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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


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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.
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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
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.
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
( 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:
Contract/grant sponsor: Harvard Business School Division of Research.
Copyright #2006 John Wiley & Sons, Ltd.
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 learnthan 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
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
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 trendsincreasing knowledge, specialization, and interdependencewhich 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
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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,
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
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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 resulta 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 demographicare more likely to be asked for their opinion than those with low status.
Accustomed to having their opinions soughtoften 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
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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
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.
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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.
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DOI: 10.1002/job
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
Copyright #2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 941–966 (2006)
DOI: 10.1002/job
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
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
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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
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
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
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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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.
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.
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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
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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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
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
6. Gender 1.10 0.30 0.23
0.05 0.04 0.02
7. Years in any NICU
4.17 1.19 0.08
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
9. Years in current NICU
3.84 1.31 0.05 0.03 0.04 0.02 0.02 0.08
10. Hours per week in NICU 33.84 13.46 0.35
0.05 0.03 0.10
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.
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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
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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was positive and significant (r
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
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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
¼0.21) and engagement in quality improvement work (F(22, 1352) ¼7.67, p<0.001;
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.
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DOI: 10.1002/job
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
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DOI: 10.1002/job
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 workloadsuggest 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.).
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DOI: 10.1002/job
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.
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 datasetwhether 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
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,
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DOI: 10.1002/job
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-
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.
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
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DOI: 10.1002/job
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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... Table 1 shows how the theoretical concepts underpinning inclusive leadership were reflected on and interpreted by the SNMRLs before being applied to the JLA PSP. Inclusive leadership can be defined as 'words and deeds by a leader or leaders that indicate an invitation and appreciation for others' contributions', with inclusive leaders shaping situations where 'voices are genuinely valued' (Nembhard & Edmondson, 2006). Furthermore, positive correlations have been found between inclusive leadership styles, innovative work behaviours and psychological empowerment (Javed et al., 2018). ...
... Furthermore, positive correlations have been found between inclusive leadership styles, innovative work behaviours and psychological empowerment (Javed et al., 2018). Through the provision of a supportive climate and attempts to include others in discussions and decisions where their TA B L E 1 Reflections on inclusive leadership theory and its application to the JLA process voices and perspectives might otherwise be absent (Nembhard & Edmondson, 2006), this model of leadership was applied to the JLA PSP in an attempt to empower and inspire others to engage in reallife issues surrounding community nursing practice. ...
... The collaborative, inclusive approach generated by the SNMRLs was and influence (Nembhard & Edmondson, 2006). This was achieved by understanding the views and needs of the people involved in the process and by actively drawing on the diversity and richness of different perspectives, backgrounds and experiences (Amin et al., 2018). ...
Full-text available
Aims This paper focuses on the benefits of inclusive leadership when undertaking a priority setting partnership in community nursing, through providing a collaborative and committed nurse‐led forum for initiating impactful changes, identifying evidence uncertainties and driving research capacity‐building initiatives. Design This is a Discussion paper. The project was undertaken between 2020 and 2021. Data sources This paper is based on shared reflections as 70@70 Senior Nurse Research Leaders and is supported by literature and theory. It draws on issues relating to collective leadership, stakeholder engagement, diversity, inclusivity and COVID‐19. Implications for nursing The James Lind Alliance Priority Setting Partnership catalysed the development of a rigorous evidence‐base in community nursing. The collaborative opportunities, networks and connections developed with patients, carers, nursing leaders, policy makers and healthcare colleagues raised the profile of community nursing research. This will benefit nursing research, practice, education and patients in receipt of community nursing care. Collective buy in from national leaders in policy, education, funding and commissioning has secured a commitment that the evidence uncertainties will be funded. Conclusion Four key learnings emerged: collective leadership can ensure learning is embedded and sustained; developing an engaged stakeholder community to promote community nursing research is essential; a diverse membership ensures inclusivity and representation; and insights into the impact of COVID‐19 aid progress. The process increased research engagement and created capacity and capability‐building initiatives. This will help community nurses feel empowered to lead changes to practice. Sustained engagement and commitment are required to integrate research priorities into community nursing research, education and practice and to drive forward changes to commissioning and service delivery. Impact The study promoted research capacity building through inclusive leadership. This can increase community nurses' research engagement and career development and patient care quality and safety; this can incentivize funders and policy makers to prioritize community nursing research.
