Psychological safety (PS) is the perception that an environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of being shamed, blamed, or ignored.1 Psychological safety was originally coined by Amy Edmonson, an organizational behavioral psychologist who defined the term based, in part, on studies of medical error reporting in healthcare teams, noting that people were more likely to talk about mistakes, and find new ways to catch them, when the team leadership and interpersonal climate of the team supported candor, humility, learning from error, and an appreciation of input from everyone on the team.1 Psychological safety is considered a “team-level” phenomenon, meaning it is a quality of a defined team, rather than an entire institution, and can vary significantly from team to team within a given institution.1

HOW PSYCHOLOGICAL SAFETY IS CREATED

Leaders of teams, be they care teams, educational programs (clerkships, residency programs), or departments, play an important role in fostering PS for the groups that they manage. Thus, while PS is an interpersonal and team-level phenomenon, its presence or absence can be supported or hindered by the nested institutional structures that surround and support a given team unit. To create PS, Dr. Edmonson defines three key leadership tasks: (1) set the stage (frame the work and emphasize purpose), (2) invite participation (practice inquiry, demonstrate humility, and set up structures and processes for input), and (3) respond productively (express appreciation, destigmatize failure, and sanction violations of team culture).1 Together, these actions can generate shared expectations and meaning, create confidence that voice is welcome, and emphasize continuous learning. Team leader behaviors that impair PS tend to fall on the opposite side of the spectrum for each of these leadership tasks, such as having an authoritative leadership style and associated rigid hierarchy, assigning blame for errors, using fear or shame as a motivating force, and poor communication between team members.1

BENEFITS OF PSYCHOLOGICAL SAFETY

Since its inception, PS has been studied in a wide variety of work settings, with clear benefits.1 The presence of PS in work environments both inside and outside of medicine has been shown to boost team member engagement, job satisfaction, productivity, “team effectiveness” (variably defined by industry), and reduce turnover.2,4,5,6,7,8,8 Outside of medicine, team leader inclusivity (defined as words and deeds by a leader that indicate an appreciation for others’ contributions), and team member perception that their voices are genuinely valued, has also been associated with the presence of PS.9 Further, PS has been described as a mediator of whether employees believe they can bring their “true selves” to work in demographically diverse workplaces, without fear of being judged as inferior or incompetent.10 This relationship was found to be stronger for racial minority team members compared to White team members, suggesting that creating PS within an organization may have larger and more meaningful impacts for minority team members than majority team members.10 In medical education, studies suggest that PS frees learners from constant self-monitoring, allows them to be engaged and present in the moment, and reduces fear of asking questions.11 Psychological safety in feedback conversations fosters a willingness to disclose gaps in knowledge,12 and may also increase receptivity, credibility, and acceptance of feedback.13 Based on data from both medicine and organizational psychology, fostering PS in our clinical learning environments would be expected to bring about parallel benefits for trainees: allowing them to focus on learning, build an improved sense of belonging and engagement, and foster sustained diversity through genuinely inclusive environments.14,16,16

ABSENCE OF PSYCHOLOGICAL SAFETY

Teams that lack PS are characterized by fear, silence, and a high degree of self-monitoring and image management to avoid negative consequences.1 A lack of PS in medical students has been also associated with withdrawal, trainee disengagement, and large extraneous cognitive burdens related to image and evaluation, at the expense of learning.17

In medication education, threats to PS can be described on a spectrum, with feelings of competition with peers,11 apathy, or exclusion from team members18 on the mild end, an assessment atmosphere favoring performance over learning in the middle,19 and more obvious examples of mistreatment including racism, microaggressions, and humiliation on the severe end.20,22,23,23 Despite attention to mistreatment of trainees since at least 1990,21 significant improvements to the learning environment have been difficult to achieve. Twenty years later, the 2010–2011 Medical Student Perceptions of the Learning Environment Survey (MSLES) still demonstrated negative experiences for students, and progressively worsening perceptions of the learning environment as medical school progresses, with the most precipitous drop occurring in year three.24 More recently, the 2020 AAMC Medical Student Graduation Questionnaire revealed that 40% of learners have been “publicly embarrassed” at least once in medical school, most commonly by clerkship faculty or residents/interns. Following an event, 76% of the students did not report the incident, most commonly citing fear of reprisal or a belief that nothing would be done.25 Unsafe learning environments impact residents as well as students. In 2021, the ACGME Clinical Learning Environment Review (using data from 2017) reported that about half of trainees had worked with an attending who made them feel uncomfortable asking for help, most often related to potential resistance from supervising physicians or fear of retaliation.26 Together, these data demonstrate that the behaviors that threaten safety for trainees are not isolated events, but cultural norms, and that many medical schools and residency programs continue to struggle to create environments that are safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of being shamed, blamed, or ignored.

