by Scott Hayes M.ISRM
My colleague Musaab Fagiri recently wrote about hearing the raw sound of a crisis unfolding through the lyrics of a rap track and asking a simple question, “What are you going to do when the shit hits the fan?”. But one paragraph from his article stuck with me:
“By the time the problem becomes visible, people are often more focused on defending territory, contracts, reputations, or decisions made months earlier than solving the actual threat in front of them and that is how organizations come apart during a crisis. Not always because they lack resources. Often because they lack honesty, trust, and the ability to move together when the situation stops being theoretical.”
Musaab’s paragraph exposes what I think is a more pervasive problem lurking underneath, and it’s harder to fix for any risk professional, even once you know it’s there.
The Instinct Is Not the Aberration
Anyone who has sat through an organizational crisis knows the shape of it: the crisis is still ongoing, or freshly concluded, and the conversation quickly turns to who was told what and when. People are quick to point out whose recommendation went unheeded or unactioned, and rest assured, they are all “bringing receipts”.
It’s easy to attribute this to a character problem specific to the people in the room but it’s more likely just human nature and psychology combining into a self-preserving feedback loop. It’s self-serving attributional bias, claiming credit for good outcomes and attributing bad ones elsewhere, and it’s among the best-documented effects in social psychology (Mezulis et al., Psychological Bulletin, 2004) though its strength varies considerably across cultures.
The people defending their positions aren’t doing something unusual, they’re reverting to the default position under the conditions that make this default position the strongest: visible failure, personal exposure, and an audience. Unfortunately for everyone, there is some evidence this reversion to the default might be contagious. Fast and Tiedens (Journal of Experimental Social Psychology, 2010) found that people exposed to someone blaming others externally would themselves likely go on to also blame others for their own unrelated failures. It is worth flagging this is a single paper without independent replication, but I think many of us have seen this behaviour in action, so while it is certainly a plausible pattern, it should be taken more anecdotally rather than empirically.
The Failure Started as Silence
The blame conversation at the beginning of a crisis, or in the review of it afterward, is likely to be the visible end of something that was there long before the crisis arrived; the concerns somebody had but wasn’t secure enough to raise.
Milliken, Morrison and Hewlin (Journal of Management Studies, 2003) interviewed employees about what they withheld from the managers above them, and the reasons cluster tightly: the fear of being labelled negatively, fear of damaging a relationship, and a belief that speaking up would change nothing. Hao and colleagues (Journal of Business and Psychology, 2022) added quantitative weight, meta-analyzing 168 samples and more than 63,000 people, and found silence is not merely the absence of a voice, but rather a distinct behaviour with its own drivers, with psychological safety among them.
This holds even where the stakes may be unambiguous. Schwappach and Gehring (PLoS ONE, 2014) found that between 45 and 81 percent of clinicians said they would point out a colleague’s missed hand disinfection, depending on the circumstances, with anticipated discomfort and decision difficulty among the significant predictors. The fact that concerns go unraised beforehand is well evidenced and comports with what we see in our everyday lives. That crisis-time blame occurs downstream of that silence, however, is an inference rather than measurement. While I was unable to find a study following one organization through both, I think many of us have seen this play out in real time, so the gap between the two is small.
Nobody Needs to Be Chastised
“Chastised” implies an event where someone spoke up, got slapped down, and everybody inside and outside the room learned. That happens. But it is not the main mechanism, and the alternative is the finding I’m more interested in.
Detert and Edmondson (Academy of Management Journal, 2011) call these ‘implicit voice theories’, rules about when speaking up is dangerous and which operate below conscious awareness, are shaped long before the current job, and suppress the opinion even where the supervisor is genuinely open to hearing it. In both the corporate and public sector domains, we teach it on purpose by discouraging employees from raising a problem unless they arrive with evidence and a solution. It might as well be a billboard hanging in every manager’s hall and office, “Don’t bring me problems, bring me solutions.”
But consider what this filter actually selects for, which is a fully evidenced issue arriving with a remedy attached. That isn’t an early warning, it’s a status update or a fully formed option to consider. Early signals are partial, not fully thought out, and unresolved by definition. It’s a dependency that doesn’t seem quite right, a temporary workaround that quietly became “the process”, or that nagging alert in your head that you can’t quite put your finger on, at least not yet. The person recognizing the early signal cannot meet the standard for voicing it, so it goes unsaid, and most would think of this as being professional rather than being silent.
The problem is that this filter is not neutral. It bites hardest where intervention would be at its cheapest, but the voicing of the information only occurs once the problem has already happened.
What Safety Buys, and What It Doesn’t
The term has been stretched well past its original meaning. Psychological safety should not mean comfort, nor should it mean lowered standards. Psychological safety is about the cost of speaking: “Will I be embarrassed, sidelined, or marked as difficult if I raise this?” Feeling heard is about the consequence of having spoken: “Did it go anywhere? Was it acknowledged and/or acted upon?” A great illustration of this is Amy Edmondson’s hospital study (Journal of Applied Behavioral Science, 1996), where nursing units with the best climate, and the most respected leaders, still recorded the highest medication error rates. This wasn’t because they made more mistakes but because they felt able to report them.
Psychological safety isn’t a beneficial factor by itself. Independently it creates little value. Rather, it is the freedom to speak early, set within the context of your whole organization’s culture that produces the benefit. A large longitudinal test found psychological safety alone did not improve performance (Higgins et al., Academy of Management Discoveries, 2022), where the strongest-performing conditions resulted from relatively low safety environments but with high accountability. It would be more appropriate to view safety as an accelerant on accountability, rather than a good in itself.
I don’t think that undermines the argument, I think it sharpens it. Safety without accountability does nothing more than produce a comfortable team that escalates nothing of substance. It’s running in place. A crisis requires people who will say the uncomfortable thing out loud and then own having said it.
