The duality of manufacturing psychological safety

A story about the hazards of business vs people management

Andrew Howden
9 min readJan 5, 2019


Photo by Alvin Mahmudov on Unsplash (Edited)

I think a lot about the human side of software development. My background into software development was not a traditional one; instead falling into it through a combination of an absurd amount of luck, an affinity with computers and the premature end of my previous career as fitness coach.

One of the areas in which I am most interested is in the area of “disaster management”, “incident response”, “post mortems” — any sort of crisis management. It’s through this study, and the excellent Google SRE and team management books that I came across the notion of psychological safety. Wikipedia defines it as follows:

Psychological safety is a shared belief that the team is safe for interpersonal risk taking. It can be defined as “being able to show and employ one’s self without fear of negative consequences of self-image, status or career”.

The examples I have seen personally are:

  • A team member or colleague makes a serious mistake. How long before they report it, if at all?
  • If a team member sees something that they think is morally or economically reprehensible, do they speak up?
  • How much of a risk is an employee willing to take, given that it could reflect badly on them?

In the scenarios above and if I am taking the risk, psychological safety is how much I trust my teammates will factor in my intentions, empathize with my situation and attempt to make judgements upon my actions based on what I am going through, rather than merely on the objective outcomes.

Fostering a safe work environment

The literature surrounding psychological safety indicates that its perhaps the most important factor in predicting “high performance” teams. Google’s reWork study has it at the 1st place and Brené Brown calls it “the birthplace of innovation, creativity and change”. The standing practice for the failure analysis process terms “post mortems” is to have it “blameless”; to deliberately not attempt to find fault with a single person or team but rather consider the entire process for analysis, treating human action as an emergent property of the social system.

Given this literature surely fostering psychological safety should be among managerial and C level staffs highest priorities! Indeed, we see that some companies are embracing this cultural change, but even those chief among them indicate that such an understanding was hard to come to. To quote from the reWork study:

We were pretty confident that we’d find the perfect mix of individual traits and skills necessary for a stellar team — take one Rhodes Scholar, two extroverts, one engineer who rocks at AngularJS, and a PhD. Voila. Dream team assembled, right?

We were dead wrong. Who is on a team matters less than how the team members interact, structure their work, and view their contributions. So much for that magical algorithm.

It is an intuitively paradoxical understanding that to get the best out of people, we must remove some of the ways in which we otherwise provide accountability to our teams. Rather than falling back to criticism and punitive consequences to approach our teams with an intent to understand.

However, I would propose that there is a fundamental dichotomy between developing a highly efficient organisation and developing a psychological safe one. In many cases, I think our organisations are fundamentally geared to remove psychological safety.

Efficient → good…​ mostly.

As we exist in a business, and particularly as software engineers we’re forever under pressure to make ourselves more efficient. A combination of the massive gains in efficiency that IT sometimes brings and the inherently bespoke nature of software engineering means that software engineers are rare, and software engineers that excel rarer still. Those that can be found are tremendously expensive.

Accordingly, we’re always on the lookout for ways to reduce the ongoing cost of software. Things like:

  • Code reuse
  • Testing
  • Observability
  • Automation
  • Resilience Engineering

Are all about reducing the level of effort required to design and test new features, find and resolve issues and maintain production systems. Our race is against the clock.

In my experience efficiency gains are usually found incrementally as developers get more used to a given software environment, more familiar with tools or more adept and unpacking and expressing problems as code. A pattern is identified, and problems are generally pushed towards being solved in that pattern. For example, in a professional context I would probably not want to implement a web service in C++, as I am far faster in PHP. Instead, I would look for a way to solve a given problem in PHP.

Over time the number of solutions known within a development team gets larger, and the need to innovate gets smaller. This is a good thing; teams that are very experienced and knowledgeable are able to solve a large number of problems more quickly and easily than teams who are not. However, there is a nasty side effect to this increased efficiency, and decreased innovation.

As a team improves its efficiency, those who depend on that team become accustomed to this new, increased team throughput. Decisions that jeopardize this throughput start to become tacitly discouraged in favour of “safer” decisions.

This works in conjunction with the guaranteed change inherent in any organisation:

  • Team members joining, leaving, having children or getting sick
  • Upstream providers going out of business or being purchased out
  • Other businesses selling new, and perhaps better services
  • Political instability
  • Natural disaster

Change over any length of time is a statistical certainty and the primary cause of failure, but the more efficient a team becomes the less it can “afford” that failure. This combination of pressures over a length of time can destroy psychological safety.

If failure cannot be tolerated within a team, employees compensate by taking decisions that they feel are safer or at least will not reflect badly on them. Consumers of a team who are used to a given level of efficiency might raise their ire when told a given project is over time and budget. Team members might not be drawn to have conversations that could point to systematic issues as they will personally suffer the consequences of discovering such issues.

One day a set of circumstances arises that lines up perfectly to exploit each of these half truths. A product will be dramatically over budget, a production system will fail or any other catastrophe — the direct result of a set of defensible, but incorrect decisions.

The increase in efficiency has directly led to an inefficient business.

