Despite decades of attention to the learning environment, national data continue to demonstrate a lack of many of the fundamental components of psychological safety in the current clinical teaching environments, 1–5 and that navigating hierarchical power dynamics in learning teams continues to be a significant distraction from learning. 6
Psychological safety (PS) refers to how safe one feels to take a risk and “be wrong” without being shamed, blamed, or ignored. Amy Edmonson, the first researcher to coin the term psychological safety, defines 3 key leadership tasks that create PS in teams: (1) set the stage (define purpose, set expectations and ground rules, destigmatize failure and risk), (2) invite participation (emphasize that all voices are credible, listen to inputs, demonstrate humility and openness to change), and (3) respond productively (express appreciation, offer help, consider next steps, sanction “group rule” violations). 7 In other sectors, PS has been tied to team effectiveness, creativity, and learning. 8–11 Health professions education literature suggests that PS enables learners to focus on the tasks at hand and disclose knowledge gaps. It also alleviates students’ fear of asking questions and focus on image. 12,13 The presence of PS has also been tied to wellness, 14 retention, 15 and inclusiveness. 8,16 The absence of PS is often associated with rigid hierarchy and power differentials in the workplace. 16–18
There is evidence that leadership behaviors can create PS in traditional work environments. 11 Clinical teachers operate as learning team leaders in patient care and clinical education settings. They model cultural and team norms and have the ultimate influence on the learning environment. However, the lack of well-elucidated clinical teacher leadership behaviors in clinical undergraduate medical education settings limits our ability to translate these concepts into clinical teaching environments. Existing data on PS in medical settings has focused on simulation and prevention of medical errors in interprofessional teams 16,18–21 and reported on the impacts of the presence or absence of PS. 12,13,18 It remains unclear how clinician teacher team leaders can translate these concepts to authentic clinical learning environments to create PS and support learning. To address this gap in the medical education literature, this study sought to explore how leadership behaviors influence PS for medical students in the clinical learning environment for them to maximize their learning.
Method
This was a multicenter, cross-sectional, qualitative, semistructured interview study of fourth-year medical students using both deductive and inductive grounded-theory analysis within a constructivist research paradigm. 22 We chose semistructured interviews to gather unique perspectives in a confidential manner given the sensitive and personal nature of the topic. We conducted this study at the University of Washington School of Medicine and the University of Colorado School of Medicine. In keeping with a theoretical sample approach to recruitment, all fourth-year medical students who had completed their required third-year clerkships but had not yet matched into residency were invited via email to participate in 1-hour interviews via zoom (Zoom Video Communications, Inc., San Jose, California). We wanted to obtain students’ perspectives about their clinical clerkships. We also wanted to capture those perspectives after they had recently rotated in the clerkships that are common to many medical students, to maximize transferability and before when they matched into residency, to minimize the influence of specialty identity in their responses. At the University of Washington, required third-year clerkships include a traditional curriculum of family medicine, internal medicine, obstetrics–gynecology, pediatrics, psychiatry, and surgery or a longitudinal integrated clerkship. At the University of Colorado, these also include a traditional curriculum of family medicine, internal medicine, obstetrics–gynecology, pediatrics, neurology, psychiatry, and surgery. We were cognizant that many social and individual influences would impact the results, and therefore, used a maximum variation sampling approach to guarantee a variation in students’ professional and personal identities. For example, after interviewing our initial list of respondents, we intentionally scheduled further interviews to ensure a diversity of participants and perspectives.
We sent an email invitation to all fourth-year medical students at each institution to participate in a semistructured interview. The lead investigator (A.H.M.) conducted all the 1-hour semistructured interviews with participants between October 2020 and February 2021. Participation was voluntary and compensated with a $50 gift card that could be redeemed at a variety of merchants.
We employed the PS theoretical framework to inform our interview guide to investigate students’ experiences within the clinical learning environment. We asked students to reflect on what impacted the PS of their clinical learning environments. To understand the permanence of a student’s perception of a clinical learning environment, we then invited them to describe their experience with the safety of an environment changing. We then followed up with probing questions to better understand negative, surprising, and salient findings. We audio recorded all sessions, transcribed them using Rev.com, and used Dedoose (SocioCultural Research Consultants, Manhattan Beach, California) to code all transcripts.