... Inclusive leadership was first proposed in the field of organizational management, aiming to solve the problems caused by employee diversity. It is embodied in paying attention to the needs of subordinates and demonstrating openness, effectiveness, and accessibility in their interactions with subordinates (Nembhard and Edmondson, 2006). Subsequently, Carmeli et al. (2010) proposed inclusive leaders are those who demonstrate visibility, accessibility, and availability when interacting with subordinates. ...
... At this point, the openness shown by inclusive leaders is more likely to encourage employees to take innovative actions and ensure that employees will not be punished when negative results occur so that employees can obtain greater psychological safety (Carmeli et al., 2010). Inclusive leaders are good at encouraging employees to contribute their ideas in direct cooperation with employees and helping them develop psychological safety (Nembhard and Edmondson, 2006). Inclusive leadership focuses on open communication and building strong relationships with employees who feel psychologically safe enough to take risks that may arise in their work (Carmeli et al., 2009;Shore et al., 2011). ...
... Inclusive leadership focuses on open communication and building strong relationships with employees who feel psychologically safe enough to take risks that may arise in their work (Carmeli et al., 2009;Shore et al., 2011). Based on those research results (Nembhard and Edmondson, 2006;Carmeli et al., 2010;Hirak et al., 2012;Javed et al., 2017;Ye et al., 2019), a positive correlation between inclusive leadership and psychological safety can be inferred. ...
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The COVID-19 pandemic has transformed the politics, economy, and society of the world, which has dealt the most severe blow to the hospitality industry. Meanwhile, the pandemic and government control policies have brought high psychological pressure to hospitality front-line employees, resulting in emotional exhaustion. As a part of burnout syndrome, emotional exhaustion poses a threat to employees’ mental health, career sustainability, and well-being. Therefore, the purpose of this paper was to investigate the curb effectiveness of inclusive leadership on emotional exhaustion and to explore the mediation roles of ethical climate and psychological safety between them. Time-lagged data were collected from 65 teams and 358 hospitality front-line employees working in Chinese hotels in two stages with a one-month gap. This research verified that inclusive leadership has a negative impact on emotional exhaustion both indirectly through the mediation roles of ethical climate and psychological safety. And the ethical climate and psychological safety played partial mediation roles between inclusive leadership and emotional exhaustion. In theory, the findings explored the dual mediation mechanism of the inhibitory effect of inclusive leadership on emotional exhaustion. In practice, we provided the training and correct guidance to develop inclusive leadership for hotel enterprises and to resolve the emotional exhaustion of employees, which can enhance sustainability in careers.
... A mindful individual with an inclusive leader can play a very positive innovative role due to acknowledgement, admiration and receptiveness [61]. Inclusive leadership appreciates ideas from subordinates, increases trustworthiness and provides emotional support [92], in terms of beneficial resources like time, innovation-related information, materials and space [129]. Employees will feel more comfortable sharing their ideas and improving their innovative work behaviour [62]. ...
... Therefore, inclusive leadership has been introduced as a situational factor that contributes to TAT, in strengthening the mindfulness and innovative work behaviour relationship. The inclusive leadership concept was first introduced by Nembhard and Edmondson [92] in Organisational Science, and they defined it as 'words and deeds by a leader or leaders that indicate an invitation and appreciation from subordinates' contributions'. According to Hollander [55], employees and leaders are interdependent, therefore, when both support each other, a win-win situation is created. ...
