) ¼0.33, p<0.001) who in turn reported more psychological safety than

respiratory therapists (t(1111) ¼0.11, p¼0.02); the overall planned contrast was signiﬁcant

(F(2, 1111)¼14.11, p<0.001).

To determine whether the effect of professional status on psychological safety varied across

multidisciplinary teams, as predicted in Hypothesis 2, we examined the interaction term composed of

professional status and unit team membership. The interaction was signiﬁcant (F(31,1111) ¼2.22,

p<0.001), indicating that the difference in psychological safety felt across status groups varied across

teams, even as the main effect of status on psychological safety remained signiﬁcant. In some teams,

status differences were less important, such that members of different professional groups felt similarly

safe. In others, professional status differences led to larger disparities in psychological safety among

groups.

Hypotheses 3 and 4 that leader inclusiveness predicts psychological safety, and moderates the

relationship between status and psychological safety, were tested using GLM analyses. First, however,

we assessed the properties of leader inclusiveness, as a new construct. Just as prior work (Edmondson,

1999; Shamir, Zakay, Breinin, & Popper, 1998) has shown convergent perceptions of leadership

behavior in teams, we anticipated that views of leader inclusiveness would be shared in the NICUs

studied. To test this, we performed a one-way analysis of variance with unit team membership as the

independent variable and leader inclusiveness (rated by non-physicians only) as the dependent variable.

The ANOVA results showed signiﬁcant variance at the group level of analysis for leader inclusiveness

as reported by low-status individuals (F(22,1095) ¼9.44, p<0.001), and an intraclass correlation that

Table 2. Results of general linear model analysis

Model Independent variables F-ratio p

Y¼Ln(Psychological safety) Gender F(1,1111) ¼0.01 0.93

Years in any NICU F(4,1111) ¼3.54 0.01

Years as a hospital employee F(4,1111) ¼2.09 0.08

Years in current NICU F(4,1111) ¼3.09 0.02

Hours per week in NICU F(1,1111) ¼0.24 0.62

Professional status—three groups F(2,67) ¼8.46 0.001

Unit team membership F(22,41) ¼2.08 0.02

Professional status (3) unit team membership F(31,1111) ¼2.22 <0.001

Y¼Ln(Psychological safety) Gender F(1,1126) ¼0.10 0.76

Years in any NICU F(4,1126) ¼3.98 0.003

Years as a hospital employee F(4,1126) ¼1.66 0.16

Years in current NICU F(4,1126) ¼2.43 0.05

Hours per week in NICU F(1,1126) ¼0.001 0.97

Professional status—two groups F(1,1126) ¼11.58 0.001

Leader inclusiveness F(21,1126) ¼4.27 <0.001

Professional status (2) leader inclusiveness F(18,1126) ¼1.78 0.02

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STATUS AND PSYCHOLOGICAL SAFETY 955

was positive and signiﬁcant (r

ICC

¼0.35), conﬁrming leader inclusiveness as a group-level measure

(Kenny & LaVoie, 1985). We therefore entered the team’s leader inclusiveness score (the team average)

as the individual’s score for each member of the team in the individual-level dataset.

We used this dataset and a GLM to test Hypotheses 3 and 4 that leader inclusiveness is positively

associated with psychological safety and moderates the relationship between professional status and

psychological safety. The dichotomous professional status variable (high status, if physician and low

status, if nurse or respiratory therapist), leader inclusiveness, and their interaction served as

independent variables, along with all of the control variables. Again, the reﬂected, logarithmically

transformed psychological safety measure served as the dependent variable. The results shown in the

lower section of Table 2 support the hypothesized relationships. When physician leaders were

perceived as inclusive and welcoming of others’ ideas and efforts, psychological safety was greater

(F(21,1126) ¼4.27, p<0.001) (Hypothesis 3). Also, as predicted in Hypothesis 4, leader inclusiveness

moderated the relationship between status and psychological safety, as indicated by a signiﬁcant

interaction term (F(18, 1126) ¼1.78, p¼0.02). Low leader inclusiveness was associated with a greater

disparity in psychological safety between high and low-status individuals to the disadvantage of low-

status individuals. In contrast, high leader inclusiveness was associated with a lower difference in

psychological safety between the two groups, raising the psychological safety of low-status individuals

closer to that of their high-status team members. (See Figure 2).