We used the PS framework to structure the initial coding scheme. We also used constructivist grounded theory to inductively code the data for elements outside of the PS framework. 23 Verbatim transcripts of the interviews underwent constant comparison and iterative data reduction and analysis by all 3 authors, and occurred while interviews were ongoing, to allow for mutual influence. All 3 authors coded line by line, consolidating initial codes to identify categories. We met regularly to review the resulting categories, our corresponding analytical memos and the overarching themes, and their relationships to one another. During the analysis, we chose to use self-determination theory (SDT) and critical theory as sensitizing concepts, to focus our attention on the learners’ relationship with the clinician teachers, the social power structures within medical education, and the way that team leader and member behaviors impact of them. 24–28 We conducted interviews until reaching a point of thematic sufficiency. After 12 interviews, the developed coding framework seemed to sufficiently represent the data we had gathered from our participants. We continued our analysis beyond thematic sufficiency and purposefully explored counter examples. We conducted another 6 interviews to interrogate our coding framework in relation to a wide variety of lived experiences in our students and to ensure the framework was not institution-specific. We did not find any additional insights requiring changes to the coding structure, suggesting that our sample was sufficient for our study purpose.
Because our qualitative approach was one of active engagement between ourselves and the data, we were intentionally and regularly reflexive about how our identities may have impacted what we were coconstructing among ourselves and the participants. Our research team consisted of 3 clinician teachers, 2 at the University of Washington and 1 at the University of Colorado. None of us had a student–teacher relationship with any of the participants in the context of the required third-year clerkships we explored. One of us identifies as male, 2 as female, and 1 of us is from a historically marginalized group in medicine. Two of us are internal medicine physicians and 1 is an emergency medicine physician. These identities and their intersectionality influenced how we made meaning of the data, enabling us to relate it to our own experiences and intentionally, deeply explore discrepancies in the data. To avoid extraneous bias, we met regularly to reflect on how the intersectionalities of our identities and experiences may have impacted our interpretations.
The Human Subjects Division at the University of Washington deemed the study to be exempt from review.
Results
We interviewed 18 fourth-year medical students, 9 students from each medical school. Participant demographics are presented in Table 1. Twelve students (66%) identified as female, and 5 students (27%) in our sample stated that they identify with a racial or ethnic group that is underrepresented in medicine. 29
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Table 1: Participant Characteristics
Students described several team leader behaviors that impacted medical student PS in clinical teaching environments. Overall, we found that many of the clinical teacher behaviors that students reported could be characterized within 1 of the 3 PS leadership tasks, and also fell within a spectrum of the 3 key domains of SDT: relatedness, autonomy, and competence (Table 2). Figure 1 is a conceptual model of clinical teaching behaviors that impact students’ perception of PS and influence learning behaviors. Results are presented below according to the PS leadership tasks. The PS of the learning environment affected students’ willingness to initiate learning behaviors, impacted their cognitive load, and was associated with student focus on image and assessment. Students diagnosed their environments early on in team formation. First impressions of the environment were formed quickly, were relatively durable, and had a powerful impact on trainee experience.
Table 2: Exemplary Quotes of Clinical Teacher Behavior Within the Self-Determination Theory Framework That Contribute to Students’ Psychological Safety
Figure 1: Conceptual model of clinical teaching behaviors and impacts on psychological safety.
Features of safe learning environments
Student definitions of safety included 3 key themes: (1) the ability to ask questions or express a concern without fear of judgment, public humiliation, or retaliation; (2) a flattened hierarchy; and (3) supportive team member relationships. Simply being acknowledged and addressed by name was frequently cited as a behavior that made students feel that environments were safe and welcoming. Going beyond simple acknowledgment, teams with a flattened power structure, where team leaders and senior residents approached students as equal participants in teamwork and learning, were often described as places where students felt safe.