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This study investigates the relationship between project employee mindfulness and project success using innovative work behaviour as a mediator and the project manager’s inclusive leadership style as a moderator. Project Manager with high inclusive behaviour will strengthen the relationship of employee’s mindfulness and innovative work behaviour. The data were collected in three-time intervals from a total of 347 information technology project employees. The study findings validated the proposed model wherein employee personality traits, such as mindfulness, have a key impact on the initiation of project employees’ innovative work behaviour. Information Technology projects require innovation due to rapid technical improvements. The study confirms that innovative work behaviour adds to the project’s success. Furthermore, inclusive leadership helps mindful employees become innovative. Thus, the leadership roles should also be emphasised in IT projects.
... Leader inclusiveness is a scale that has been shown to be an important factor in healthcare for helping people on the frontlines of care to speak up with concerns and questions, 14 and recent research has suggested that feeling that one can speak up and be heard is associated with lower burnout. 15 Leader inclusiveness offers a modifiable factor that may influence feelings of burnout through increasing feelings that people can speak up and be heard. ...
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Objective: We examined the relationship of team and leadership attributes with clinician feelings of burnout over time during the corona virus disease 2019 (COVID-19) pandemic. Methods: We surveyed emergency medicine personnel at 2 California hospitals at 3 time points: July 2020, December 2020, and November 2021. We assessed 3 team and leadership attributes using previously validated psychological scales (joint problem-solving, process clarity, and leader inclusiveness) and burnout using a validated scale. Using logistic regression models we determined the associations between team and leadership attributes and burnout, controlling for covariates. Results: We obtained responses from 328, 356, and 260 respondents in waves 1, 2, and 3, respectively (mean response rate = 49.52%). The median response for feelings of burnout increased over time (2.0, interquartile range [IQR] = 2.0-3.0 in wave 1 to 3.0, IQR = 2.0-3.0 in wave 3). At all time points, greater process clarity was associated with lower odds of feeling burnout (odds ratio [OR] [95% confidence interval (CI) = 0.36 [0.19, 0.66] in wave 1 to 0.24 [0.10, 0.61] in wave 3). In waves 2 and 3, greater joint problem-solving was associated with lower odds of feeling burnout (OR [95% CI] = 0.61 [0.42, 0.89], 0.54 [0.33, 0.88]). Leader inclusiveness was also associated with lower odds of feeling burnout (OR [95% CI] = 0.45 [0.27, 0.74] in wave 1 to 0.41 [0.24, 0.69] in wave 3). Conclusions: Process clarity, joint problem-solving, and leader inclusiveness are associated with less clinician burnout during the COVID-19 pandemic, pointing to potential benefits of focusing on team and leadership factors during crisis. Leader inclusiveness may wane over time, requiring effort to sustain.
... In support of this perspective, empirical research shows that individuals perceive voice as safer and more worthwhile-and are more likely to speak up-when they perceive that their leader is open, supportive, and responsive to voice (e.g., Detert & Burris, 2007;Janssen & Gao, 2015;Tangirala & Ramanujam, 2012;Yang et al., 2021). Research in the healthcare setting further underscores leaders' significant role in encouraging voice in teams, which is instrumental to reducing errors and facilitating learning (Edmondson, 1996(Edmondson, , 1999(Edmondson, , 2003Nembhard & Edmondson, 2006). ...
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That individuals hold personal, implicit beliefs about the consequences of voice (i.e., implicit voice theories (IVTs)), and thus are inherently reluctant to speak up, is one of the most ubiquitous concepts in the voice literature. An extensive body of research also shows how situational factors (e.g., voice climate) profoundly affect voice. Unfortunately, few studies explore how dispositional beliefs combine with situational factors to influence voicing in teams; thus, the literature is unclear about whether and how leaders can encourage voice when their team members implicitly believe that voice is unsafe and inappropriate (i.e., high IVTs). We address this question by proposing a moderated-mediation model linking leaders’ prior reactions to voice (i.e., voice acceptance versus rejection) to team voice intentions via voice climate, such that encouraging leader behaviors (acceptance), unlike discouraging leader behaviors (rejection), creates positive voice climates that increase team voice intentions. Furthermore, drawing from the trait activation theory, we propose that team IVTs composition (i.e., the average IVTs held by each team member) moderates the mediated effect of voice climate on team voice intentions, such that this relationship is strongest for teams with high IVTs because, for these teams, positive voice climates are both highly salient to, and disconfirming of, implicit voice beliefs. Results of a multi-task team experiment support this model. We discuss the theoretical implications of considering person and situation factors in tandem, the potential influence of team IVTs composition, and practical implications for how leaders can inspire voice in teams.
