Helen, please could you introduce us to the work that you do with VetLed?

I am Research and Development Director at VetLed. My main role is to provide training to individuals, groups, teams and organisations on all things human factors.  

Our training introduces teams to the scientific discipline of Human Factors and helps them understand the non-clinical side of being the best veterinary team. We help teams understand how they feel and function, what their human limitations and capabilities are and how/why these impact on us every day in a practice setting.  

Human Factors bridges that gap between our vast technical skill and knowledge that we learn at vet school or nursing college, and our ability to deliver that knowledge/skill to our patients on the ground in practice.   So that bridge between having skills/knowledge and delivering them most effectively might cover things like communication (within the team and outwards to clients), leadership, team dynamics, and the systems and processes that we work within, for example, effectively using checklists to keep our patients safer.  We also talk about health and wellbeing – how we feel and function – this is so important and is intrinsically linked to our outcomes (and therefore patient safety), our likelihood of staying in a job, and our overall satisfaction at work.

Much of this sounds very logical but the reality is that we don’t always do a great job in these areas, and it is encouraging to know that there is a huge evidence base behind how to improve in these skills or how to set up better processes that help our teams succeed.

Vet Led are currently running the ‘Safe To Speak Up Campaign’. Would you be able to tell us about it?

Yes absolutely. It’s something that I’m really, really passionate about. The Safe to Speak Up Campaign is all about psychological safety. This might be a bit of a new concept in veterinary, but as I explain, people can always relate to it!

Psychological safety is broadly defined as a climate in which people are comfortable to speak up.  An environment where they feel able to share their concerns and mistakes without fear of embarrassment or retribution.  Such an environment enables individuals to speak up knowing they won’t feel humiliated, ignored or blamed. If you don’t feel safe to raise ideas, then you also won’t feel safe to speak up when there might be a problem, which can have a negative impact on our patients in terms of patient safety and outcomes.

It must be really important in clinical practice, because if people don’t feel capable of speaking up, there could be some serious consequences.

Definitely. There is a lot information about human factors in aviation and health care which we can learn from. Serious, even fatal, accidents have happened simply because people didn’t feel able to speak up. They weren’t working in an environment or culture that was psychologically safe. Probably one of the greatest examples of this is the Tenerife air disaster. You would imagine that, as a trained pilot, if you thought there was a plane on the runway that you would crash into as you were about to take off, causing the loss of your own life as well as your passengers’, you would, of course, speak up. But what happened in the Tenerife air disaster was that the co-pilot hinted that he thought that there was a plane still on the runway, but because in those days the captain was revered as a god-like figure and had dismissed his concerns, the co-pilot didn’t feel psychologically safe enough to raise it again. That lack of psychological safety meant that 500 people tragically lost their lives that day.

We can easily see within veterinary and human healthcare how important it is to be able to raise your hand and raise your voice if you see something is going wrong.  It is so important to be able to say, “We need to stop and rethink this, reconsider our decisions for the safety of the patients – and the safety and wellness of the team as well.”

So how can leaders within practices help to encourage psychological safety?

I think it’s about small changes.  One of the most significant small changes you can make is asking people what they think.  Whatever position of seniority you work at, demonstrate curiosity, level the hierarchy and encourage people to speak up.  There is so much to gain as a team in terms of performance when we make sure that our teammates know that their thoughts and voices are important. By doing this, by demonstrating curiosity, you build trust from both leaders and from each other. It’s something that we all need to attend to and that we all need to practise.

At VetLed we’re going to be running some free to attend workshops, and something you can do is pop along to one of those and find out more about how you can actually implement psychological safety steps in practice.  The workshops will offer simple steps that people can take over time, which will lead to better psychological safety for their teams and their organisations.

One thing you just touched on is that leadership doesn’t just come from people in positions of hierarchical seniority and can come from anybody within the team. How can those of us who may not be in a classic leadership position encourage psychological safety within our team? Is it using the same mechanisms?

Yes, essentially it is. By building this sort of learning environment where we’re asking people for their thoughts, being curious about what they’re thinking and what they’ve seen before in their experience, we can start to build an environment where we all feel psychologically safe. That’s not just from the leaders in positions of authority; it’s from everybody. People learn through modelling behaviour.  So, if, no matter our position of seniority, we model curiosity, starting conversations and actively listening to each other to really understand what others’ points of view are, we can all contribute to creating this psychologically safe environment. 

How does psychological safety benefit veterinary practices and individuals?