What does safe mean? I think it’s physical safety, feeling like I can inhabit the space that I’m in physically, but also emotionally. I think it means feeling like I can fully express myself or my thoughts and opinions without fear of retribution, or even if someone disagrees, they would do so in a positive, tactful kind of way. So, safe means I can learn and it’s less performative. Instead of someone kind of judging my ability to do something, it’s more about adding to my ability to already do certain things that I can do, or adding to my ability to do things that I might not be able to do. —Participant 14
Team leader behaviors that promote safety
Many of the behaviors reported by students that helped to establish safety could be classified according to PS’s established leadership tasks.
Setting the stage: Building relatedness and setting them up for success in learning.
Setting the stage arose from students’ descriptions of having clear work expectations and the expected level of mastery. This also included clinical teachers explicitly stating a team focus on learning. A sense of team cohesion as well as collegial and supportive team member relationships helped build a sense of belonging and relatedness.
The very first thing is just someone’s overall presentation of how eager they are to be there, if they have a positive attitude, and that they care about the team that is there if they want to get to know us. I would say someone that kind of sets expectations at the first interaction and talks about what they’re looking for, what they’re not looking for, and is also very much into being able to ask and answer questions. So just basically explicitly stating that it’s a learning experience that they want to foster for everybody involved. —Participant 9
Inviting participation: Encouraging students’ engagement in learning.
This included team leader humility and student autonomy. Leadership humility in the form of acknowledging one’s own gaps in knowledge or seeking input from junior team members was described as a way clinical teachers built safe environments. Humility normalized the learning process and modeled lifelong learning. Students described autonomy as a form of inviting participation in patient care and described how their perception of autonomy demonstrated supervisor trust in them and gave them a legitimate role on the team and in patient care. Students often described a sense of belonging and engagement when they were given autonomy.
I think that just that sense of we are here doing this together kind of also made that sense. I can trust you. We are doing this together. We are learning together. [The attending] is learning with us. We are learning. We are all working together to care for these patients. That togetherness I think made a big difference. —Participant 7
Responding productively: Reinforcing every effort as a learning opportunity.
Responding productively was described as acknowledging student effort, providing frequent feedback, and always emphasizing learning. Reemphasizing messages of learning, rather than shaming or ignoring, was particularly important when students gave wrong answers or mistakes occurred. Learning-centered responses reinforced a sense of belonging and sense of competence in their learning.
What makes me feel safe is, people that kind of respect different opinions and respond to different ideas in a supportive way. For example on clerkship, we’re really pushed to come up with the plans on our own and propose those. And I feel like what makes me feel safe is when the attending acknowledged that. And if they’re going to go with a different route, explain why. Because I feel like it just enables me to take a risk and commit to something. So that makes me feel safe. —Participant 17
Impact of safe environments
In psychologically safe environments students reported that they were able to ask questions at the point of care, disclose gaps in knowledge, seek out challenges, and focus on learning rather than image or grading. Students described a sense of agency in their own learning process, a sense of purpose within the team, and the ability to gain a deeper understanding of medical information and management when they were in safe environments.
Features of unsafe environments
Conversely, students described psychologically unsafe environments in similar terms, with behaviors that seemed to directly oppose the 3 core components of PS. Unsafe environments were created by (1) team leader indifference to students, (2) exclusion from patient care, and (3) responding to inquiry or error with oppressive or dehumanizing language or actions.
Throughout nearly all student responses were undercurrents of the power dynamics within medical teams and the ways that hierarchy negatively impacted the student experience. Many students described their experiences as a function of their low position in the hierarchy, or behaviors of attendings and senior residents as being understandable “given their position,” as though it is an accepted part of the culture to mistreat or ignore students. There were both implicit and explicit ways that students were seen as being “at the bottom” of the hierarchy, which often led to feelings of exclusion, or withdrawal.
And I felt like when I introduced myself as a medical student, they were very standoffish and really wanted nothing to do with a medical student. I feel like a lot of times we were kind of treated like children where it’s like, “If you’re doing something wrong, I’m going to kind of like tell you that you’re doing something wrong. But otherwise, I’m going to have no interaction with you at all.” —Participant 6
Team leader behaviors that threaten PS
Indifference: Unkind, avoidance.
