Creating Psychological Safety in the Learning Environment: Straightforward Answers to a Longstanding Challenge

Abstract

Purpose: Psychological safety refers to the perception that a learning environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of negative consequences. 1,2 The 3 core components of psychological safety are: set expectations, invite participation, and respond productively. The presence of psychological safety has also been tied to wellness, 1 retention, 2 and inclusiveness. 3 The medical education literature suggests that psychological safety frees learners from image management, enables learners to concentrate on the current tasks, and reduces fear of asking questions. 4 However, national data demonstrate that many of the fundamental components of psychological safety are lacking in our current learning environments. 5 While we have evidence for those behaviors that create psychological safety in traditional work environments, these behaviors have not been well elucidated for clinical undergraduate medical education settings. Therefore, we sought to understand how psychological safety is created, destroyed, and rescued in the clinical learning environment. Methods: This was a multicenter, cross-sectional qualitative study of fourth-year medical students from 2 institutions using semistructured interviews. In keeping with a theoretical and purposeful sample approach to recruitment, all fourth-year medical students were invited to participate in an 1-hour interview via zoom. Verbatim transcripts of the interviews underwent constant comparison and iterative data reduction and analysis by all 3 authors. Analysis continued beyond thematic sufficiency and counter examples were purposefully explored. Results: Twenty students participated in 1-hour interviews. Students described key themes related to the creation, destruction, and restoration of psychological safety in the clinical learning environment. They described clear expectations, self-efficacy, team engagement, autonomy, and frequent feedback as important to establishing a psychologically safe learning environment. They reported educator disinterest in students, dismissal of questions, lack of autonomy, and unclear expectations as destructive of a psychologically safe learning environment. Most students were unable to describe a time psychological safety was restored if lost. Early impressions of individual learning environments and establishment as “safe” or “unsafe” were durable and rarely changed. Behaviors such as acknowledging and apologizing for team member misbehavior were among the few that did improve the learning experience once safety was lost. Discussion: Our findings demonstrate that while it is difficult to repair an atmosphere that is psychologically unsafe, there are several simple actions that can be put into motion early on to ensure the learning environment is safe and remains so. Early and intentional demonstrations of investment in learners and their growth are critically important to build psychological safety. Creating safe and inclusive learning environments for students is a high priority with inherent merit, and it will also likely create progress toward larger goals in academic medicine such as fostering and supporting workforce diversity. Future research should investigate whether faculty development targeted to build specific skills and observable behaviors can improve the learning environment for students and other trainees and whether these changes ultimately impact larger issues of importance such as patient care, workforce diversity, and physician and trainee well-being. Significance: Building a psychologically safe environment has been shown to be foundational to supporting diversity, inclusion, and well-being of employees across business and general educational fields. If we fail to identify behaviors that promote psychological safety in medical education, we risk these domains for our learners. This study is the first to identify behaviors that promote safety in clinical undergraduate medical education settings specifically and offers themes for future research and interventions to construct psychologically safe clinical teaching environments.

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