Overcoming Professional Silos and Threats to Psychological Safety: A Conceptual Framework for Successful Team-Based Morbidity and Mortality Conferences.

Overcoming Professional Silos and Threats to Psychological Safety: A Conceptual Framework for Successful Team-Based Morbidity and Mortality Conferences - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Jt Comm J Qual Patient Saf . Author manuscript; available in PMC: 2026 Jun 1. Published in final edited form as: Jt Comm J Qual Patient Saf. 2025 Feb 27;51(6):415–422. doi: 10.1016/j.jcjq.2025.02.005 Overcoming Professional Silos and Threats to Psychological Safety: A Conceptual Framework for Successful Team-Based Morbidity and Mortality Conferences Brian A Campos 1, 2 , Mary Brindle 1, 3 , Emily Cummins 1 , Alexander Hannenberg 1, 4 , Danielle Salley 5 , Yves Sonnay 1 , Aubrey Samost-Williams 1, 6 Author information Article notes Copyright and License information 1 Ariadne Labs, Harvard T. H. Chan School of Public Health, Boston, MA 2 Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 3 Department of Surgery, Cumming School of Medicine, University of Calgary, Canada 4 Department of Anesthesiology, Tufts University School of Medicine, Boston, MA 5 Department of Quality and Clinical Projects, Children’s Memorial Hermann Hospital, Houston, TX 6 Department of Anesthesia, Critical Care and Pain Medicine, University of Texas Health Science Center, Houston, TX ✉ Corresponding Author: Brian A. Campos, 401 Park Dr 3rd Floor, Boston, MA 02215, bcampos@ariadnelabs.org Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12124946  NIHMSID: NIHMS2074673  PMID: 40234184 The publisher's version of this article is available at Jt Comm J Qual Patient Saf Abstract Background: Adverse events in healthcare are frequently discussed in morbidity and mortality conferences. However, while healthcare has evolved to be delivered by interprofessional teams, morbidity and mortality conferences have been slow to include all team members. One particularly potent barrier to conducting an interprofessional team–based morbidity and mortality conference is a lack of psychological safety among team members. Clinicians from various professions bring differences in perspectives, culture, perceived hierarchy, and assumptions about other professions. These perspectives may bring value to the interprofessional team–based morbidity and mortality conferences, but they may also degrade psychological safety. Methods: In this report, we explore the link between professional silos and psychological safety among the healthcare team in the context of an interprofessional team-based morbidity and mortality conference using the perioperative space as an example. We draw on the concept of team fault lines—a potential division along a team member’s characteristic that can divide a group or team into subgroups. We then trace the roots of perioperative professional silos, which define these fault lines, to the historical context of the healthcare professions, the individual development of professional identities, and the role of organizations in maintaining these silos. From these observations, we propose a framework for describing these foundations, which we use to evaluate the broader teamwork-in-healthcare literature to generate specific recommendations to promote psychological safety in team-based morbidity and mortality conferences. Conclusion: This framework can be used to postulate strategies for improving the ability for teams to learn from morbidity and mortality conferences. However, future work remains in implementing and studying these recommendations. Holistic patient care is the product of diverse skill sets. Perhaps nowhere in the healthcare system do interprofessional teams interact so closely as in the operating room (OR), where surgeons, anesthesiologists, nurses, advanced practice clinicians, and allied health professionals all work literally shoulder to shoulder to support the care of a surgical patient. Patient outcomes, both good and bad, are strongly influenced by the successes and failures of this teamwork; yet, adverse events in the perioperative space tend to be explored in single-discipline morbidity and mortality conferences in the United States and elsewhere. 1 , 2 Morbidity and mortality conferences are large forums for frontline clinicians to discuss and learn from an adverse event. These differ from root cause analyses, where a smaller group of clinicians and safety experts analyze adverse events to understand their causes and patient safety implications. Morbidity and mortality conferences provide an opportunity to learn together and improve systems and processes together, but that can only be accomplished if most members of the team are present and actively discuss and contribute. Team-based morbidity and mortality conferences, defined as a gathering of interprofessional clinicians who clinically work together as a team with the goal of debriefing and learning from an adverse patient event or a near miss, are growing more common throughout health care, 3 – 5 but adoption in the perioperative space lags. 6 Most perioperative clinicians report never or rarely attending team-based morbidity and mortality conferences, with nurses and surgical technologists being extremely unlikely to be exposed to any morbidity or mortality conferences. 