Clinician - Teacher - As - Leader - Creating Psychological Safety Environment

Bias, Safety, and Intersectionality
Facilitator: Tasha R. Wyatt, PhD
Clinician Teacher as Leader: Creating

Psychological Safety in the Clinical Learning
Environment for Medical Students
Adelaide Hearst McClintock, MD, Tyra Leigh Fainstad, MD, and Joshua Jauregui, MD
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Abstract
Mi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/02/2023
Purpose Method a high extraneous cognitive load. Most

Psychological safety is the perception This was a multicenter, cross-sectional, students were unable to describe a time
that a group environment is safe for qualitative study of fourth-year medical psychological safety was restored if lost.
interpersonal risk taking, exposing students from 2 institutions using
vulnerability, and contributing semistructured interviews. Verbatim Conclusions
perspectives without fear of negative transcripts underwent constant comparison Clinical teachers’ leadership behaviors
and iterative data reduction and analysis, can directly impact students’ perception
consequences. The presence of
continuing beyond thematic sufficiency. of psychological safety in the clinical
psychological safety has been tied to
learning environment. Psychological
wellness, retention, and inclusiveness.
Results safety increases students’ sense
National data demonstrate that many
Eighteen students participated in of belonging, self-efficacy, and
of the fundamental components of interviews. Participants described key engagement. The findings demonstrate
psychological safety are lacking in themes of relationships, an emphasis on that while it is difficult to repair an
clinical learning environments. There learning, clear expectations, autonomy, atmosphere that is psychologically
is evidence that leadership behaviors and frequent feedback as promoting unsafe, there are several actions that
can create psychological safety in psychological safety. Safe environments can be put into motion early on to
traditional work environments. The lead to a sense of belonging and agency. ensure the learning environment is safe
authors sought to understand how They reported educator disinterest in and remains so. Future research should
clinical teachers’ leadership behaviors students, dismissal of questions, lack of investigate whether psychologically
can create, destroy, and rescue autonomy, and unclear expectations as safe environments lead to meaningful
psychological safety in the clinical destructive of psychological safety. Unsafe differences in assessments of student
learning environment.

environments lead to withdrawal and learning and effective cultural change.
D espite decades of attention to the 3 key leadership tasks that create PS in work environments. 11 Clinical teachers
learning environment, national data teams: (1) set the stage (define purpose, operate as learning team leaders in patient
continue to demonstrate a lack of many set expectations and ground rules, care and clinical education settings. They
of the fundamental components of destigmatize failure and risk), (2) invite model cultural and team norms and have
psychological safety in the current clinical participation (emphasize that all voices the ultimate influence on the learning
teaching environments, 1–5 and that are credible, listen to inputs, demonstrate environment. However, the lack of well-
navigating hierarchical power dynamics humility and openness to change), elucidated clinical teacher leadership
in learning teams continues to be a and (3) respond productively (express behaviors in clinical undergraduate
significant distraction from learning. 6 appreciation, offer help, consider next medical education settings limits our
steps, sanction “group rule” violations). 7 ability to translate these concepts into
Psychological safety (PS) refers to how In other sectors, PS has been tied to team clinical teaching environments. Existing
safe one feels to take a risk and “be wrong” effectiveness, creativity, and learning. 8–11 data on PS in medical settings has focused
without being shamed, blamed, or ignored. Health professions education literature on simulation and prevention of medical
Amy Edmonson, the first researcher to suggests that PS enables learners to errors in interprofessional teams 16,18–21 and
coin the term psychological safety, defines focus on the tasks at hand and disclose reported on the impacts of the presence or
knowledge gaps. It also alleviates students’ absence of PS. 12,13,18 It remains unclear how
Please see the end of this article for information fear of asking questions and focus on clinician teacher team leaders can translate
about the authors.
image. 12,13 The presence of PS has also these concepts to authentic clinical
Correspondence should be addressed to Adelaide been tied to wellness, 14 retention, 15 and learning environments to create PS and
Hearst McClintock, 4245 Roosevelt Way NE, Box inclusiveness. 8,16 The absence of PS is often support learning. To address this gap in
354765, Seattle, WA 98107; email: ahearst@uw.edu.
associated with rigid hierarchy and power the medical education literature, this study
Acad Med. 2022;97:S46–S53. differentials in the workplace. 16–18 sought to explore how leadership behaviors
First published online August 9, 2022 influence PS for medical students in the
doi: 10.1097/ACM.0000000000004913
Copyright © 2022 by the Association of American There is evidence that leadership clinical learning environment for them to
Medical Colleges behaviors can create PS in traditional maximize their learning.
S46 Academic Medicine, Vol. 97, No. 11S / November 2022 Supplement
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Method voluntary and compensated with a $50 gift We did not find any additional insights
This was a multicenter, cross-sectional, card that could be redeemed at a variety of requiring changes to the coding structure,
qualitative, semistructured interview merchants. suggesting that our sample was sufficient
study of fourth-year medical students for our study purpose.
using both deductive and inductive We employed the PS theoretical
grounded-theory analysis within a framework to inform our interview Because our qualitative approach was
constructivist research paradigm. 22 guide to investigate students’ experiences one of active engagement between
We chose semistructured interviews within the clinical learning environment. ourselves and the data, we were
We asked students to reflect on what intentionally and regularly reflexive
to gather unique perspectives in a