Enforcing a tolerable level of inefficiency

To start to address this it’s first important to find and validate the aforementioned pattern within an organisation. Common ways this is expressed is team members who work longer hours than normal, budgets becoming over budget or employees no longer taking the time for self development. The patterns that indicate an organisation is sacrificing longer term outcomes for short term efficiency are also the patterns that lead to “burn out”.

However, it is inherently difficult to pick out employees that are close to “burn out”, or situations that are unsustainable. Teams that are highly efficient are sustainable by definition, until they either burn out or suffer disaster. Doing an analysis (post mortem) on team burnout or disaster may provide useful insights into whether a teams performance is too efficient but such disasters are enormously expensive.

Accordingly, proxy measures of efficiency should be established. There are promising ways of evaluating psychological well being of team members, such as:

  • Automated surveys
  • Scheduled 1 on 1s with team members
  • Agile retrospectives
  • Team activities

Additionally, it may be worth establishing a pattern of deliberate inefficiency. Within Sitewards this has been implemented as an “improvement day” approximately 1x per month and there have been signs of it in other organisations such as Google’s “20%” time.

However, the implementation will vary on an organisational basis. It’s perhaps most important to understand that pursuing maximal efficiency is a bit line pursuing 100% uptime: It works until it really doesn’t.

Listening for “unknown unknowns”

Psychological safety is not a derivative simply of a level of efficiency. It is the result of a much broader set of incentives within an organisation. Such incentives are often not deliberate, but rather simply an emergent property of how an organisation is structured.

There are times when these incentives can adversely affect psychological safety. For example, a well intentioned member of an executive team may issue a directive that a certain process must be used when implementing a given solution. For example, that “Java” must be the language used to implement all future projects or that all services will be implemented on “bare metal”, rather than on “the cloud”. From the executives point of view, these decisions are defensible — Java as a language makes it much easier to hire future developers, and the executive understands that “bare metal” leaves the company in greater control of its data.

However, by making such decisions the executive has violated established norms that have otherwise been established within the company. Such norm violation does not simply carry the consequence that the norms must be readjusted and that responsibilities have shifted, but additionally that the executive does not trust the implementing teams to make appropriate decisions about their technological stack or find new colleagues.

Ironically, in environments of high psychological safety a team member would rapidly reach out to such an executive team member and query for additional information; perhaps informing them of their unintentioned message. However, the nature of social power means that such communication is inherently difficult for employees, and that such messages are extremely difficult to communicate back.

There are a couple of ways that this feedback may come back:

  • The executive team may directly solicit feedback, in which case employees may feel safe to communicate how this was received.
  • A limited number of employees will communicate it upstream regardless of personal consequences

The latter set of employees is a significantly rare set. “Speaking up” is an inherently dangerous activity, and it is only if the user either feels safe due to circumstances outside the organisation such as having a large pool of savings to fall back on, or if the user feels so compelled by their moral compass they do it regardless of personal consequence, or a mixture of the above.

However, within a position of power it is important to attempt both to listen for these warnings. They indicate issues that will otherwise go unexplained, instead resulting in employees silently leaving or otherwise compensating, negatively affecting business outcomes.

Regardless of the specific circumstances, understanding and cultivating employees who do voice feedback that indicates there are structural problems may provide valuable insights of aspects of the business that are otherwise invisible. The nature of such employees is their actions give direction to their colleagues and can significantly influence company outcomes.

The flip side of a completely safe environment

Lastly, it’s worth determining whether psychological safety is a universally positive force. Psychological safety is the acceptance that a user can take a given amount of risk without fearing the consequence. However, there are areas in which it is not appropriate to take risks.

For example, it may be that an employee considers that their gender makes them inherently better as a software developer, or that members of a given college are demonstrably superior in their assessments and thus have more say in company decisions.

In each case, voicing those opinions either explicitly or tacitly has significant negative impacts on their team, presuming their team includes members of which that opinion reflects poorly. This damage may produce even further negative outcomes than would a discussion on the merits of those beliefs in a clear and open way; famously reflected in the case of James Damore at Google.

It is also possible that within a company it is better to mitigate business risk, though the area in companies is certainly a lot greyer than the aforementioned sexist and elitist examples.

It is perhaps most important to be deliberate in cultivating the “appropriate” amount of psychological safety; especially in determining what areas it is acceptable to be experimental and in what areas certain rules apply absolutely. In the cases where there are absolute rules it should be clearly communicated how and why such rules exist, and in what cases they should be revisited.

In Conclusion

Our organisations are complex social affairs, full of an array of personal, team and corporate incentives and designs. However psychological safety is uniquely beneficial in that it allows the analysis and contribution of all team members to improve the businesses capability to solve the problem it is designed to solve. Some of the incentives that govern a business and are otherwise viewed as “good” may negatively affect psychological safety, and organisational leaders should thus be cognisant of these risks and manage them directly and explicitly. Team members who are able to voice concerns even though that puts them at personal risks provide a valuable additional lens through which to understand the organisation and should be looked after accordingly. However, just like efficiency psychological safety is not a universal good, and there are some areas of the business that may be unquestionable.

If you made it this far, I hope you enjoyed the read!