To test Hypothesis 5 that psychological safety is positively associated with engagement in quality

improvement work, we conducted a regression analysis on the group level dataset. Using this dataset,

allowed us to not only test our hypothesis, but also as important, examine the relative inﬂuence of a

competing group-level variable on engagement: staff workload or busyness of the work environment.

Prior work has identiﬁed staff workload as a predictor of quality-related behavior (Oliva, 2001;

Tucker & Edmondson, 2003). Overburdened employees facing competing priorities are less likely to

further quality goals. Therefore, to continue with our model of engagement in quality improvement

Figure 2. Psychological safety as a function of professional status and leader inclusiveness

DOI: 10.1002/job

956 I. M. NEMBHARD AND A. C. EDMONDSON

work, the question of relative inﬂuence had to be addressed to provide assurance that our model was not

mis-speciﬁed in emphasizing psychological safety as a determinant of engagement. We ﬁrst performed

one-way analysis of variance and intraclass correlations for psychological safety (F(22, 1366) ¼8.62,

p<0.001; r

ICC

¼0.21) and engagement in quality improvement work (F(22, 1352) ¼7.67, p<0.001;

ICC

¼0.18) to conﬁrm the group level status of the variables before proceeding with the analysis. We

then regressed engagement on psychological safety and the ratio of staff-to-patient beds, (mean ¼3.31,

SD ¼0.91), our measure of staff workload. The results provided support for our hypothesis that the

more members feel they work in a team characterized by interpersonal trust and respect, the more

enthusiastic and devoted they are to participating in quality improvement efforts, which often require

the interpersonally risky act of collaborative learning (B¼0.62, p¼0.001). We found this relationship,

even after accounting for the competing inﬂuence of staff busyness, which was an insigniﬁcant

predictor of engagement (B¼0.14, p¼0.09) and thus eliminated from further analyses.

To test Hypothesis 6, that psychological safety mediates the relationship between leader inclusiveness

and engagement in quality improvement work, we estimated three regression equations to satisfy the

conditionsfor mediation (Baron & Kenny, 1986). The ﬁrst condition is that the independent variable must

signiﬁcantly affect the mediator; second, the independent variable must predict the dependent variable;

and third, the mediator must signiﬁcantly predict the dependent variable when entered in the same

regression equation as the independent variable, while the independent variable drops in signiﬁcance or

becomes insigniﬁcant. We assessed whether these conditions were satisﬁed using group-level data

because leader inclusiveness (our independent variable), psychological safety (our proposed mediator),

and engagement in quality improvement work (our dependent variable) are conceptually meaningful and

empirically demonstrated as group-level variables. We measured leader inclusiveness at the aggregate

non-physician level for reasons explained above, and analyses related to testing Hypothesis 5 conﬁrmed

psychological safety and engagement as group-level constructs as well.

As shown in Table 3, the results support all three mediation conditions: (1) leader inclusiveness

predicts psychological safety (B¼0.53, p<0.001), (2) leadership inclusiveness predicts team

engagement at the group level (B¼0.41, p¼0.004), and (3) when included in the same model, leader

inclusiveness becomes insigniﬁcant (B¼0.11, p¼0.52), while psychological safety remains

signiﬁcant (B¼0.57, p¼0.03). Thus, the data support psychological safety as a mediator of the

relationship between leader inclusiveness and team engagement in quality improvement work.

In sum, all of our hypotheses were supported by the data. Not only do high-status individuals differ

from low-status individuals in psychological safety, but also there is an interaction between status and

unit team membership, and between status and leader inclusiveness. Greater inclusiveness minimizes

the effect of status on psychological safety in the team, and vice versa. Moreover, with more leader

Table 3. Tests of psychological safety as a mediator between leader inclusiveness and engagement in quality

improvement work (N¼23)

Conditions to demonstrate mediation



Independent variable B tpR

1. Does leader inclusiveness predict

engagement in quality improvement work?

Leader inclusiveness 0.41 3.19 0.004 0.33

2. Does leader inclusiveness

predict psychological safety?

Leader inclusiveness 0.53 5.02 <0.001 0.55

3. Does the effect of leader inclusiveness

drop substantially or become insigniﬁcant when

psychological safety (the mediator) is included in

the model for engagement in quality improvement work?