7 One significant barrier to the acceptance and adoption of team-based morbidity and mortality conferences is the challenge of creating psychological safety in the conference setting. 7 Psychological safety allows clinicians and nonclinicians of diverse backgrounds and experiences to voice their perspective without fear of humiliation or negative consequences. 8 We posit that the diversity of professional backgrounds, while bringing significant value in their particular perspectives on the system, at the same time can hamper the development of psychological safety. Traditional hierarchical structures of the OR, if transferred to team-based morbidity and mortality conferences, can further contribute to an environment where individuals are uncomfortable speaking up. 7 , 9 The strength of these silos and hierarchies in the perioperative space make this environment an excellent exemplar for exploring the threats to psychological safety. Our aim in this manuscript is to examine the literature on psychological safety, team diversity and fault lines, and professional identity formation to understand the keys to stronger team-based morbidity and mortality conferences for the perioperative space and beyond, which would promote better clinician education and a wider range of quality improvement recommendations. This document draws on the organizational psychology and sociology literature to explore this relationship between professionally diverse (or interprofessional) teams and psychological safety. We begin by reviewing the literature around psychological safety before moving into a review of team divisions (fault lines) and their association with psychological safety. We will integrate the idea of professional identity formation at the historical, individual, and organizational level to describe the creation of these professional team fault lines. Finally, we will use this framework to understand the implications for conducting successful team-based morbidity and mortality conferences, both in the perioperative space and more broadly in health care, and we will close with potential recommendations for promoting psychological safety in the face of team diversity within the context of team-based morbidity and mortality conferences, enabling these conferences to live up to their full potential as educational and quality improvement tools. However, there remains a need for empirical research to support these recommendations. This manuscript is grounded in the example of the perioperative healthcare team, but the framework and recommendations are generalizable to other diverse healthcare teams. PSYCHOLOGICAL SAFETY The concept of psychological safety as a team-level phenomenon was first proposed and supported with empirical evidence in 1999. 10 Psychological safety can be defined as the shared belief held by members of a team that the team is safe for interpersonal risk taking, reflecting the belief that one is not at risk of embarrassment or rejection in a particular setting or role. 10 Since the initial conceptualization of psychological safety, it has been empirically associated with multiple positive team outcomes and improved team performance, including reduced stress among colleagues 11 and decreased fear associated with learning from mistakes, leading to quality improvement. 12 Psychological safety becomes possible when leaders set an example of ethical behavior; a recent study at New Zealand law firms showed that when leaders engender psychological safety, they positively influence the employee’s general wellbeing. 13 When Google set out to understand what drove success in its teams, the characteristic most associated with team effectiveness was team psychological safety—specifically, allowing team members to take risks with each other without negative consequence, within limits. 14 In healthcare teams working in multiple domains, evidence shows that psychological safety mitigates stress at work, 15 provides inclusivity despite rank, 16 and contributes to the overall wellbeing of every team member, even during difficult periods like the COVID-19 pandemic. 17 Psychological safety additionally has been positively associated with improved team performance, including in sharing information and procedural knowledge, 18 arriving at creative solutions to patient care challenges, 18 improved technical performance in anesthesia teams, 19 and increased team learning and quality improvement at the level of a hospital unit. 15 , 20 A lower level of team psychological safety in healthcare teams has been linked to decreased team member voice—the likelihood that they will speak up with their perspective or concerns—raising a theoretical concern for decreased patient safety among teams with poor psychological safety. 21 The exact association between patient outcomes and team psychological safety, however, remains an underexplored area. These team performance improvements are associated with psychological safety through an empirically supported theoretical framework where team learning leads to team performance, and psychological safety modifies the ability for a team to learn (see Figure 1 ). 