BUILDING PSYCHOLOGICAL SAFETY

Building PS in our clinical learning environments will require significant culture change. Educators and institutional leaders will have to lead change that redefines the norms of the current culture of medical education and the clinical learning environment. This paper describes the current barriers to PS in medical education, and sets out an agenda for educational administrations and institutional leaders to foster structural and cultural change that can create PS in our clinical learning environments and support the inclusion and success of all medical trainees (Table 1).

Table 1 Specific Recommendations to Support Psychological Safety in Medical Education
Full size table

Studies have attempted to define attributes of an environment that foster PS in medical education specifically and have developed several key themes.11,12 In the following section, we will describe key facilitators of PS in medical education, illustrate how the existing structure of medical education poses barriers to achieving them, provide evidence to support a proposed change, and describe anticipated outcomes.

Continuity and Consistency of Team Members, and the Presence of High-Quality Interpersonal Relationships

Continuity with team members, interpersonal connection, and a sense that team members care for each other as people is one facilitator of PS for trainees.11 Together, these features free learners from fear of judgment by peers and more senior team members.11

However, the reality of medical education is a constant shifting of team members, with a goal of frequent rotation for broad exposure in a short period of time, which is in direct opposition to continuity. This is a particularly challenging phenomenon for inpatient care teams, though this type of longitudinal continuity has already been accomplished in some outpatient settings, and has led to improved student and resident perception of the clinical learning environment.27,29,30,30

Prioritizing continuity between attendings, residents, and students when building schedules for clinical rotations for UME and GME trainees is one opportunity to promote PS. In addition to reducing fear of judgment, creating more opportunities for relationship building would be expected to have additional outcomes of interest for medical education, including reducing bias,31,32 creating a foundation for equitable assessment33 and promoting trainee beliefs that supervisors are invested in their development.28,34

Absence of Social Positioning and Hierarchy

Aspects of leadership style play a powerful role in determining the safety of a work environment.8,35,36 Leaders who emphasize teamwork, request input from all team members, and demonstrate an appreciation of individual contributions, rather than treating team members as though they hold discrete and disparate statuses in a hierarchy, are more likely to build psychologically safe learning climates.1,11

Unfortunately, the well-ingrained hierarchy of academic medicine poses problems for the desired absence of social positioning. Larger-perceived power differentials are highly correlated with lower PS of team members in medicine,37,38 and studies show that students are often hyperaware of hierarchical structures within their learning and patient care teams, and spend a significant amount cognitive energy trying to navigate them.39 Many of our commonly used teaching methods, like the Socratic method, have also been highlighted as hierarchy-reinforcing and often humiliating practices, which impair PS in the clinical learning environment.40,41 These cultural traditions in medical education can serve an important purpose for trainee support, supervision, and patient safety, but when reinforced in ways that hinder participation in less experienced team members, can reduce the PS within a team.

Reconceptualizing the role of hierarchy and reducing power differentials in medical education will require broader culture change that will need to start from the institutional level.42,44,44 Individual faculty can be taught skills to promote PS, but if the institution does not reward or support these behaviors as cultural values and norms, they are unlikely to lead to broader change. To facilitate culture change, institutional leaders can acknowledge and explicitly call out the role of power dynamics in the learning environment, highlight a common mission of learning, invite improvement perspectives from all levels of the continuum of medical education, and develop institutional practices that reward speaking up and asking questions, even when doing so may mean challenging the traditional hierarchical structures.45 Just as we will need to reward these behaviors, we will also need ways to sanction behaviors that violate these new organizational norms and expectations, such as removing physicians from teaching settings who are repeatedly reported by students as demonstrating disrespectful, belittling, or rude behaviors. To respond productively (Edmondon’s leadership task #3), educational leadership should communicate back to trainees what sanctions have occurred to restore and maintain the safety of the learning environment. This type of culture change has already been successfully implemented throughout medical systems for interprofessional collaboration and patient safety,43,44,46,47 but has not yet been applied to the power structures within medical education.

While we target larger culture change, we can work at the individual level within our current organizational and educational structures. Specifically, we can teach faculty how to operationalize the three leadership tasks through core interpersonal skills such as emphasizing learning as a core value, setting expectations, inviting input from all levels of trainee, modeling humility by acknowledging when they have gaps in their own knowledge, and responding respectfully to questions or concerns raised by trainees.1,12,17,45 These specific behaviors are well-documented leadership methods for creating PS.1 and in medical education specifically have been shown to increase trainee engagement and the belief that their role on the team is important, and that their input is valued.38,39,46

Creating well-defined and easy-to-access lines of communication between traditionally higher- and lower-ranking team members is another way to mitigate hierarchical traditions and invite participation (leadership task #2).1 This can be within a single patient care team (inviting input at all levels from the group when designing patient care plans, setting regular check-ins between teaching physicians and trainees working together on a team), establishing regular check-ins between trainees and medical school or residency program leadership, or through establishing reporting processes between trainees and organizational leadership. These lines of communication provide a clearly defined way for when and how trainees can communicate with higher-ranking team members and institutional leaders, demonstrate to lower-ranking team members that their input is wanted, and allow lower-ranking team members to contribute input or voice concerns.1