Psychological safety 0.57 2.32 0.03 0.47

Leader inclusiveness 0.11 0.65 0.52



Dependent variables are in italics.

DOI: 10.1002/job

STATUS AND PSYCHOLOGICAL SAFETY 957

inclusiveness comes greater psychological safety, which in turn predicts greater team engagement in

quality improvement work.

Discussion and Conclusions

Toward a theory of role-based status and psychological safety in teams

This paper empirically examined the effect of professional status on psychological safety in health

care teams, motivated both by the theoretical role of psychological safety in team learning

(Edmondson, 1999) and by the practical need for team learning in today’s hospitals. As anticipated,

psychological safety was signiﬁcantly associated with professional status in these data. The results thus

suggest that, in health care, professional status inﬂuences beliefs about how easy or appropriate it is to

speak up to offer ideas, raise concerns, or ask questions. At the same time, our results showed

signiﬁcant differences across groups in the strength of the association between status and psychological

safety, suggesting that this relationship need not be deterministic. In some teams, members with high

(i.e., physicians) and low (i.e., nurses and respiratory therapists) status reported more similar levels of

safety than in other teams, in which relatively large disparities in psychological safety between

professional groups were found. This ﬁnding provides reassurance that the effects of traditional status

differences in health care may be overcome, facilitating full participation in cross-disciplinary team

improvement efforts.

Unlike in other industries, where employees may advance in the hierarchy—moving from sales

assistant to sales associate or from analyst to consultant to principal, for example — medical

professionals cannot rely on professional mobility to confer greater status. Professions tend to be stable

over a career. Nurses and respiratory therapists generally do not become doctors. As a result, the

opportunity for natural status gains by lower status individuals can be rare. With history and industry

structure as perpetuators, profession-related status differences continue. And, the growing

interdependence among professions only heightens intergroup tensions. According to social

psychological (Alderfer, 1977; Alderfer & Smith, 1982; Messick & Mackie, 1989) and ethnographic

(Dougherty, 1992) research, this is natural.

Our results suggest leader inclusiveness—words and deeds by leaders that invite and

appreciate others’ contributions— can take nature off its course, helping to overcome status’

inhibiting effects on psychological safety. In cross-disciplinary teams with high leader

inclusiveness, the status–psychological safety relationship was weakened. We thus suggest

that active, inclusive behavior on the part of physician leaders may be an essential means of

facilitating others’ meaningful engagement in team-based quality improvement work. Thus, a

key contribution of this study is the identiﬁcation of an interpersonal strategy for improving the

climate for learning within cross-disciplinary teams in health care. This extends prior work that has

shown psychological safety consistently to be related to leader behavior (Edmondson, 1999, 2003;

Hult, Hurley, Guinipero, & Nichols, 2000; Lovelace,Shapiro,&Weingart,2001;Norrgren&

Schaller, 1999), by narrowing and sharpening the nature of leader behaviors that promote

psychological safety.

Recent studies of psychological safety and communication in the health care environment

have also highlighted the role of the leadership in cultivating a culture of safety, but have

not articulated the actual practices of leaders that are needed, other than training staff to speak

DOI: 10.1002/job

958 I. M. NEMBHARD AND A. C. EDMONDSON

up (Leonard et al., 2004; Maxﬁeld, Grenny, McMillan, Patterson, & Switzler, 2005). Our

research suggests that training leaders to invite team members’ comments and to appreciate

those comments overtly is as important. As we did not test any training methods, we cannot

draw conclusions about what training strategies will work. However, training that includes

instruction in the timing and phrasing of invitation and appreciation may be useful. Boyle and

Kochinda (2004) tested a training intervention to improve communication between nurse and

physician leaders,

and found that staff perceptions of leadership, communication, and problem-

solving between professional groups improved in the post-intervention period, afﬁrming that

leadership training is a promising route to improved team climate. Our results also suggest it is a

route to increasing engagement in quality improvement.