Team leader indifference to students was a common reason students used to describe feeling unwelcome, disconnected, and unsafe in the learning environment. Indifference took various forms including not greeting or acknowledging students or addressing them by name, acting irritated or annoyed with students, providing brief “yes/no” answers to questions, not setting any expectations for student work, unclear learning objectives, or not providing adequate supervision for work that they did not feel prepared to take on. Body language such as not looking at students while speaking or presenting or being otherwise occupied (on their phone, for example) when students were speaking was another common reason for feeling unwanted, unwelcome, and unsafe in the learning environment. Educators providing nonspecific feedback was also commonly viewed as indifference, demonstrating that educators were not invested in individual student growth and professional development (or had not been paying enough attention to students to know what feedback to give).
Like just not even looking in your direction, not even … like there was no seat at the table for you, you had to stand in the back or—I remember not having—I don’t know … yeah, it was just … they didn’t even acknowledge you, they didn’t talk to you unless they needed you to go check on a patient or something, and they didn’t want to walk up there themselves or … just stuff that. It was just not a very good environment. —Participant 1
Exclusion: Not giving students a chance.
Not inviting meaningful participation in patient care or excluding students was another common way that PS was impaired. This included examples such as being placed in a part of the operating room that did not allow them to see or follow a surgical case, or clinical teachers taking over for them rather than helping them learn something. Students felt excluded and unsafe when they did not feel like they had autonomy and found themselves only shadowing or having their work micromanaged.
Just that feeling of you’re not really welcome here, or I know that you’re expendable, so I don’t really care to either teach you or to help you out because I have my own responsibilities to get done. Some of them are even just resistant to you helping them at all, because they feel like you’ll just mess things up or do things wrong. So, they don’t teach you at first and then they never teach you in the end, which is kind of sad. —Participant 13
Responding unproductively: Oppressive, dehumanizing, and hierarchy-reinforcing responses to students.
Environments with rigid hierarchy were often cited as places that felt unsafe to students. Similarly, behaviors that students perceived as reminding them of their low position in the hierarchy were commonly mentioned as behaviors that reduced safety in the learning environment. One often cited behavior was repeatedly asking questions of students when they had already demonstrated a lack of knowledge about a topic. This was seen as highlighting how little students knew compared with more senior members and was often cited as a form of public humiliation and highlighting power dynamics within a team. Responses that compared students with one another was another common source of feeling dehumanized and embarrassed publicly, while also creating competition between peers. Students reported that these responses often lead to self-isolation and disengagement.
He asked me a specific question and I was on the tip of my tongue and I couldn’t remember the exact word and he kept pressing, and kept pressing, and kept pressing, and I started kind of freaking out, and I said the word … it was the platysma muscle, I said “platysmus” and then the second attending came in and just they started making fun of me for that. And so the rest of the case, I felt awful for that reason, and the pimping kind of escalated from there because I think they were having fun, and that day was just a horrible feeling, like I felt really dumb and I felt like they were kind of ganging up on me. —Participant 2
Impact of unsafe environments
Unsafe environments lead to loss of confidence and an increase in cognitive burden. Students had to constantly monitor the environment and manage their image, both of which detract from learning. Students in unsafe environments often reported withdrawal and disengagement from the learning environment, trying to avoid drawing any attention to themselves, and described “just waiting for it to be over.”
In unsafe environments, students described the use of less efficient learning strategies, like going home and reading on their own, which they described as “missed opportunities” to learn from experts at the point of care through dialogue.
First impressions: How students diagnose the learning environment
Students diagnosed their environment through interpretations of direct interpersonal interactions with team members, and through monitoring of team members interactions with others, including other students, residents, nonphysician care team members, and patients. Additionally, students noted that their decisions about safe or unsafe environments occurred very quickly and were relatively durable within a given team or relationship with a supervisor.