... As Edmondson (2004) addressed, the openness, availability, and accessibility exhibited by leaders are likely to promote the development of psychological safety. By being open, inclusive leaders actively communicate with employees about achieving work goals or catching new opportunities, and the feeling of being invited and appreciated for their voice would help facilitate the development of employees' psychological safety (Nembhard and Edmondson, 2006). By being available and accessible, inclusive leaders send a clear signal that employees can easily get in touch with them and address issues (Carmeli et al., 2010). ...
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Taking both individual and team levels into consideration has been called for years in terms of research on leadership. Inclusive leadership, a trending leadership style emerging from the global needs of managing the increasingly diversified workplace nowadays, has yet been rarely studied at both levels. To answer these calls, we specifically analyzed the relationship between inclusive leadership, team psychological safety, and innovative performance via a multilevel analysis. The results are based on a study of 356 employees from 90 working teams. Individual perceptions of inclusive leadership are positively related to the individual innovative performance through the mediation of individual psychological safety. Team perceptions of inclusive leadership are positively related to the team innovative performance through the mediation of team psychological safety. Moreover, team perceptions of inclusive leadership are positively related to the individual innovative performance through the cross-level mediation of individual psychological safety. Implications for both theory and practice are discussed.
The importance of appropriate communication skills within a health care setting rests upon the need for effective information sharing. When successful, this provides a supportive working environment for staff and has a positive impact on patient care and outcomes. The purpose of this study was to explore how knowledge/evidence is acquired, shared, and applied in the Critical Care (CC) environment for staff and patients/family members. A qualitative approach was used, consisting of semi‐structured interviews and focus groups. Data analysis was conducted using an iterative thematic approach. Data collected prior to the COVID‐19 pandemic from United Kingdom (UK) critical care workers (N = 46), patients, and family members (N = 21) identified four communication roles performed by the nursing staff: team member; diplomat; translator and friend. It was evident that without suitable training and support, the stresses and demands placed upon the nurses could lead to disenfranchisement and burnout. These findings are relevant and timely given the impact of the pandemic, highlighting the need for accessible and alternate communication strategies to support nurses by reducing stress, moral distress and increasing psychological safety. Improved communication can provide tailored information for staff and patients/family improving the CC experience for all.