10 A psychologically safe work environment has been linked to an increased likelihood of reporting adverse events. 22 This is the first step to discussing these incidents in settings such as root cause analyses or morbidity and mortality conferences, where psychological safety allows for a more diverse array of perspectives and opinions, more creative solutions to safety challenges, and more frank and educational discussions, thereby increasing team learning and, ultimately, team performance in their future work together. Figure 1: Open in a new tab Edmondson empirically showed that team psychological safety promotes team learning, which in turn promotes team performance (the model in blue). 10 We extend this model (in red) by suggesting that professional silos inhibit team psychological safety and professional silos in turn are promoted by the historical development of healthcare professions, the impact of organizations on maintaining professional boundaries, and the individual development of a professional identity. Professional Silos as Team Fault Lines Team-based morbidity and mortality conferences are unique from single-specialty morbidity and mortality conferences in that they bring together team members from a variety of professional backgrounds with the goal of learning together from their diverse perspectives. However, professional silos can also be a threat to psychological safety and the ability of these conferences to meet their intended goals. We draw here on the concept of team fault lines as a lens through which to understand the impact of professional silos on a team. Fault lines are defined as “hypothetical dividing lines that may split a group into subgroups, based on one or more attributes.” 23 , 24 These attributes might include gender, ethnicity, educational background, or—most relevant for team-based morbidity and mortality conferences—seniority and professional roles. The more aware a team is of these fault lines, the more likely they are to affect team performance. 24 Therefore, in a team with strong hierarchical relationships between team members, as may sometimes occur between physicians and nurses, these fault lines are more likely to disrupt team performance. Stronger fault lines have been associated with decreased team satisfaction, 25 increased intragroup conflict, 25 and decreased group cohesion, trust, and respect. 26 , 27 Fault lines may also be dormant, where the team remains cohesive until a triggering event splinters it into subgroups. 24 In interprofessional teams, these triggers may include differential treatment, differing values, or humiliation and/or insult among the subgroups. 28 In a team-based morbidity and mortality conference, it is unfortunately all too easy to imagine scenarios where one professional group accuses another of poor patient care, leading to humiliation and subsequent rallying to the accused clinician’s defense by others in the same professional group. This triggers a team fault line, decreasing group trust and therefore eliminating the psychological safety needed to learn from the adverse event. Fault lines are a team-level construct, but their development can be traced to individual-level and organizational-level inputs. Below, we expand on the idea of professional identity development , an individual-level contribution to fault lines or professional silos, and organizationally maintained professional boundaries , the top-down influence on professional silos and team fault lines. These individual and organizational concepts are further influenced by history, which will be detailed first. Historical Development of Healthcare Professions It is important to consider how the professions in perioperative care first took form. The professionalization—or the evolution of professions over time 29 —in this space can be traced back thousands of years. For the purposes of this paper, we will look at more modern roles starting from the late 1800s, coinciding with the adoption of antiseptic technique and anesthesia in the OR and the development of modern nursing. During that time, the surgeon was solely responsible for the life of the patient, including the administration of anesthesia and performance of all those in the OR. The surgeon eventually delegated administering anesthesia to a technician; and once the risks of anesthesia and its complex pathophysiology were appreciated, the technician gave way to a physician specialist. As anesthesia practice evolved in the 1930s, the surgeon’s role changed as the responsibility for patient outcome shifted from being solely the surgeon’s to being shared with the anesthesiologist. 30 The field of nursing was also transformed during this period; the formalization of surgical nursing education and emergence of key perioperative nursing associations in the 1960s and 70s led to significant professional socialization. 31 Suddenly the OR became filled with multiple professionals, with the surgeon’s role diminished though still considered pre-eminent, 30 and the OR followed more of a shared leadership model. 