Day one. Definitely on the first day. I mean, the first day of meeting people. Because on some rotations the people stayed fairly constant, and then there were other rotations where every few days the team was like changing, and the attending and the residents were kind of like shifting. But I felt like on the first day in interacting with any given team member, I could get a sense of like if I’m going to feel comfortable or not. —Participant 4
Repairing an unsafe environment
Most students were unable to think of a time when a safe environment became unsafe, or an unsafe one became safe again. Of the few students who could identify when unsafe environments were returned to safe, it was typically through behaviors such as acknowledging and apologizing for team member misbehavior. A small number of students (2) could identify a time they had directly spoken up to their supervisor to improve a negative learning experience.
One of the residents was not doing something correctly and the attending got really mad and started yelling. And so that made the situation unsafe initially, but then, I don’t know, he was able to acknowledge that he was angry. Maybe for me, this is really important when people acknowledge the feelings in the room at the time. He acknowledged he was angry and then he said something along the lines of like, “It’s okay. Let’s just keep moving forward,” and his tone got a little bit more calm. So, that was a situation maybe where it changed the feeling and the feelings in the room made me feel safer as a student. —Participant 14
Discussion
This study identifies clinical teacher leadership behaviors that directly promote or hinder PS in naturally occurring undergraduate clinical learning environments. While much of the existing literature on the learning environment tends to focus on what faculty should avoid doing to enhance the environment for students, our findings identify simple and concrete ways that educators can create supportive and inclusive clinical learning experiences for students. Students’ decisions about whether the learning environment was safe or unsafe were often made through monitoring of specific clinical teacher behaviors and their interpersonal interactions with students, underscoring the significant influence of clinical teachers in building safe or unsafe environments, and the amount of power that they possess in the eyes of students.
Medical students in psychologically safe clinical learning environments described reduced extraneous cognitive load, and a stronger sense of belonging, self-efficacy, and engagement. SDT describes the psychological needs necessary to create an environment that promotes intrinsic motivation, deep learning, well-being, and better performance. 28 The 3 psychological domains that contribute to SDT are relatedness, autonomy, and competence. 28 Our corresponding findings to each domain of SDT include: Relatedness—students’ perception of their clinical teachers level of interest in them as a person and the perceived power difference between one another; Autonomy—students’ perceived level of autonomy from their clinical teachers; Competence—students’ perception of their effectiveness in learning and patient care based on their clinical teacher’s responses. In psychologically safe environments, students felt welcome and wanted, rather than “tolerated.” They had more agency, could focus on learning, safely disclose knowledge gaps, and ask questions or seek help.
Unsafe environments led to high extraneous cognitive load and were often associated with exclusion from learning and withdrawal. Prior studies have linked exclusion in learning environments to learners experiencing hostile treatment, and ultimately to higher drop/push-out rates, specifically in students who are underrepresented in medicine. 30 The finding of belonging, then, is especially notable, and suggests that building PS in learning environments may be one way to support inclusion and belonging for all students, an important step toward building and retaining a more diverse physician workforce.
Our data support a growing body of research on the importance of trust and relationships for high-quality learning. 25,31–33 Clinical teachers are ultimately team leaders, and as such, can have an outsized impact on students’ experiences in the learning environment. Students who perceive a sense of safety and trust in their clinical teachers are able to more fully focus on their learning and operating in their zone of proximal development. 34 Interactions and relationships that were perceived as transactional, without true investment in the learning and growth of the student, tended to reduce perceptions of PS.
Our findings also demonstrate that students often make quick and durable assessments of the environment, making it difficult to repair an atmosphere that has been deemed psychologically unsafe. However, simple actions can be put into motion early on by clinical teachers to ensure the learning environment is safe and remains so. The degree to which small behaviors by clinical teachers can build PS was an unexpected finding. Behaviors as simple as acknowledging students, calling them by name, inviting them to ask questions, and giving them an active role in patient care can create safety. It is especially surprising given how seemingly simple these are, that there are still many learning environments where these are not done and students feel unsafe. Additionally, while relationships were important, they were not always time dependent. Establishing PS could still be accomplished using the same behaviors in settings where there was minimal continuity between educators and students. Effective leadership was not a matter of time but of behavior.