The psychology surrounding this area is absolutely fascinating. We know that when people feel psychologically safe (“safe to speak up”), it creates a positive emotional state, which grows trust and curiosity. This positive emotional state causes ‘happy hormones’ such as dopamine, serotonin and endorphins to be released.  When we’re in this state of ‘thrive’ rather than a neutral state or a survival state, interesting things begin to happen…  Our learning improves, our ability to retain information improves and this state enables our minds to broaden. Our resilience and persistence are also seen to improve, so psychological safety even builds our personal wellness resources – physical, intellectual, or social. And working in a culture of psychological safety also improves our cognitive ability. Our brains are 31% more effective when we’re in a thrive state rather than neutral or survive.

All of these things together mean that we’re happier, we’re learning more, we’re more resilient and our brains are functioning at their optimum. This all contributes to improved performance, and in our setting, we would measure performance by patient safety and patient outcomes. So, it really is hugely important, the benefit is very obvious… and it’s evidence based.

We also know that the converse will happen if people do not have these things in place. If they don’t have psychological safety and they don’t feel safe to speak up, people will have most of their cognitive bandwidth taken up by worrying about things; why they’re not trusted or why they don’t feel able to speak up.  When people’s bandwidth is taken up by other concerns, they can’t focus so well on their work, errors are more likely to happen, and they’re distracted from the tasks they need to perform.

Therefore, it’s so, so important to ensure that every team member feels safe to speak up.

That’s really interesting. The benefits, as you say, are just huge. Why do you think the importance doesn’t seem so widely recognised yet?

I think in the profession we have been so focused on our clinical skills and our knowledge for so long, that’s where our attention has been placed. Whilst our clinical skills and knowledge are paramount to being able to do our job well, we need to expand that lens slightly.  We can be so focused on how our practical skills and theoretical knowledge are developed, that we sometimes forget about how to deliver them. It is so important for veterinary teams to look beyond the clinical skills in order to do the best for ourselves, our teams and our patients, and as part of that, s humans working in a safety-critical industry, we have to understand how our minds work and how that impacts on how we do our job.  We need to consider our non-technical skills, we need to consider what stops us feeling and functioning our best and how that limits our ability to work to the best of our ability. That’s where human factors really embodies the discipline of psychology as well. It’s intrinsically linked to how our minds work and what affects us, both positively and negatively as highly-skilled individuals seeking to do a good job.

What first led you to become interested in human factors?

I first became interested in human factors in my role as senior surgical nurse at the Animal Health Trust. I was aware that the vast majority of things went right, and we had good systems and processes in place. We had a great team who were really cohesive and very good at communicating. I recognised that when I was mentoring new students or nurses, we wanted them to be able to adapt to the environment quickly and to feel safe and comfortable within that environment and I began to look at what was necessary to make that as easy as possible.

“How could I expect somebody new in that role to feel and function at their best when they didn’t feel psychologically safe?”

I was also aware that throughout my 23 years as a veterinary nurse, there’s always been an undercurrent of incivility, and that really came into play with the teaching and mentoring I was doing. How could I help a new member embed into the team quickly, without them feeling nervous that somebody could be in a bad mood, or would be aggressive or uncivil in the way that they spoke? How could I expect somebody new in that role to feel and function at their best when they didn’t feel psychologically safe?

I began talking to different people about all these things, and soon realised was that I was talking about human factors. I’ve always really enjoyed learning and was looking for something to stretch me, so I found the Master’s in clinical human factors and patient safety, which is run by Edinburgh University, and decided to embark upon that, which was fantastic and absolutely enlightening as a course. In fact, I enjoyed it so much that when I finished it, I was still so passionate that I decided to go on to start my PhD. I do believe that learning is very much a journey. I will never know everything that I need to know or could know about a subject, but I’m very committed to do my best to try and find out as much as much as I can about it.

My special area of interest is non-technical skills – things like communication, leadership, teamwork, managing stress, coping with fatigue, situational awareness, decision making.  These are things that, for me, fill that gap between our performance and our clinical skills and knowledge.

I truly believe when you start to understand being human and how your brain works, it affects every part of your life, not just your work. You can take a step back from an immediate emotional reaction, be more rational and more reasonable in your approach and demonstrate more compassion and empathy towards others. I think it’s just such an enlightening subject. It’s really been an eye-opening journey of personal growth as well as professional growth for me.

What do you think are the most valuable ways you’ve been able to apply your learning within your own workplaces?

My learning on civility during my studies was a bit of a lightbulb moment and led to the ‘Civility Saves Lives’ campaign about how we can start to understand this problem and rather than letting problems fester, actually start conversations and begin to talk about civility.

When I’ve talked to nurses in practice recently, one of the things they’ve frequently said is that since the pandemic they haven’t been able to take breaks as they would have done previously. At the beginning of the pandemic, it was a case of “everybody together and fight to do everything we can to keep the ship afloat”, but a couple of years down the line, what we’re finding is nurses and other team members have not gone back to taking their breaks. So, I’ve been talking about the HALT campaign, the importance of taking breaks and showing people how they can embed that in their practices.

