The NHS has been urged to learn from research showing minority ethnic staff can face barriers to raising concerns about patient safety. But creating genuine psychological safety requires more than encouraging people to speak up. Employers must confront workplace bias, build trust and equip employees to navigate difficult conversations, says workplace-bias expert and author Buki Mosaku

Recent NIHR-funded qualitative research from the University of Leicester has found that some minority ethnic NHS staff feel unable to raise patient-safety concerns. Frontline participants described cultural divides, discrimination and workplace microaggressions shaping their decision to speak up.

Writing in The Guardian last month, the researchers also highlighted accounts of ethnic minority staff not being heard, unclear routes for raising concerns, fear of backlash, exclusion and bullying. Visa-dependent staff described particular anxieties, while some participants said these experiences reduced their trust in their organisations.

These findings are clearly troubling, raising serious welfare questions for patients and loved ones, but beyond that, they expose a weakness in the way many organisations across the UK approach psychological safety. 

Whether employees actually raise concerns depends heavily on what they have seen happen when colleagues challenge decisions, raise uncomfortable issues or call out behaviour they believe to be biased. Assurances that every voice is welcome carry little weight if experience suggests that speaking up comes at a personal cost.

Addressing this, be it within the NHS or other organisations, requires openness about where the system is failing minority staff. Leaders need to acknowledge problems and address them, with visible consequences when biased behaviour occurs. Employees are unlikely to place much faith in assurances about openness if previous concerns have resulted in retaliation, isolation or career damage.

I think of this as the first stage of a continuous improvement loop for institutional psychological safety: Track Record. Every occasion on which an organisation handles challenge fairly helps establish evidence that speaking up can be safe. Over time, those experiences give institutional promises credibility.

The second stage is Cultural Competency. Bias can surface through everyday interactions, assumptions and interpretations between people from different backgrounds, alongside more explicit discrimination. In healthcare, where staff often work under pressure and make complex judgements quickly, failures of understanding can affect working relationships and the quality of decision-making.

Improving cultural competency means helping people understand different cultural norms and recognise where bias may be influencing their interpretation of colleagues, patients or situations. Without that understanding, stereotypes can become embedded in apparently ordinary professional judgements.

From there comes Trust. This only develops when institutional behaviour gives staff good reason to believe the system will protect them. When an institution acknowledges where it is getting things wrong and starts addressing the cultural competency deficit behind some of those failures, staff have a stronger basis for trusting it. With that foundation in place, organisations can reasonably ask people to talk openly about their lived experiences.

Expecting employees to disclose vulnerability while they still regard the environment as unsafe places the risk on them. As trust develops, however, staff can begin to describe subtle as well as blatant forms of bias without assuming that doing so will bring retribution, isolation or career damage.

Lived Experience is the fourth stage of the process. It brings forms of bias into the open and gives organisations something concrete to address. It can also expose the gap between formal commitments to psychological safety and employees’ actual experiences.

The pivotal fifth stage is Bias Navigation Skills, an area too often missing from conversations about psychological safety.

People need practical tools for dealing with bias at the moment they sense it, alongside procedures for reporting concerns afterwards. For diverse staff, that means tactical frameworks that help them illuminate, call out and navigate potential bias while maintaining as much psychological safety as possible within the interaction itself.

Those skills are also needed by the person whose behaviour or decision has been challenged. Leaders and colleagues need to know how to respond when someone tells them that something they have said, done or assumed may have been biased.

This is vital as being challenged can provoke what I call ‘micro-disengagements’: unspoken defensiveness or grievances that are allowed to linger rather than being resolved. Over time, those silent tensions can create a vicious cycle between people experiencing bias and those being challenged over it, making psychological safety harder to achieve for everyone involved.

More overtly, someone may reject the other person’s interpretation, dismiss the concern or turn the discussion into an argument about intention. Where one person holds more authority than the other, that response can reinforce the fear that speaking up carries a personal cost.

Bias-navigation tools therefore need to work in both directions. They should enable someone to raise a concern while helping the person receiving that challenge to de-escalate the situation, consider what has been said and, where appropriate, identify a possible misinterpretation without resorting to defensive fragility – the propensity for people to become defensive when accused of something that paints them in a negative light, particularly discriminatory behaviour – gaslighting or retaliation.

Psychological safety also needs room for honest examination. A concern about bias can be taken seriously while still allowing the circumstances and interpretation to be explored properly. The aim is to create conditions in which difficult interactions can be surfaced and worked through safely.

That process completes the continuous improvement loop. Greater institutional honesty supports better cultural competency, which helps earn trust and makes fuller disclosure of lived experience possible. Those experiences show institutions where bias is occurring, while practical navigation skills give employees and leaders a better chance of dealing with it constructively when it does.

Each successfully handled interaction then contributes to the institution’s track record and helps shape how the next employee judges the risk of speaking up.

Employees ultimately learn whether a workplace is psychologically safe from what happens when somebody challenges the system. Institutions that want people to speak have to give them good reason to believe that doing so will be worth the risk.

The issues brought to light within the NHS are, sadly, still widespread across British workplaces, and until they are addressed, talk of psychological safety will continue to ring hollow for minority staff.

Psychological safety can only begin to take hold when an organisation’s response to challenge gives people reason to trust it. Every concern handled fairly strengthens that credibility; every defensive or retaliatory response weakens it.

It remains to be seen how the NHS will take these insights forward, but within any institution the real test comes when the next person decides to speak up — and sees how the employer responds.

Buki Mosaku is the world’s leading expert on workplace bias navigation and the founder of the DiverseCity Think Tank in London. His educational programmes are used by organisations around the world to navigate all career-stifling bias with psychological safety in the workplace, increase representation of diverse groups in senior roles and to educate employees and employers about how to deal with race-related bias effectively. He is the author of I Don’t Understand: Navigating Unconscious Bias in the Workplace.

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