A more nuanced look at team learning for health care improvement efforts

The study also provides insight into a more focused type of team learning than has been investigated in

prior-related research: team learning for quality improvement. First, we found evidence that

psychological safety, in combination with leader inclusiveness, promotes team engagement in quality

improvement work. Second, the ﬁnding that psychological safety mediates between leader

inclusiveness and engagement in quality improvement extends prior work that showed psychological

safety to be a mediator between the broader construct of team leader coaching behavior and team

learning behavior, more generally (Edmondson, 1999). Finally, our model and ﬁndings shed light on

the important but rarely studied phenomenon of engagement in discretionary, effortful quality

improvement activities. Although our emphasis was on the effects of psychological safety, we also

acknowledge that there may be other processes that contribute to engagement (e.g., psychological

availability (Kahn, 1990)) that we have not addressed. Future research should explore additional

mechanisms by which teams become actively engaged in quality improvement work.

The challenge of engaging busy, overworked professionals and service workers —already burdened

by the heavy demands of their ‘‘real jobs’’— in quality improvement activities should not be

underestimated. In the course of a day, health care professionals are continuously called upon to

immediately address the many needs of patients and co-workers. The requests are so many that nurses

often sacriﬁce their personal breaks (e.g., lunchtime) and work overtime without compensation in order

to complete their daily clinical care tasks (Tucker & Edmondson, 2003). The time pressure to complete

tasks is so great that the most burdened frequently neglect to wash their hands, despite almost universal

awareness that hand hygiene is a cornerstone of good clinical practice (Institute of Medicine, 2003).

In this challenging work environment, competing demands could surely relegate the perceived extra-

role work of participating in quality improvement efforts to the background unless engagement ignites

a counter response. Our analyses —using staff-to-patient beds as a measure of workload—suggest that

the engagement needed to motivate such efforts is related more to psychological safety within the unit

team than the burden created by competing demands and workload. This is good news for health care

because it suggests that improvement efforts need not be delayed until greater slack is created; rather

engagement in improvement efforts may occur in unit teams once a climate of psychological safety for

The ‘‘collaborative communication intervention’’ employed by Boyle & Kochinda (2004) consisted of multiple learning

activities, small group skill practice and problem solving decisions; feedback and reinforcement of newly learned skills; a

planning assignment for on-the-job applications; and assessment and feedback after the intervention. Participating ICU leaders

spent a total of 23.5 hours learning communication and process skills (e.g., how to open a conversation, how to seek ideas from all

involved, etc.).

DOI: 10.1002/job

STATUS AND PSYCHOLOGICAL SAFETY 959

learning is cultivated. Thus, another contribution of the present study is to illuminate organizational

antecedents of engagement, which can be a difﬁcult state to elicit naturally.

Limitations

This study is not without limitations. First, our use of a sample consisting exclusively of NICUs and

their professionals may limit the generalizability of the ﬁndings. While NICUs are similar to other

health care units in exemplifying the trend toward cross-disciplinary teams mentioned at the outset

(associated with increasing knowledge, specialization, and interdependence), one could argue that

these trends are heightened in NICUs, making the setting unusual. Moreover, the fragility of the (infant)

patient and the importance of timely communication and action are also special characteristics of the

NICU. These contextual variables may foster an appreciation for teamwork and recognition of each

discipline’s contribution such that leader inclusiveness is more prevalent in NICUs than in other health

care settings, and more likely to elicit responsiveness. Other unit types (e.g., outpatient units) may be

slower to realize the unique contributions of traditionally lower status team members and the

interdependency among disciplines. Therefore, status differences may be greater in those unit teams

compared to those in the NICU environment, and leadership’s achievement of inclusiveness may be

more difﬁcult. Our data do not allow us to make a comparison based on unit type. However, the

presence of signiﬁcant variance between NICUs with respect to leader inclusiveness suggests that

leader inclusiveness is not a universal NICU attribute. Some NICU leaders experience signiﬁcant

difﬁculty behaving inclusively. Whether this relationship varies across unit types will have to be

investigated in future work.