Are there any tips that you can give teams to help them make positive changes within their organisation?

Yes, probably the most important thing to recognise is that you need to make small consistent steps. You need to start the conversation; so, if you go to a workshop and you want to know more, then find out information, and bring it back. In your practice, find out who else might be interested in this area so that you build a team of people who are invested, and want to get other people on board. There will be a tipping point where everybody wants to know about it and everybody is happy to make small changes that will affect big change. It takes somewhere between 25-40% of people to be on board with a change for that change to become the cultural norm.

You can learn more about the non-technical aspects of your performance and choose one or two areas to focus on by attending a psychological safety workshop, finding out more about the HALT campaign or implementing a new checklist. Do something small to start off with – start conversations, get people interested and on board and then it will naturally grow from that. And if there’s anything along the way that I can help you with then please do just reach out to VetLed or helen@vetled.co.uk

“My first top tip would be to contribute to a positive culture every single day.”

That’s super advice, thank you. What is it that you most enjoy about training practice teams?

This is actually quite an easy question because it’s the light bulb moments. It’s the realisation that everything about human factors just makes sense, and in the context of psychological safety, that if we can’t speak up because we’re worried that we’ll be embarrassed or punished, or we don’t feel able to voice our concerns, then how can we keep our patients safe?

So, the flipside of that is to ask ourselves, “What can I do to make sure that I feel like I can speak up, because I know that’s going to keep my patients safer?”

Have you got some top tips you can share about self-care in practice?

Oh, absolutely. It really does start with each and every one of us to attend to self-care for ourselves and care for each other.

My first top tip would be to contribute to a positive culture every single day. Never be afraid to start the conversation about workplace culture, to ask questions and be curious. Encourage civility and psychological safety at every single level. Whether you are someone who works one day a week or five days a week; whether you are in upper management, or you’ve just begun in the practice; everybody needs to contribute to that positive culture every single day and consciously tend to it.

It was recently mentioned to me that psychological safety is like a fine glass vase. It takes a long time to build, and once it’s made, it’s a thing of beauty. But we need to make sure that we keep it safe, – and we do that by tending to all of the different aspects that contribute to maintaining psychological safety every single day.

Another tip is to make sure that you HALT. Take your breaks and work them out with your team. Start the conversation at the beginning of the day to work out what time people are going to have their breaks. It can be a really simple conversation, but it’s the job of everybody to make sure people can take their breaks.  For example, it’s really important that the first person goes on time so that everybody else gets their lunch break later on. Small things like that can really make a difference to our wellbeing because we all know that horrible feeling when we’re very tired or hungry: everything seems worse, and it really does damage our wellness. It can mean that when we get home, we’re probably not going to make the best choices for our evening either, so we might just go for junk food and a glass of wine over a nice walk with the dog and some healthier food.

“Ring-fence time for the things that bring you joy.”

My next tip is to investigate debriefing. I absolutely love the STOP 5 protocol. It’s really simple: taking five minutes at the end of the day or at the end of a procedure when something hasn’t gone as you’d expected, to chat as a team and check in how everyone is doing, so that you’re not taking that anxiety and concern home with you.  It only takes 5 minutes, and it makes a real, tangible difference to the whole team.

And I think the last one is to make sure that you ring-fence time for the things that bring you joy. They don’t have to take a long time – if you’ve got one minute, you could maybe send a text of gratitude or you could have a snack or a coffee or a stretch. If you’ve got an hour, you might be able to go for a walk or run or even have a power nap. For me at the moment, I find great joy in walking my dog in the sunshine and listening to podcasts. There’s so much amazing stuff out there on podcasts that’s so uplifting and inspiring – I definitely recommend finding one you enjoy. And always practice empathy. Always practice compassion.  Always practice gratitude.

Helen Silver-MacMahon MSc, Cert VNECC, DipAVN (surg), Cert SAN, RVN, is Research and Development Director at VetLed. She spent over 20 years working in general practice, referral hospitals and nursing education, gaining extensive professional experience which she applies to her passion of developing the veterinary profession’s understanding of Human Factors as a powerful aid in improving patient safety, enhancing performance and supporting the wellbeing of the veterinary team.

She is a RCVS Knowledge Champion for her role in the sustained training and use of a surgical safety checklist within the small animal theatre at the former Animal Health Trust.

In 2021, Helen completed an MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. For her dissertation project Helen researched situational awareness in the veterinary operating theatre, she has recently embarked upon a PhD at Lincoln university to explore non-technical skills in the veterinary profession.

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