32 The role of professionalization in the perioperative space developed to define areas of expertise and authority, while sharing legal exposure, but this had the significant side effect of formalizing fault lines along professional roles. The formalization of these professional roles and their complex interrelationships set the stage for the organizational maintenance of the boundaries between them and the formalized pathways of specialized (and siloed) training to introduce new professionals. Individual Professional Identity Development These roles changed and new ones were created in the 20th century, leading to several generations of professional socialization, or the way these individuals integrate into their specialties by adopting the norms and behaviors of their colleagues and mentors as well as their preconceptions toward and stereotypes of outsiders. 29 Professional identities in healthcare begin forming early, when clinicians are in their undergraduate studies, and continue to develop throughout their career. This occurs through a multipronged process whereby individuals identify role models in the profession to which they aspire. They may then “try on” that persona, either in whole or in part, and evaluate what aspects are most consistent with their internal values and identity, the aspects that elicit the desired reactions from the people around them. 33 Thus, novices tend to be forming professional identities, which grow more stable as the individual becomes more senior in their professional role. 34 However, individuals may alter a professional identity as they enter new professional roles, such as taking on a leadership position. 33 Professional identity formation among surgeons, anesthesiologists, and nurses has been studied closely in OR teams. 35 Like trying on prototype identities, novice clinicians, typically residents, mimicked the talk they heard from more senior members of their profession as a way of signaling an intent to be in that group. This frequently included a degree of othering the other professional groups in the operating room team. Furthermore, as novices are developing this new identity, they are more likely to exaggerate the talk they hear from their senior colleagues, such as more extreme stereotyping and characterization of other professional groups in their proximity. This includes jokes about blaming everything on anesthesia or orthopedic surgeons who know very little about their patient except they have a fracture that needs repair. 36 This division of the team into a professional “in-group” to which the novice aspires and other professional “out-groups” strengthens this professional identity fault line further while threatening the larger interprofessional team. Role of the Organization in Maintaining Professional Boundaries The professional silos and team fault lines are further maintained through the social boundaries created in an organization’s culture, creating a top-down influence on the interprofessional teams. The theory of boundaries emerged as a concept in the social sciences, which explored the way they are constructed, negotiated, and maintained among social groups. Drawing heavily from the seminal work of 20th century sociologist Pierre Bourdieu, scholars began to investigate the ways boundaries, as a mechanism to maintain and solidify social hierarchies, shape social life. 37 – 40 The concept of boundary work was first put forth by Thomas Giyern to explain how scientists differentiate scientific from nonscientific knowledge. 41 As a primarily discursive strategy, this boundary work allowed scientists to position scientific knowledge as a legitimate way of knowing. 42 Boundary theory provides insights into the ways dominant social groups vie to maintain their position relative to others. This line of inquiry posits that social inequality, in part, emerges from the maintenance of these boundaries, which are used to classify and categorize people according to a hierarchy, typically based on social class position. 43 In this line of inquiry, boundary work typically refers to the maintenance, creation, or resistance to boundaries, including professional boundaries. Social scientists have applied boundary theory to the workplace, noting that boundary work has the potential to both foster collaboration and reinforce hierarchies. 44 Here, scholars dissect the ways professional knowledge, skill, and expertise are shored up in organizational contexts to reinforce differences among professional groups. To do this, workers continually engage in informal practices of exclusion, sometimes referred to as “strategies of distinction,” 40 that construct an organizational other against which their own status position is secured and maintained. 45 Research has also examined boundary work and boundary dynamics specifically in the healthcare setting. In a 1997 study of the maintenance of professional boundaries between doctors and nurses, Allen found that the boundary work done between the two groups involves asserting professional identities, guarding specific tasks, and contesting certain responsibilities. 