**4. Leadership**

#### **4.1 Leading with humility**

Leading with humility is an attribute sought after in healthcare, mainly because most subject matter experts undergo rigorous training and become highly skilled before being able to treat and manage critically ill patients. Bringing these experts together and capturing the collective genius requires humble leadership, collaboration, and a shared purpose: to produce safety outcomes. Owens et al. proposed several characteristics of leader humility: "(a) a manifested willingness to view oneself accurately, (b) an appreciation of others' strengths and contributions, and (c) teachability or openness to new ideas and feedback" [87]. Leading with humility is a signature trait [88] of inclusive leadership characterized by humble inquiry. Considering the fast-paced environment of our current ICUs and the commitment to patient safety, servant leadership is key to being open to asking the questions to which we do not know the answers. Centering the message around the patient, we recognize the importance of leading with humility.

#### **4.2 Inclusion**

The current volatile, unpredictable, complex, and ambiguous healthcare environment suggests that everyone's voice can be mission-critical [89]. This can be

accomplished if we cultivate inclusive and agile leadership. In this climate, inclusive leadership is crucial to collaboration and the avoidance of preventable failures. ICU teams' structure involves physician attendings, residents, nurses, respiratory therapists, advanced practice providers and many other roles from diverse backgrounds.

Empirical evidence continues to grow about the importance of inclusive leadership and its influence on culture in healthcare. The *Leadership Saves Lives* study demonstrated that organizational culture and performance improvement significantly influence mortality rates for patients experiencing acute myocardial infarction [90]. Inclusive leadership crosses hierarchies and invites distinct perspectives and authentic participation. This helps build trust among peers, psychological safety, and situational humility. For example, when physician leaders of intensive care units invite dialog on "what else can we do; how can we tackle this opportunity together," they demonstrate openness to other ideas and foster collaborative problem-solving. Inclusion leads to greater engagement, team performance, and improved patient outcomes [91]. The care for our critically ill patients has become increasingly complex, and teams rely on each other to save lives.

#### **4.3 Psychological safety**

Psychological safety is foundational to healthcare organizations and the conduit through which patient safety occurs. This phenomenon and its related antecedent concepts have been studied since the 1990s, with much progress made in recent years. It has been linked to team performance [92], ethical conduct [93], team diversity [94, 95], incivility [96], reporting of medical errors [94], innovation [97], and has been identified as a predictor for turnover intent [98]. A great problem occurs when medical errors are not reported due to lower psychological safety. The organization and patients suffer as a result, either through direct harm or missed opportunities to prevent latent failures.

Compelling evidence shows that when team members speak up, they are willing and able to talk about mistakes, collectively tackle improvement, and are more likely to innovate and drive solutions [91]. Nembhard and Edmondson discovered that intensive care units which foster high levels of psychological safety spontaneously decreased morbidity and mortality without additional interventions such as training or education. Despite growing evidence, psychological safety in healthcare organizations remains an untapped opportunity. Some factors include unmitigated and unapologetic hierarchies, fear of endangering someone's life, and old authoritarian leadership models. Fostering psychological safety in the current complex environment is crucial for catching near misses [69], addressing medical errors, and continuously learning from them.

High psychological safety is a prerequisite to advancing patient safety. Over the years, research in social psychology has identified humble inquiry as the avenue to build psychological safety. Recent data shows that leaders can effectively build it not only through seeking feedback from team members, but also by sharing criticism they previously received, and by being openly vulnerable. Grant and Coutifaris randomly assigned leaders to criticize themselves as opposed to asking for criticism. Just inviting them to do that once, it increased psychological safety in their teams for at least a year [99]. This led teams to organize monthly vulnerability meetings and reserve time for "check-ins" on what needs to improve. Other structured practices that enable and support psychological safety include time outs, huddles, debriefs, listening and communication as agreed upon competencies, understood method to raise a concern or question, and escalation protocols.

*Patient Safety in the Critical Care Setting: Common Risks and Review of Evidence-Based… DOI: http://dx.doi.org/10.5772/intechopen.108005*