Background Inner context organizational factors proximally shape therapist experiences with evidence-based practice (EBP) implementation and may influence therapist self-efficacy, which has been linked to sustained use of EBPs in community mental health settings. Research has primarily focused on constructs such as implementation leadership and climate. However, the effects of such factors may depend upon other inner context dimensions, such as psychological safety. Psychologically safe environments are conducive to taking risks, speaking up about problems, and requesting feedback and may promote therapist self-efficacy during implementation. This study examines whether organizational sustainment leadership and sustainment climate relate to therapist EBP self-efficacy only under conditions of psychological safety. Methods Data were collected from 410 clinicians in 85 programs during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. Therapists reported on their organization's sustainment leadership, sustainment climate, psychological safety, and their own self-efficacy in delivering specific EBPs. Multilevel regression analyses were conducted to account for nested data structure. Results Among program-level variables, sustainment leadership and psychological safety both significantly predicted therapist self-efficacy. However, there were no significant interactions between program-level sustainment climate and psychological safety. Exploratory post-hoc analyses revealed a significant interaction between program-level sustainment leadership and therapist-level perceptions of psychological safety such that that the conditional effect of psychological safety on EBP self-efficacy was significant at high levels of sustainment leadership, but not at low or average levels. Conclusion We noted independent links between sustainment leadership, organizational psychological safety and therapists feelings of confidence and mastery with EBPs. Therapists’ individual perceptions of psychological safety were linked to self-efficacy only in programs with high sustainment leadership. Thus, sustainment leadership and psychological safety may both represent implementation intervention targets, but it may not be critical to assess for perceptions of psychological safety before deploying organizational leadership strategies. Plain language abstract Therapist self-efficacy is a therapist's belief that they are capable, knowledgeable, and skilled enough to deliver evidence-based practices (EBPs), and is thought to promote improved clinical and implementation outcomes, such as therapists’ sustained use of EBPs. Conditions within community mental health organizations may influence therapists’ sense of EBP self-efficacy. Leaders’ support and expectations for EBP implementation, and collective staff perceptions about the organization's climate to support EBPs are linked to positive therapist attitudes and EBP adoption. However, less is known about how these implementation-specific organizational factors associated with therapist EBP self-efficacy in the long-term, and how this may depend on general workplace conditions. Specifically, psychologically safe environments – where therapists feel safe taking risks such as asking questions, admitting mistakes, and trying new skills – may be needed to promote self-efficacy when therapists are tasked with learning and using complex multi-component EBP innovations. The current study tested the prediction that leader-driven and program-wide focus on EBP sustainment may promote therapist EBP self-efficacy only in organizations where conditions for learning are psychologically safe. Our findings confirmed that fostering strong sustainment focused leadership and psychologically safe environments may each be important for increasing therapists’ EBP self-efficacy. The model results suggested that individual therapist perceptions of psychological safety were more strongly related to EBP self-efficacy in programs with greater implementation leadership. Findings suggest the importance of increasing EBP leadership behavior to fully potentiate other facilitating conditions for therapist learning in the sustainment phase of EBP implementation initiatives.
Weather warnings are critical risk communication messages because they have the potential to save lives and property during emergencies. However, making warning decisions is challenging. While there have been significant advances in technological weather forecasting, recent research suggests that social factors, including communication, influence warning meteorologists’ decisions to warn. We examine the roles of both scientific and social factors in predicting warning meteorologists’ decisions to warn on tornadoes. To do so, we conducted a cross-sectional survey of National Weather Service forecasters and members of management in the southern and the central regions of the United States, as well as conducted a retrospective data analysis of cross-sectional survey data from the central region Tornado Warning Improvement Project. Results reveal that dependency on radar velocity couplet and a variety of social factors predicted decisions to warn.
This paper consolidates literature that justifies effective knowledge management as a precursor for mitigating the effects of a crisis, Covid-19 pandemic in particular, through key antecedents of leadership, culture, and information and communication technology (ICT). A thorough review of retrieved literature relevant to the topic was conducted. The study materials were rigorously screened to limit any potential biases regarding their selection. Through the study, the paper concludes that the fight against Covid-19 crisis indeed requires knowledge to, among other things, find a lasting solution, mitigate the impacts, limit misinformation, revert to normalcy, and plan for similar crises in future. Further, the paper concludes that sustainable knowledge management during the Covid-19 crisis largely depends on a decisive leadership style that puts employees at the centre; a culture that embraces knowledge as a core asset, and supportive ICT infrastructure. Furthermore, the study reveals that relevance of ICT in the process of managing knowledge, largerly depends on a culture that accepts knowledge as a critical resource. The study establishes some challenges associated with ICT where a way forward for migrating from knowledge capture to knowledge creation and sharing has been re-affirmed. The present paper has led to the development of a model that further explains the relationships between the determinants of leadership, culture and ICT against effective management of a crisis using knowledge as a strategic resource. Further, six propositions have been put forward to provide clarity on the relationships.
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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.
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.