Using ‘Psychological Safety’ to Improve Education
By Gary Evans
Creating psychological safety in medical education opens up learners to the experience, making it more likely they will ask questions and actively participate, Gillian Lashen, PhD, an assistant professor of psychiatry at the Oregon Health and Science University, said recently at IDWeek 2022.
A psychologically safe educational environment means learners know they will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.
“This is a learning environment that is safe for interpersonal risk-taking,” Lashen said. “It’s essentially the degree to which someone feels like they can speak up, ask questions, or share concerns. More specifically, medical trainees in the literature have defined it as not feeling judged.”
A psychologically safe learning environment should be high candor and low fear, which seems potentially contradictory. “High candor meaning that direct, honest communication is encouraged, and low fear meaning that folks aren’t spending a lot of time or energy worrying that if they do speak up and participate, that they might be judged in some fashion,” Lashen said. “A presence of psychological safety has also been tied to wellness, retention, and inclusiveness in medical education.”
The term sometimes invokes negative connotations, like lowering standards or giving everyone a participation trophy. “The name sometimes conjures up those ideas, but it’s really the opposite,” Lashen explained. “It’s central to hold learners to high performance standards, to hold them accountable for their learning behaviors, for an environment to feel safe.”
Interpersonal risk-taking includes asking for help, which some learners view as a failure. “It is important that we’re creating an environment where we’re normalizing that. Of course you’re going to ask for help,” Lashen said. “We expect that. A culture of silence is a dangerous culture. There’s a lot of examples in history of that. But we want learners to tell us if they’re experiencing doubt — if they’re fearful they may have made a mistake. This is a culture of near misses, good catches. We know that it improves outcomes for our patients and that it helps teams work safer.”
Research in this area indicates healthcare workers with a higher degree of psychological safety are more likely to report medical errors, trying to learn from them and not repeat them. “When psychological safety is low, we see learners perhaps fall into the apathy or the anxiety zone,” Lashen said. “These people are choosing to play it safe, disengage, stay quiet, in service of staying safe.”
In doing so, they may develop an “imposter syndrome,” feeling like if they give a wrong answer they will be exposed as a fraud. “It’s worth noting that in terms of prevalence, imposter syndrome disproportionately affects folks who identify as any sort of part of a marginalized group,” Lashen explains. “In medicine, that includes women, historically marginalized groups, or underrepresented in medicine groups, folks who identify as members of the LGBTIQA+ community. If you think about it, this makes a lot of sense. It’s hard to believe you deserve a seat at the table if you don’t see anyone who looks like you sitting around that table.”
An easy way to build relations with learners is to memorize their names and use them. “If clinician educators are doing this, learners feel more safe, they feel like they belong, they feel like they matter on the team,” Lashen noted.
Another strategy is “situational humility,” which involves normalizing the learning struggle and maybe sharing something you went through in training. This is one way to “to flatten the hierarchy,” which gives learners a greater sense of safety and belonging to a team.
“In a dynamic and ambiguous environment like a hospital or a clinic — anywhere in healthcare, really — no one can know everything,” Lashen said. “No one can predict the future or know all [the] particular variables. Really sort of embracing humility in that sense helps flatten hierarchy and engage learners.”
Creating psychological safety in medical education opens up learners to the experience, making it more likely they will ask questions and actively participate. A psychologically safe educational environment means learners know they will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.
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