Future work should also address imperfections of our data. We received completed surveys from

only 58% of the NICUs in the collaborative and only 46% of unit team members contacted (excluding

survey pilot sites). Although demographic comparison of participating and non-participating NICUs

showed no differences between the two groups and our response rates are similar to other studies in

hospitals (Edmondson, 1996; Kaissi, Kralewski, Curoe, Dowd, & Silversmith, 2004; Jacob &

Deshpande, 1997), we cannot ignore the possibility of non-response bias at the group and individual

levels. The latter is a most serious concern if individual non-respondents are those who did not feel

psychologically safe and included. The absence of their responses biases their unit data upward,

incorrectly giving the appearance of units that have managed to minimized status differences in

psychological safety and that are inclusive. Subsequent studies with higher response rates are needed to

address this concern. Additionally, those studies are advised to examine a relationship we were unable

to test with our dataset—whether specialization among nurses is associated with differences in

psychological safety. Nurse respondents did indicate their professional training (e.g., neonatal nurse

practitioner vs. Master’s prepared nurse) in their survey responses; however this was not enough

information to accurately identify different specialties within the nursing populations across units. We

urge scholars in this area to collect information about daily tasks and speciﬁc care delivery roles to

further assess the effects of specialization and status within a professional group on psychological

safety.

Finally, we must acknowledge that team engagement in quality improvement work is an

intermediary outcome. The ultimate goal of health professionals involved in quality improvement work

is to close the gap between current and evidence-based practice to produce the highest quality care

possible in a consistent manner (Shojania, McDonald, Wachter, & Owens, 2004). Although we lack

data in this study to test the relationship between engagement in quality improvement work and team

learning as evidenced by quality improvement outcomes, past research shows a positive relationship

between employee engagement and other organizational outcomes, including customer satisfaction,

DOI: 10.1002/job

960 I. M. NEMBHARD AND A. C. EDMONDSON

productivity, proﬁt, and safety (Buckingham & Coffman, 1999), and future research should further test

this relationship.

Practical implications

In sum, this study extends a stream of research on creating psychological safety for learning within

cross-disciplinary teams, and begins the discussion about team engagement in quality improvement

work. At a time when much attention is centered on how to advance quality improvement efforts in

health care, this paper offers initial theoretical and practical insight. Speciﬁcally, training leaders to be

inclusive to foster psychological safety may be a critical antecedent of effective quality improvement,

because it may create the engagement that is necessary for teams to participate in the speciﬁc learning

activities required for quality improvement. We ﬁnd, in related work, that psychological safety enables

the performance of ‘‘learn-how’’ activities— experimental activities such as pilot projects, dry runs,

and problem-solving cycles —which are interpersonally risky yet often required for the

implementation success of quality improvement projects in health care (Tucker et al., 2006).

Together, these ﬁndings imply a focus on team leader behavior to create the conditions (i.e.,

psychological safety) and then the opportunities (i.e., learn-how activities) for team quality

improvement efforts.

We do not intend to suggest that the development of inclusive leaders within NICUs would affect

psychological safety or engagement in other parts of hospital systems. NICU leaders rarely interact

with other clinical units, thus the opportunities for their inclusive nature to shape the climate of

other multidisciplinary care delivery teams directly is limited. Likewise, NICU team members

typically do not work on other care teams, so any habit of collaborative interactions is mostly NICU-

contained.

Although this research took place in the health care context, the ﬁndings may apply to other

organizational contexts as well. In particular, in other organizations with cross-disciplinary teams,

status diversity and a need for teams to continuously improve the services or products the organization

produces, the model developed in this paper may be highly relevant. A growing number of industries

are characterized by these features, as organizations realize that individuals in different functions,

locations, and stations of life possess specialized knowledge that can be valuable for problem-solving

and innovation, if shared and combined with the knowledge of other employees through teamwork.

Therefore, our model may have wider relevance than just health care, but health care, with its

prevalence of cross-disciplinary teams, salient status differences, and many quality improvement

efforts is particularly conducive for exploring and developing these ideas.

Acknowledgements

This research beneﬁted greatly from the expert help of health care management and operations

researchers Anita L. Tucker and Dr. Richard Bohmer (also a physician), as well as the superb research

assistance of Laura Feldman. We thank the participants in the Leadership and Groups seminar at

Harvard University, Denise Rousseau and two anonymous reviewers for constructive comments on

earlier versions of this manuscript. We also appreciate the invitation to conduct this research provided

by Dr. Jeffrey Horbar, Kathy Leahy, Paul Plsek and the Vermont Oxford Network, as well as the

willingness of nurses, physicians, respiratory therapists and other staff members of the participating

DOI: 10.1002/job

STATUS AND PSYCHOLOGICAL SAFETY 961

hospitals to engage in this research. Their time, effort, and honesty provided an invaluable contribution,

for which we are deeply appreciative. The Harvard Business School Division of Research provided

ﬁnancial support.