46 Allen notes that, despite the hierarchical nature of this context, team-based settings can lead to a softening of the barriers between roles, making collaboration more effective. 46 Similarly, in a qualitative study of the medical-nursing boundaries, Liberati outlines several factors that shape, shift, and uphold the boundaries between doctors and nurses. 47 She finds that while this boundary is often upheld due to hierarchies and power dynamics inherent in nurse/physician relationships, there is also room for collaboration and understanding the nature of these boundaries matters for improving teamwork. For example, Liberati distinguishes between collaborative power and competitive power—the former recognizes that each profession has different competencies and patient care is carried out by a certain boundary blurring, where these competencies can support one another in service of providing patient care. In other cases, though, what Liberati terms competitive power allows one group to win in this hierarchy, such as when nurses do surgical work that is not acknowledged by the physicians. Ultimately, the physician-nurse boundary can be a negotiated order that allows for flexibility and collaboration as well as the maintenance of boundaries. 47 Beyond the social boundaries erected amongst professional groups, additional boundaries present in the physical environment of healthcare buildings contribute to the siloing of the professions. This physical design affects the teamwork accomplished among healthcare teams. 48 , 49 Having shared clinical areas such as physician-nursing workspaces can promote interactions and therefore communication between physicians and nurses, 50 while having spaces set aside for informal team meetings, such as shared lounges, can additionally break down the barriers to collaboration among team members from differing backgrounds. 51 When workspaces and lounges are physically separated, the opportunity to overcome the metaphorical separation between professions is lost. While these studies were done in the context of inpatient ward-based care and emergency rooms, anecdotally, the same patterns of divided spaces and physical barriers to interaction occur throughout perioperative spaces, including ORs and recovery rooms. Connecting Fault Lines and Psychological Safety We posit that in a team-based morbidity and mortality conference setting, strong dormant fault lines present in the interprofessional team can easily emerge during the discussion of an emotionally charged case with a poor outcome. While the diversity of professional perspectives involved in team-based morbidity and mortality conferences is a strength of that format for discussing adverse events, 7 if these interprofessional groups break down along professional lines there can be significant threats to psychological safety and resulting hazards beyond the conference. Fault lines along professional identity boundaries threaten group cohesion. Within these subgroups, members share a similar educational experience, understanding of their role in the team, and understanding of the work they do. The history, individual identity development, and organizational culture encourages the learning of behaviors to distinguish themselves as members of an in-group, partially by othering the out-group through assumptions of certain stereotypes. This strong professional subgroup identity provides a sense of comfort within these subgroups, but that strong sense of comfort in the subgroup can undermine team members’ sense of membership in the larger interprofessional team. This can lead to an increased psychological safety within the subgroup, while undermining the psychological safety of the larger interprofessional group. See Figure 1 for a graphical depiction of these relationships. As aforementioned, team psychological safety is the trust among team members that there will be no negative consequences to speaking up, voicing their opinion, or reporting a concern. 10 If subgroups composed of different professional identities embrace stereotypes and negative assumptions, this will quickly lead to negative consequences for speaking up, increase self-censoring, and yield intragroup conflict, all of which research on team diversity has shown to occur. 52 Broadly speaking, interprofessional groups, such as in team-based morbidity and mortality conferences, encompass two distinct types of diversity: variety and disparity. 9 Variety diversity refers to categorical differences in team members, such as differences in expertise or educational background, while disparity diversity refers to differences in hierarchical power. Diversity has mixed impacts on team performance, with some studies showing increased creativity and innovation while others suggest increased conflict and poor team outcomes. 52 Team performance is enhanced when the benefits of variety diversity are maximized and the hazards of disparity diversity mitigated. 