Your Culture Taught the Silence
Bransby, Kerrissey and Edmondson (Academy of Management Discoveries, 2025) tracked more than 10,000 healthcare workers over time. Newcomers reported higher psychological safety than their tenured colleagues and then appeared to lose it the longer they stayed. In other words, people didn’t necessarily arrive guarded…you might have taught it to them. Which is why “my door is always open” often doesn’t work for this type of feedback. Not because the executive is insincere, but because the rule being applied was not written by them. You are not persuading someone that you personally are safe to approach; you are working against a default they walked in with, and that your organization may be tacitly reinforcing.
I don’t know of a study that demonstrated psychological safety can’t be built during a crisis, as no one seems to have tested it. What we do know is that the beliefs which suppress your employees’ voices came well before the current situation, that a safety climate erodes without maintenance, and that trust is slower to build than to lose (Slovic, Risk Analysis, 1993). A crisis supplies exactly the conditions under which organizations narrow their information processing and revert to well-learned responses.
What to Do About It
None of this is meant to be a culture program lecture. As I outlined in a previous ISRM article, executives already face a persistent problem around decision fatigue and present bias in their everyday work, and coordinating a “whole of organization” approach is likely a bridge too far for many organizations. Instead, I hope the following are some ideas to put in your toolbox to help your team or organization be better equipped in the future.
Legitimize the doubt structurally. Kahneman devotes part of “Thinking, Fast and Slow” (2011) to Gary Klein’s idea of a “premortem”. Assume the plan you are considering was launched, and a year later it failed outright, then look for the reasons why. This exercise specifically demands unevidenced and unsolved speculation and it turns dissent into a specific task, rather than a personal risk. It disarms the implicit voice theories (bring solutions, not problems) since the initiative hasn’t failed yet, so no one is actually to blame for anything. The main virtue of the premortem is that it legitimizes doubts.
Collect positions before you discuss them. In Noise (Kahneman, Sibony and Sunstein, 2021), a core element of decision hygiene is gathering judgements independently before group discussion, because deliberating groups amplify noise through cascades. In practice, get written or verbal positions before the meeting. The first confident voice should not set the frame for everyone else.
Measure whether people feel heard, not just safe. They are different things. A team can be perfectly safe and still learn that nothing it raises goes anywhere. The silence that follows is indistinguishable from the silence caused by fear. Kerrissey and colleagues (Health Care Management Review, 2022) surveyed emergency department staff during COVID and found “feeling heard” scored lower on average than psychological safety, though that study is cross-sectional and confined to two ER departments in a single health system. Measure only safety and you are measuring the half that flatters you. The gap between them is the more useful number. Unlike culture, it points at something you can build: a channel that tells people what became of the concern they raised.
What we can do is build the structures that make dissent an expected input rather than an act of courage, and it’s more important to build them while nothing is on fire. The crisis does not create the culture, it only illuminates the culture you had before it started.
References
A note on method and limitations: The argument and the writing are mine. AI was used for research support and editorial review. Several of the studies cited sit behind paywalls, and where I could not obtain the full text I have relied on the published abstract. Readers who want to go further should go to the sources directly. This is a practioner article informed by research rather than a formal literature review and should be read on those terms.
Bransby, D. P., Kerrissey, M. J., & Edmondson, A. C. (2025). Paradise lost (and restored?): A study of psychological safety over time. Academy of Management Discoveries, 11(3), 403-422
Detert, J. R., & Edmondson, A. C. (2011). Implicit voice theories: Taken-for-granted rules of self-censorship at work. Academy of Management Journal, 54(3), 461–488.
Edmondson, A. C. (1996). Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error. Journal of Applied Behavioral Science, 32(1), 5–28.
Fast, N. J., & Tiedens, L. Z. (2010). Blame contagion: The automatic transmission of self-serving attributions. Journal of Experimental Social Psychology, 46(1), 97–106.
Hao, L., Zhu, H., He, Y., Duan, J., Zhao, T., & Meng, H. (2022). When is silence golden? A meta-analysis on antecedents and outcomes of employee silence. Journal of Business and Psychology, 37(5), 1039–1063.
Higgins, M., Dobrow, S. R., Weiner, J. M., & Liu, H. (2022). When is psychological safety helpful in organizations? A longitudinal study. Academy of Management Discoveries, 8(1).
Kahneman, D. (2011). Thinking, Fast and Slow. Farrar, Straus and Giroux.
Kahneman, D., Sibony, O., & Sunstein, C. R. (2021). Noise: A Flaw in Human Judgment. Little, Brown Spark.
Kerrissey, M. J., Hayirli, T. C., Bhanja, A., Stark, N., Hardy, J., & Peabody, C. R. (2022). How psychological safety and feeling heard relate to burnout and adaptation amid uncertainty. Health Care Management Review, 47(4), 308–316.
Mezulis, A. H., Abramson, L. Y., Hyde, J. S., & Hankin, B. L. (2004). Is there a universal positivity bias in attributions? A meta-analytic review of individual, developmental, and cultural differences in the self-serving attributional bias. Psychological Bulletin, 130(5), 711–747.
Milliken, F. J., Morrison, E. W., & Hewlin, P. F. (2003). An exploratory study of employee silence: Issues that employees don’t communicate upward and why. Journal of Management Studies, 40(6), 1453–1476.
Schwappach, D. L. B., & Gehring, K. (2014). Silence that can be dangerous: A vignette study to assess healthcare professionals’ likelihood of speaking up about safety concerns. PLoS ONE, 9(8), e104720.
Slovic, P. (1993). Perceived risk, trust, and democracy. Risk Analysis, 13(6), 675–682.