Author biographies

Ingrid M. Nembhard is a doctoral candidate in the Ph.D. Program in Health Policy (Management

Concentration) at Harvard University. She received her S.M. in Health Policy and Management from

the Harvard School of Public Health. Her research interests include intra- and inter-organizational

learning, collaborative teams, and quality improvement in health care.

Amy C. Edmondson is Novartis Professor of Leadership and Management at Harvard University. She

received her A.M. in Psychology and Ph.D. in Organizational Behavior from Harvard. Her research

focuses on understanding and improving processes through which organizations learn and innovate, in

health care and other industry settings.

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May 2025

Avinash Tyagi

The article examines the various aspects of "work spouse" relationships that exist in contemporary professional environments. This research unites organizational behavior findings with social psychology data and management studies to develop an integrative conceptual framework that describes these specific workplace dyads. The study evaluates both positive effects (better collaboration, emotional support, and higher job satisfaction) and negative effects (perceptions of favoritism, boundary confusion, and team exclusion) of these workplace relationships based on Social Exchange Theory, Attachment Theory, and Role Theory. The research develops advanced knowledge of professional relationship impacts on organizational performance while presenting evidence-based organizational approaches to support beneficial work spouse relationships, while addressing potential risks. The research expands traditional workplace relationship studies by recognizing work spouse dynamics as unique professional bonds with unique origins and results, while delivering practical leadership guidelines to boost the workplace environment and performance.

Clinicians’ Perceptions About Institutional Factors in Moral Distress Related to Potentially Nonbeneficial Treatments

Article

Jun 2025

Importance Clinicians commonly experience moral distress related to potentially nonbeneficial life-sustaining treatments (LST). Hospitals’ institutional culture (eg, shared beliefs, values, and practices), structures (eg, policies, practices, resource allocation), and societal-level factors (eg, national culture, local and national policies, medical hierarchies) may contribute to moral distress related to potentially nonbeneficial LST. Objective To investigate clinicians’ perspectives on how hospitals’ institutional culture and structures might exacerbate, prevent, or mitigate the influence of societal factors contributing to moral distress related to potentially nonbeneficial LST. Design, Setting, and Participants This qualitative study used comparative ethnographic methods. Semistructured, in-depth interviews were conducted between February 2018 and June 2022 at 4 West Coast academic hospitals selected for their varying intensities of end-of-life care. Interview participants were hospital-based clinicians (eg, nurses, physicians), hospital leaders (eg, unit nursing and medical directors), and administrators with differing clinical backgrounds and professional responsibilities. Data were analyzed in 2 phases, from January 2019 to December 2022 and from June to September 2024. Main Outcomes and Measures Clinicians were asked about their hospitals’ institutional culture and structures and their relationship to clinicians’ experiences of moral distress related to potentially nonbeneficial LST in end-of-life care. Results A total of 122 interviews were conducted (75 physicians [61%]; 22 nurses [18%]; 6 advanced practice clinicians [6%]; 68 [56%] women; mean [range] age, 42 [27-74] years). Respondents felt hospitals’ institutional culture and structures could exacerbate moral distress. Respondents reported that a hospital culture of health care consumerism influenced clinicians’, patients’, and families’ expectations for treatment intensity, contributing to morally distressing situations. Nurses and primary team physicians felt constrained by medical hierarchies, leading to perceptions of disempowerment and moral distress. Clinicians also reported that institutions lacked sufficient structures to support efforts to de-escalate potentially nonbeneficial treatments. However, respondents also reported that hospitals’ institutional culture and structures could prevent or mitigate moral distress. Respondents felt policies empowering clinicians across the medical hierarchy to participate in decision-making reduced moral distress. They reported that institutional resources could manage conflicts and provide emotional support when moral distress occurs. Furthermore, respondents felt that clinician-driven quality improvement initiatives and supportive hospital leaders could address hospitals’ institutional cultural and structural contributors to moral distress. Conclusions and Relevance In this qualitative study, clinicians perceived that institutional factors affected their experiences of moral distress related to potentially nonbeneficial LST by exacerbating, preventing, or mitigating the influence of 3 societal factors: defaults of high-intensity treatments, health care consumerism, and medical hierarchies. These results have implications for developing tailored institutional-level interventions to address societal and institutional contributors to moral distress from potentially nonbeneficial LST.

