Bridging the Gap Between Educator and Learner: The Role of Psychological Safety in Medical Education

Psychological safety is the perception that a working environment is safe for team members to express a concern, ask a question, or acknowledge a mistake without fear of humiliation, retaliation, blame, or being ignored.¹  The concept of psychological safety was largely developed in the organizational and patient safety fields, with demonstrated benefits of improved learning, creativity in problem solving, and productivity.¹  Establishing psychological safety in medical education has been shown to (1) free learners from being constantly self-conscious about image and competence, (2) enable them to be present in the learning moment and concentrate on the task at hand, and (3) reduce fear of asking questions.^2,3  Without psychological safety in clinical learning environments, students focus on evaluation and grading at the expense of growth and developing new skills^3–6  (Fig 1).

The team structures and cultural traditions inherent in medical education present many barriers to building an environment of psychological safety. Psychological safety is facilitated by the following factors: (1) high-quality relationships among team members at all levels of training, (2) an emphasis on interdependence and teamwork, and (3) leaders who invite, listen to, and respond respectfully to perspectives and input from traditionally lower-ranking team members.¹  The strong tradition of hierarchy and power differentials in medicine can interfere with building a team mentality and discourage less-experienced and less-knowledgeable members from speaking up.^2–5  Medical teams also manage high workloads, are limited on time, and rarely have ongoing continuity among students, residents, and educators, making it difficult to build high-quality relationships. Despite these barriers, clinician-educators who practice the leadership tasks described below can help to shift the learning environment for medical students toward psychological safety.

To support a psychologically safe learning environment, clinician-educators can use the following 3 core leadership tasks: (1) setting the stage, (2) inviting participation, and (3) responding productively.¹  These 3 tasks build an environment that emphasizes learning and reduces anxiety about failure and performance.^1,7,8  Actions in line with these leadership tasks can help to narrow the power distance between educators and students through the sharing of roles traditionally held exclusively by higher-ranking team members, such as defining the learning agenda, guiding patient care, and developing plans for change. Table 1 describes the 3 leadership tasks with case examples, guiding principles, and suggested language to facilitate their application in practice.

The task of setting the stage commences when a new student first arrives at the learning environment. Clinician-educators can “frame the work” by setting expectations about student roles and responsibilities within the health care team. Educators who set clear expectations reduce student anxiety about performance and feedback and help learners to focus their time and effort.^7,9  To help students understand the teaching intent behind future interactions, educators can provide a framework that states overall goals, stresses the importance of teamwork, and describes one’s teaching style. This framework may be of particular importance because some teaching styles may inadvertently reinforce power structures and widen gaps between educators and learners.¹⁰  Additionally, educators should consider the goals of the learners themselves, as this demonstrates investment in students’ professional development, provides purpose and a scaffolding for teaching and feedback, and allows students to contribute to the learning agenda and modify their own learning goals.¹¹  Setting the stage lays the foundation for restructuring rigid educational hierarchies by stating directly to students that clinician-educators are focused on their learning and invested in their success.

The task of inviting participation can help students to speak up, inquire, and engage with the team. Inviting participation in medical education allows students to become an active part of the team through their unique contributions to patient care rather than through relying solely on the decision-making of more-senior team members. By modeling humility and demonstrating a mindset of lifelong learning, educators can signal to students that knowledge gaps are part of the growth process rather than personal failings. Educators can help students to gain confidence and a sense of autonomy by inviting students to offer input into patient care. Asking questions such as, “What would you do here?” helps students to contribute and gives them a sense of belonging. Using open-ended questions rather than questions with a single correct answer can help students to demonstrate what they know and allow educators to build on the students’ existing knowledge rather than highlight gaps. Educators who invite participation reduce the power distance between themselves and students by making the learning process toward competency more transparent and accessible, demonstrating that all team members are valued and make unique contributions, and providing students meaningful roles in patient care.

The leadership task of responding productively when students make mistakes is where educators can reinforce the early message to students about a learning-centered environment. Educators can do this by expressing appreciation for students, destigmatizing “failure,” and offering future-oriented feedback. Acknowledging and thanking students for tasks done well, offering specific and personalized coaching toward defined learning goals, and providing feedback that is oriented toward learning and actionable changes can help highlight student accomplishments and contributions and reward growth over performance. In so doing, educators highlight team learning and limit the extent to which students experience embarrassment for their mistakes. This leadership task acknowledges the work and value of team members at all levels, reinforces student attributes, and provides reassurance that gaps in knowledge or mistakes are viewed as learning opportunities.

Clinician-educators can create environments that promote learning by prioritizing psychological safety. By applying the 3 psychological safety leadership tasks, educators can set clear standards for learners to optimize their success, invite their participation in patient care, allow students to direct their own progress, and emphasize the values of learning and growth. In so doing, educators can reduce the tension between learning and evaluation often experienced by students and diminish the vulnerability associated with learning. As more medical educators practice these leadership tasks, we may make significant positive change in medical education culture to emphasize learning and growth over performance.