Psychological safety is a term that originates in the organizational research literature.1 It is a team-level phenomenon that creates a climate of interpersonal trust and mutual respect and allows people to be comfortable being themselves. In this way, psychological safety reduces interpersonal risk. As Karlyn Borysenko describes it,
Psychologically safe learning environments provide learners with the freedom to be fallible and the support to succeed. Because of this, psychologically safe environments enable learning behaviors, such as: seeking feedback, sharing information, asking for help, experimenting, and talking about errors1 (Table 1). Psychological safety has been shown to increase learner engagement in the surgical learning environment,3 can help learners develop a growth mindset,4 and improve patient outcomes.5,6
Because psychological safety instills trust in the teacher-learner relationship, the learner has confidence that the environment is supportive of their individual learning needs. This feeling of safety gives learners the ability to take risks and learn from both correct and incorrect decisions, which in turn fosters a growth mindset in learners because it illustrates how skills can be developed through hard work, good strategies, and input from others.4 In contrast, in psychologically unsafe environments, learners are less likely to take risks that make them vulnerable to criticism from others,7 which translates to a reluctance to ask questions, try new skills, share concerns, or express novel ideas.
Fostering connection is at the core of building psychological safety in the surgical learning environment.8 This article proposes a conceptual framework educators can use to create psychological safety in the surgical learning environment through the use of specific behaviors (Table 2). These behaviors include:
- Building rapport
- Respect and empowerment
- Acknowledging vulnerability
Building Rapport
Building rapport means developing connection and mutual trust so that both parties feel supported and understood. To build rapport, surgical educators can demonstrate to learners that they are an important and valued part of the surgical team. This process starts with engaging learners—asking learners for their goals for a rotation, a day in clinic, or even a particular operation requires them to invest in the process. It also demonstrates that as an educator you care about their unique learning objectives.
Building rapport on a personal level can help learners feel psychologically safe. Asking someone “Tell me something interesting about yourself” is a common practice during interviews or meetings. This seemingly benign question can prime a learner to become anxious about the image they project with their response, particularly in the hierarchical context of surgery. Instead, try asking a learner “Tell me something ordinary about yourself.” You might give an example about yourself first, such as “I’m right-handed, I like coffee, and I have a pet cat.” These personal details are low stakes, might elicit a chuckle, and, often, lead to further conversation.
Asking questions of learners is also a great tool for increasing psychological safety in the surgical learning environment. The most important part of asking questions is the use of appropriate scaffolding that helps the learner access what they already know and move forward from that point.9 Psychological safety can be increased when asking questions based on how questions are phrased, the tone in which they are delivered, and the subsequent response to the learner’s answer. Shaming a learner who does not know the answer to a question or gives the wrong answer10 is one of the fastest ways to decrease psychological safety in the surgical learning environment because it makes the act of vulnerability feel unsafe. If a learner struggles to give an immediate answer to question, providing a series of multiple choice options is one technique to help prime them to make a choice, which you can then discuss. For example, you could ask, “What surgical excision margins are recommended for a melanoma that is 1mm thick? Is it 5mm, 10mm, 10-20mm, or >20mm? Acknowledging vulnerability is an important part of using questions to facilitate learning. This is discussed in more detail later in this article.
Respect and Empowerment
Respect in the surgical learning environment means showing consideration towards learners, being concerned about them, appreciating them, relating to them, and admiring their strengths. Empowerment means allowing learners to step up and take ownership. Instead of deferring decisions to others, learners who are empowered to be part of the team have a stronger sense of obligation to the mission. They are more likely to propose novel solutions to problems, to speak up when they make or notice a mistake,11 and to take responsibility for their actions and learning.
Respect and empowerment can be as simple as asking for and using learners’ names and titles. Using a learner’s name shows them you care about them enough to know who they are and respect them enough to acknowledge them as a person. It begins to break down the seemingly impenetrable hierarchy of surgery and can help decrease your psychological size as a person in a position of power. Use of titles demonstrates the valuable role of the learner as a contributing member of the team—for example, referring to a resident as “Doctor” during a patient interaction.
Encouraging learners to participate in the conversation about surgical planning and patient care also builds rapport and empowers team members to innovate and engage more deeply in patient-care activities. Acknowledging learners as having equal footing on the team empowers them to act as an agent whose choices carry meaning.
Interruptions, such as during learner presentations on morning rounds, may seem like a time-efficient and benign behavior but can negatively impact psychological safety in the surgical learning environment. Frequent interruptions send the message that the educator’s time is more important than the learner’s. If you must interrupt, consider stating your reasons for doing so—for example, “I just received a page that the patient is in the operating room, so I’m going to have to speed things up a little”—and allow the learner the benefit of your full attention in the future.
Eliciting feedback from learners is a great way of enacting respect and empowerment because it allows learners to feel seen and heard. This practice also emphasizes the importance of feedback as a bidirectional process. Modeling seeking and receiving feedback from colleagues demonstrates to learners how to build a growth mindset.4
Acknowledging Vulnerability
Acknowledging vulnerability means recognizing that personal risk is an inherent part of both learning and interacting with a team. In surgery, learning also occurs in a public forum, which can feel particularly risky. Being open about the fact that learning inherently involves not knowing is a good way to start acknowledging vulnerability. This can be as simple as saying to learners something like, “Learning involves not knowing. I’m going to ask you questions and I don’t expect you to know all the answers. I’m trying to understand what your gaps in knowledge are so we can work on filling them in together.”
Another way to acknowledge vulnerability is by sharing your own limitations. When a learner asks a question that you don’t know the answer to, instead of telling them to look it up and report back, consider saying “I’m not sure, let’s look that up together.” This not only models your own growth mindset but may provide the learner with access to a new resource for answering their future questions.
Invite members of the team to bring up issues, questions, and concerns freely. This may be related to patient care, workflow, or specific operative techniques. When they do, congratulate learners for being vulnerable and take this as a sign you are creating a psychologically safe learning environment.
Setting Expectations
Setting expectations means providing clarity for the learner about what they are responsible for and how their progress will be assessed. This provides learners with the information they need to perform well. Set expectations for a learner by explaining their role on the team and assigning them specific tasks such as, “On morning rounds, you will be responsible for helping the intern by gathering supplies for dressing changes.” This centers the learner as a member in the community of practice, a critical component of professional identity formation.12
Following up and giving feedback is a critical component of setting expectations. Giving feedback to learners involves the intersection of psychological safety and accountability.13 By providing accountability in a psychologically safe environment, surgical educators challenge learners to grow. Selecting the appropriate setting and timing for giving feedback can affect perceived psychological safety. Difficult feedback is often best given in a private setting, in a planned and unhurried manner. Feedback should align with previously set expectations by being specific, objective, relevant, timely, and balanced.14
Conclusion
Psychological safety is an important tool for any surgical educator. Psychological safety increases learner engagement in the surgical environment,3 can help learners develop a growth mindset,4 and can improve patient safety.5,6 Specific strategies and behaviors can be employed by educators to increase psychological safety in the surgical learning environment.