Revolusi Manajemen Sumber Daya Manusia PT. MIFANDI MANDIRI DIGITAL

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Full-text available

Jun 2025

Wulan Purnama Sari

Perkembangan dunia kerja yang semakin dinamis menuntut organisasi untuk terus beradaptasi dan berinovasi dalam pengelolaan sumber daya manusia (SDM). Transformasi digital, globalisasi, serta disrupsi teknologi telah mengubah cara perusahaan merekrut, mengembangkan, dan mempertahankan karyawan. Buku ini, berjudul Revolusi Manajemen Sumber Daya Manusia, hadir sebagai referensi komprehensif yang mengulas perubahan besar dalam dunia manajemen SDM serta strategi terbaik dalam menghadapinya.

Droupadi Murmu: The Epitome of Transformative Leadership Excellence - A Global Theoretical Analysis of India's Most Deserving President

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Full-text available

Apr 2025

This comprehensive analysis presents Droupadi Murmu as an exemplary leader whose extraordinary journey from a tribal village to India's highest constitutional office represents the pinnacle of democratic achievement and leadership excellence. Through the integration of over twenty global leadership theories spanning Western and Eastern philosophical traditions, this paper demonstrates how Murmu embodies the highest ideals of transformative, authentic, ethical, and spiritual leadership while simultaneously revolutionizing federal governance excellence. Her remarkable trajectory—from overcoming profound personal tragedies to breaking centuries-old barriers of caste, class, and gender—exemplifies universal principles of leadership that transcend cultural boundaries. This analysis applies multiple theoretical frameworks including Transformative Federal Leadership (Pallathadka & Roy, 2025), Authentic Leadership Theory (Avolio & Gardner, 2005), Spiritual Leadership Theory (Fry, 2003), Ethical Leadership (Brown et al., 2005), Cultural Intelligence (Earley & Ang, 2003), Indigenous Knowledge Systems (Smith, 2012), and Eastern philosophical frameworks including Dharmic Leadership and Gandhian principles. The paper conclusively establishes that Murmu represents not merely a symbolic appointment but the most qualified, deserving, and transformational president in India's history—a beacon of hope demonstrating that true leadership emerges from service, resilience, and an unwavering commitment to uplifting the marginalized while maintaining the highest standards of constitutional integrity.

Severe Patent Ductus Arteriosus Is Independently Associated With Increased Ventilation Days in Very Low Birth Weight Infants

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Full-text available

Oct 2024

Kiran Sai Depala

Background: Very low birth weight (VLBW) infants with patent ductus arteriosus (PDA) have high morbidity and mortality. Studies suggest an association between PDA and duration of ventilatory support, but the additional number of ventilation days due to severe PDA is unknown. Methods: We performed a case-control study of VLBW infants born ≤ 32 weeks of gestational age between 2006 and 2014 at our institution. Infants in the study had a moderate to large PDA on echocardiogram in the first week of life and were divided into two groups based on PDA severity. Ventilation days were compared for PDA severity groups and ventilation duration-related risk factors. Adjusted multiple linear regression was used to estimate the association between PDA severity and ventilation duration. Results: The median number of ventilator days for infants with spontaneous PDA closure (8.5 days) vs. infants with severe PDA (29 days) differed significantly (P ≤ 0.001). We found that infants with severe PDA had a longer duration of ventilation than infants who closed spontaneously—approximately eight days. Conclusion: Severe PDA in VLBW infants is independently associated with a longer duration of ventilation compared to spontaneous PDA closure. Future studies should explore this association and clinical options for improving patient outcomes.

Reimagining Well-Being at Workplace: HR Professionals

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Full-text available

Jun 2025

Employee: wellbeing is a crucial aspect of effective human resource management. It encompasses the physical, mental, and emotional health of employees within the organizational context. A focus on employee well-being contributes to a positive work environment, increased job satisfaction, and improved overall organizational performance.