Learner-Driven and Flexible Learning Agenda

Power structures are also apparent in how learning objectives are designed and progress toward achievement is measured. Clerkship or residency program learning objectives and metrics of success are often designed by academic faculty, and trainees may not be included in developing or co-producing personal objectives and learning goals, or defining the metrics of success. This exclusion from the learning agenda is a missed opportunity to foster inclusion48 and demonstrate our investment in their individual growth, learning needs, and professional development. Rigid learning objectives can also have the unintended consequence of causing learners to restrict their learning to what matters for the purposes of assessment, rather than exploring their curiosity.11 A co-production model for medical education would de-emphasize the educator as the sole expert, and refocus the emphasis to be on the teacher-learner partnership, acknowledging the expertise of both parties, and working together for richer learning, growth, and continuous improvement.49,50 As we invite trainee participation and input into our learning objectives and agendas, we can also likely expect to create more opportunities for trainees to flourish through tailored learning, more perceived relevance to trainees, and increased trainee engagement.49,51

Lack of Formal Assessment

An absence of formal assessment is another feature highlighted as promoting PS in medical education.11 Medical trainees are continually assessed, and there are only rare instances where formative feedback is uncoupled from summative evaluation.52 With constant evaluation, admitting a knowledge gap can be a particularly uncomfortable experience for trainees.53

Many of our existing evaluation structures are problematic for creating PS, as they typically fail to reward growth, learning, and contribution (leadership task #3), in favor of performance.53 First, evaluation is often focused on identifying and remedying deficiencies, rather than acknowledging effort and reinforcing individual strengths and contributions. Additionally, assessment forms often use rubrics that lend to trainee comparisons as a means of determining progress, rather than providing clear criteria for whether a trainee has met specific criteria for readiness to practice,33,54 creating significant peer-to-peer competition.11 Together, these structures of assessment pose barriers to PS by making it particularly risky for learners to speak up, disclose a knowledge gap, or ask a question, as there is constant concern that these actions may impact evaluation going forward.

Educators could reduce the stress associated with constant formal assessment by creating more opportunities for low-stakes assessment, reframing assessment as formative feedback for professional development, and implementing assessment criteria that reward trainee growth and individual contributions to care, and provide clear criteria for readiness to practice.33,53,54

Time for Debriefing as a Group

Debriefing as a group is a well-established learning strategy in medicine to foster reflection, support trainees through distressing events, and offer strategies for improvement or change going forward.55,57,58,59,59 Debriefing to facilitate PS is a best practice in simulation settings,60,61 but evidence suggests that debriefing occurs infrequently in the true clinical environment,62,64,64 with inadequate time, training, and “cultural constraints” (disinterested team members or fear or personal criticism during debriefs) as often-cited barriers.64 Providing faculty with skills to lead debriefing exercises, pre-designating the type of events that merit debriefing as a team, and protecting time for debriefing in the clinical learning environment would be expected to generate opportunities for trainees to debrief more frequently,63 safely learn from mistakes, obtain non-judgmental feedback for growth, and facilitate sharing of multiple perspectives within a team.55 As previously noted, for this type of change to be successful, institutional culture must also support safe disclosure of errors and learning needs for both faculty and trainees, and refrain from blame and shame in debriefing.

The above are the immediately visible changes to our learning environments, but are not an exhaustive list of potentially meaningful interventions. Together, these changes can help us to communicate the value of every team member, strengthen trainee engagement, foster belonging, and free trainees to focus on their core tasks of learning and growth. Involving learners in the development and implementation of change will further encourage sustainable trainee-teacher partnerships, with the shared goal of building PS.

THE WORK AHEAD

Psychologically safe learning environments that are inclusive, foster engagement, and allow trainees to safely prioritize learning will not evolve through “business as usual” in medicine and medical education. Cultural changes to address the traditions of hierarchy and humiliation in our learning environments need to be replaced with practices that invite participation and honor the work and contributions of team members at all levels. Structural changes to optimize continuity, foster high-quality relationships, allow for reflection, and separate learning from evaluation are critical to ensuring the success of these efforts over the long term. Interpersonal connection and relationship have been repeatedly identified as a way to reduce bias and foster belonging and well-being for trainees, and should be the backbone to our teaching and learning environments.65,67,67 Inclusion does not always follow from diversity alone. A deliberate focus on trainee experience in the learning environment and PS in our teams are a critical first step to engaging our trainees, supporting their growth and learning, and preparing them for success. Our proposed agenda for structural and cultural change to build PS is the first step down the long road ahead.