Using a lens of Critical Theory, 27 our findings highlight the role of power and hierarchy in creating or diminishing PS in the clinical learning environment. Academic medicine has a powerful hidden curriculum of hierarchy and power differentials. 18 At best, these differentials in status can facilitate organizational structure and clear communication. They can also lead to social control by using humiliation, fear, and shame to maintain the power differential. 35 Students often learn the rules of hierarchy through teaching by humiliation 36 and intimidation, 35,37 practices that maintain the hierarchy and the power of those at the top. The social constructs related to status of team members played a significant role in how students experienced and were treated within the environment. Flattened hierarchies improved safety. Clinical teachers who aspired to build relationships with students, include them in patient care, and demonstrate an investment in student growth were seen as building safe environments that lacked traditional hierarchy and dismissiveness of students. Rigid hierarchy can be a hindrance to PS and optimal learning. Hierarchies that highlighted power differentials and distance were experienced as unwelcoming and unsafe environments. While it can be tempting to associate humiliation and intimidation with effective teaching, these instances are powerful emotional memories that actually hinder long-term memory retrieval and development. 38 These behaviors more quickly teach learners to avoid engaging than they do actual medicine. Clinical teachers who used oppressive, dehumanizing, or belittling behaviors as “teaching tools,” or were indifferent to the presence or learning needs of students, promoted withdrawal and isolation, rather than engagement and learning.
Some of the behaviors identified by students, such as frequent feedback and making learning relevant to individual learners, 39 have already been described as best practices in clinical teaching and simulation. 39–41 Our study fits these well-known teaching habits into a greater framework to help educators understand why these behaviors work, by highlighting the experience of the students and demonstrating how they “diagnose” the learning environment. PS, in a sense, represents what Kim and colleagues termed “the engine, rather than the fuel” 42 that drives the learning and skill acquisition for doctors in training. Teaching behaviors, patient exposure, and learner enthusiasm/engagement are all necessary for fuel to create growth but cannot even begin to occur in a psychologically unsafe environment. Said another way, PS represents the system in which teaching occurs, and in which students learn medicine. What we found is that it has a wide spectrum ranging from a place where students feel like they belong and are welcome to a place where students feel rejected, fear shame, and ultimately seek to avoid. These outcomes are felt most intensely by the group with least amount of power and the entire existence of the system often goes unnoticed by those at the top. Prior studies support this by showing that perception of a team leader in medical education is likely more important to the presence of PS than actual team leader behaviors or team leaders’ perceptions of their own behavior. 18 Additionally, while prior studies have demonstrated the ability to “focus on learning” in psychologically safe learning environments, 12,13 our data are the first to describe the contents of the competing cognitive load in unsafe environments, and the learning-related consequences of the experiences of exclusion and withdrawal from the clinical learning environment.
Our study is limited by the geographic distribution of participants, which included medical schools in Western and Central United States only. As a result, transferability to different institutions may be limited if regional or institutional cultures differ from our sample. Our research team also did not include any medical students, and a member check was difficult to complete because many students left their institutions for residency by the time we had completed our analysis. Finally, the USMLE Step 1 exam is changing to pass/fail in the future. This is likely to create an additional emphasis placed on clerkship grades for residency applications. This may change the context in which our data could be translated into practice. However, if anything, we anticipate this change would more likely create additional stress for students in the clinical learning environment, emphasizing the importance of our findings even further.
Conclusions
Clinical teachers’ leadership behaviors can directly impact students’ perception of PS in the clinical learning environment. Specific behaviors such as greeting students by name, asking them about their lives outside of medicine, and emphasizing learning and professional development as a common underlying goal in patient care and teaching can be employed early on in team formation to create PS for medical students. PS can increase students’ sense of belonging, self-efficacy, and engagement. Our findings also demonstrate it is difficult to repair an atmosphere that is psychologically unsafe, but that there are several simple actions that can be put into motion early on to ensure the learning environment is safe and remains so. Future research should investigate whether psychologically safe environments lead to meaningful differences in assessments of student learning and effective cultural change.
Acknowledgments:
The authors wish to thank Lynne Robbins, PhD, and Janneke Frambach, PhD, for their review and feedback before publication.
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