Effects of the co-presence of multiple languages on university websites: processing disruptions, evaluative consequences, and adaptation

Article

Jun 2025

Intra-team learning behaviors and psychological safety: linking team leader coaching behaviors and team performance in work teams

Article

Apr 2025

Purpose This study aims to investigate the serial mechanism constituted by psychological safety as an antecedent of intra-team learning behaviors in the relationship between team leader coaching behaviors and team performance. Design/methodology/approach Cross-sectional data was collected from 72 Romanian work teams. Team members rated the team leader’s coaching behaviors, psychological safety and intra-team learning behaviors ( N = 256). Team leaders provided data on team performance ( N = 72). Findings Results revealed that team leader coaching behaviors were positively and only indirectly related to team performance. The significant paths consisted of intra-team learning behaviors and psychological safety as an antecedent of intra-team learning behaviors. Originality/value These findings underscore the benefits of team coaching in the form of team leader coaching behaviors on team performance through psychological safety and intra-team learning behaviors.

Developing the Next Generation of Physician Changemakers: "You Have to Love the People, and Love the Process"

Article

May 2025

Introduction: There is a growing consensus among patients, physicians, and policymakers that healthcare must undergo a massive transformation to promote healthcare worker well-being. The Institute for Health developed the Triple Aim framework for high-performing health organizations, which focused on reducing costs, improving individual patient experience, and population health. The move from the Triple to Quadruple Aim added a focus on the well-being of healthcare professionals, acknowledging growing literature and a movement that healthcare professionals' well-being is crucial to the quality of healthcare patients receive. Objectives: This study sought to investigate the individual transformation and the organizational contributors that promote effective change. More specifically, how do attending physicians from various specialties construct their understanding and make sense of the individual and organizational factors that contribute to their development as changemakers? Given the exploratory nature of this topic and the limited existing literature, we employed a semi-structured interview format and an inductive analytic approach to allow unanticipated insights to emerge to determine the individual and organizational factors that support and enhance changemaking in attending physicians. Methods: Qualitative semi-structured interviews were conducted with 15 physician changemakers who have successfully implemented transformative healthcare initiatives. Data were analyzed using Braun and Clark’s reflexive thematic analysis (RTA) to identify key themes and develop a comprehensive understanding of their experiences. Results: Analysis at the individual and organizational level illuminated a constellation of interconnected themes propelling these physician changemakers: Participants’ insatiable appetite for learning, coupled with sustained inspiration and the capacity for embracing ambiguity and emotional regulation, drives changemakers’ courage and resilience. Notably, while challenging, participants did not perceive changemaking as unduly burdensome. At the organizational level, changemakers perspicaciously report leveraging the system, engage in job crafting through protected time, and authentically take accountability and own the change. Conclusions: With an increased focus on addressing the systems issues that impact quality healthcare, this study provides a roadmap for individual and organizational actions to expand and accelerate the number of physician changemakers.

Learning from Mistakes is Easier Said than Done: Group and Organizational Influences on the Detection and Correction of Human Error

Article

Full-text available

Jan 2004
J Appl Behav Sci

Amy C. Edmondson

This research explores how group- and organizational-level factors affect errors in administering drugs to hospitalized patients. Findings from patient care groups in two hospitals show systematic differences not just in the frequency of errors, but also in the likelihood that errors will be detected and learned from by group members. Implications for learning in and by work teams in general are discussed.

Improving Care Through Collaboration

Article

Jan 1999

C M Kilo

The opportunity to improve health care using existing scientific knowledge is immense. Much is known that is not being used in routine care, leading to a large gap between knowledge and practice. Collaborative improvement models bring health care professionals together to focus on this gap and to accelerate the pace of improvement in their organizations. This article describes one such model, the Institute for Healthcare Improvement's Breakthrough Series Collaborative model. Lessons are drawn to help inform future collaborative efforts that focus on the improvement of care.

Achieving Safe and Reliable Healthcare: Strategies and Solutions

Article

May 2005

From Embedded Knowledge to Embodied Knowledge: New Product Development as Knowledge Management

Article

Oct 1998
J MARKETING

Because new product development (NPD) teams are engaged in knowledge creation, NPD management should emphasize cognitive team processes rather than purely social processes. Using the notions of tacit knowledge and distributed cognition as a basis, the authors propose that the T-shaped skills, shared mental models, and NPD routines of team members, as well as the A-shaped skills of the team leader, are key design variables when creating NPD teams. The authors propose that trust in team orientation, trust in technical competence, information redundancy, and rich personal interaction are important process variables for the effective and efficient creation of new knowledge.

Politeness: Some Universals in Language Usage

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