title: Exploring psychological safety as a component of facilitation within the Promoting Action on Research Implementation in Health Services framework.
abstract: OBJECTIVE
  To explore holistic facilitation as an approach to enable the healthcare team to critically analyse practice and enhance patient care.
  
  
  BACKGROUND
  Globally, the challenge of changing healthcare practices for enhanced patient care is the focus of much attention. Facilitation is emerging as an important approach to assist healthcare teams to explore and improve their practice. Within the Promoting Action on Research Implementation in Health Services framework, which has been tested in an international arena, facilitation is a key element of operationalising collaborative changes in practice. This study uses the framework to explore holistic facilitation and the concept of psychological safety.
  
  
  METHODS
  An Emancipatory Action Research approach was used.
  
  
  METHODS
  Facilitated critical reflection was undertaken with the healthcare team working in an abdominal surgical unit. In addition, the lead researcher maintained a reflexive journal. Data were analysed using thematic analysis. Eighty-five per cent (n = 48) of nursing staff and individual participants from other parts of the healthcare team (n = 3) participated in the two-year study.
  
  
  RESULTS
  Data revealed 14 sub-themes that impacted upon the culture of the unit. These were as follows: support, leadership, oppressed behaviours, communication, interruptions, power imbalance, horizontal violence, threat, autonomy, distorted perceptions, vulnerability, value, trust and time. Psychological safety, leadership and oppressed behaviours emerged as three key themes in the practice context.
  
  
  CONCLUSIONS
  There is a need to create psychologically safe spaces in environments where insufficient support, weak leadership and oppressed behaviours are apparent. Psychological safety enables individuals to feel safe to engage in difficult conversations and consider changes to practice. In a theoretical contribution to the area of facilitation, it is proposed that the additional element of psychological safety needs to be incorporated into facilitation models, in particular, the Promoting Action on Research Implementation in Health Services framework, to more accurately reflect the complexities of working with healthcare teams.
  
  
  CONCLUSIONS
  The pressure on healthcare environments continues to increase. To achieve the necessary skills to lead and develop services requires more than simply highlighting what is wrong with practice. Creating psychologically safe spaces, using holistic facilitation, is essential to enabling healthcare teams to critically analyse practice and enhance patient care.
authors.affiliation: School of Nursing, Ulster University, Newtownabbey, UK. d.brown1@ulster.ac.uk.
authors.forename: Donna
authors.identifier: http://orcid.org/0000-0003-2552-4524
authors.initials: D
authors.lastname: Brown
authors.affiliation: FEANS Head of the Division of Nursing, Queen Margaret University Edinburgh, Edinburgh, UK. BMcCormack@QMU.ac.uk.|Head of QMU Graduate School, Queen Margaret University Edinburgh, Edinburgh, UK. BMcCormack@QMU.ac.uk.|Centre for Person-centred Practice Research, Queen Margaret University Edinburgh, Edinburgh, UK. BMcCormack@QMU.ac.uk.|University College of South-East Norway, Drammen, Norway. BMcCormack@QMU.ac.uk.|University of Pretoria, Pretoria, South Africa. BMcCormack@QMU.ac.uk.|Maribor University, Maribor, Slovenia. BMcCormack@QMU.ac.uk.|Ulster University, Newtownabbey, UK. BMcCormack@QMU.ac.uk.
authors.forename: Brendan
authors.initials: B
authors.lastname: McCormack
mesh_terms: D006302:Health Services Research; D006801:Humans; D016294:Models, Nursing; D009936:Organizational Innovation; D010149:Postoperative Pain / Q000451:nursing*; D061214:Patient Safety; D057184:Practice Patterns, Nurses'; D012606:Scotland; D013222:State Medicine
keywords: Promoting Action Research in Health Services framework; culture; holistic facilitation; leadership; oppression; psychological safety