9 This raises the challenge of how to overcome the risk of these fault lines and strong professional identity-driven subgroups to the overall team psychological safety. RECOMMENDATIONS FOR TEAM-BASED MORBIDITY AND MORTALITY CONFERENCES Team-based morbidity and mortality conferences are precious opportunities for team learning, but maintaining psychological safety in the face of professional silos remains uniquely challenging. Team-based morbidity and mortality conferences bring together multiple groups with strong professional identities, such as physicians, nurses, and allied health professionals. The stress of an adverse event and the risk of accusations from one professional group to another create the potential for breakdown of the team into subgroups along professional identity fault lines, undermining the psychological safety of the conference team and minimizing its ability to learn, as outlined above. While there is little research on overcoming these silos in team-based morbidity and mortality conferences, there is a body of applicable evidence from interprofessional education, managing team diversity, and the healthcare simulation literature that might be adapted to creating more successful team-based morbidity and mortality conferences. Table 1 provides a list of theoretical recommendations and practical strategies for their implementation in a team-based conference with ties back to the elements of the conceptual framework. 48 , 53 – 58 More work remains in designing and testing these ideas in team-based morbidity and mortality conferences. Table 1: Potential Recommendations for Maintaining Psychological Safety at Team Based Morbidity and Mortality Conferences (TBMMCs) Framework Component Theoretical Recommendation Strategies for TBMMCs Historical profession development Encourage dual identities in attendees, as both members of their profession and the larger care team 53 Emphasize the differing perspectives brought by each subgroup to the conference and how each contributes to make the larger team stronger Individual professional identity development Promote individual open mindedness 54 Use strong conference moderators who can set the tone of respecting and engaging with the contributions of all conference attendees Avoid the assumption that others on the team share the same background knowledge and experience Minimize the use of jargon, especially words and assumptions that might exclude other professional groups on the team 55 Organizational boundary formation and maintenance Flatten hierarchies Encourage use of first names as opposed to titles in TBMMCs discussions 56 Extend explicit invitations to participate in the discussion to voices that are typically under-represented 56 Acknowledge the expertise brought by different team members 56 Recognize and regain team psychological safety when lost Maintain a positive atmosphere, validate the team members’ experiences, and explicitly address the dynamic that breached team psychological safety 57 Create a physical infrastructure to promote teamwork and collaboration Encourage interprofessional intermingling in the seating arrangements during the TBMMCs to encourage interprofessional interactions 48 Use structure to increase effectiveness of team learning 58 Create a standardized structure for TBMMCs to promote a shared understanding among the team of what to expect throughout the conference Target the discussion among the team at the team level 58 Guide discussion by the group to focus on the teamwork of the case as opposed to singling out behaviors of individuals, which can feel more like a targeted attack in this setting Open in a new tab CONCLUSION Team-based morbidity and mortality rounds are a potentially powerful tool to bring together a diverse team of clinicians to learn together from adverse events. Psychological safety in these conferences is critical to enabling team learning and therefore improved team performance. We propose a framework linking professional silos to impaired team psychological safety. These professional silos arise from the historical context of health care, the role of the organization in creating boundaries among the professions, and the path for each individual developing their professional identity. Using this framework, we can postulate strategies for improving the ability of teams to learn from rich team-based morbidity and mortality conferences. Future research is needed to empirically test this framework and the recommendations that follow from it. Specifically, team-based morbidity and mortality conference protocols could be created guided by this framework to optimize psychological safety. Rigorous implementation science principles would be needed to ensure a smooth implementation and generalizability of the protocols. Finally, team-level outcomes and patient-level outcomes should be explored to empirically support this framework and the impact of team-based morbidity and mortality conferences on the care of our patients. Acknowledgements: This work was supported by NIH/NCATS project #K12TR004908. Submission of the accepted manuscript to the PubMed Central (PMC) repository to make the work freely accessible online is required by NIH policy. The Scholar supported by the project, Dr. Samost-Williams, and Corresponding Author, Dr. Campos, request that the publisher make the deposit to PMC. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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