confidential manner given the sensitive impacted the PS of their clinical learning about how our identities may have
and personal nature of the topic. We environments. To understand the impacted what we were coconstructing
conducted this study at the University permanence of a student’s perception among ourselves and the participants.
of Washington School of Medicine and of a clinical learning environment, Our research team consisted of 3
the University of Colorado School of we then invited them to describe clinician teachers, 2 at the University
Medicine. In keeping with a theoretical their experience with the safety of an of Washington and 1 at the University
sample approach to recruitment, all environment changing. We then followed of Colorado. None of us had a
fourth-year medical students who had up with probing questions to better student–teacher relationship with any
completed their required third-year understand negative, surprising, and of the participants in the context of
clerkships but had not yet matched salient findings. We audio recorded all the required third-year clerkships
into residency were invited via email sessions, transcribed them using Rev. we explored. One of us identifies as
to participate in 1-hour interviews via com, and used Dedoose (SocioCultural male, 2 as female, and 1 of us is from
zoom (Zoom Video Communications, Research Consultants, Manhattan Beach, a historically marginalized group
Inc., San Jose, California). We wanted California) to code all transcripts. in medicine. Two of us are internal
to obtain students’ perspectives about medicine physicians and 1 is an
their clinical clerkships. We also wanted We used the PS framework to structure emergency medicine physician. These
to capture those perspectives after they the initial coding scheme. We also identities and their intersectionality
had recently rotated in the clerkships used constructivist grounded theory to influenced how we made meaning of
that are common to many medical inductively code the data for elements the data, enabling us to relate it to our
students, to maximize transferability outside of the PS framework. 23 Verbatim own experiences and intentionally,
and before when they matched into transcripts of the interviews underwent deeply explore discrepancies in the
residency, to minimize the influence of constant comparison and iterative data data. To avoid extraneous bias, we
specialty identity in their responses. At reduction and analysis by all 3 authors, met regularly to reflect on how the
the University of Washington, required and occurred while interviews were intersectionalities of our identities and
third-year clerkships include a traditional ongoing, to allow for mutual influence. All experiences may have impacted our
curriculum of family medicine, internal 3 authors coded line by line, consolidating interpretations.
medicine, obstetrics–gynecology, initial codes to identify categories. We
pediatrics, psychiatry, and surgery or met regularly to review the resulting The Human Subjects Division at the
a longitudinal integrated clerkship. categories, our corresponding analytical University of Washington deemed the
At the University of Colorado, these memos and the overarching themes, study to be exempt from review.
also include a traditional curriculum and their relationships to one another.
of family medicine, internal medicine, During the analysis, we chose to use
obstetrics–gynecology, pediatrics, self-determination theory (SDT) and Results
neurology, psychiatry, and surgery. We critical theory as sensitizing concepts, We interviewed 18 fourth-year medical
were cognizant that many social and to focus our attention on the learners’ students, 9 students from each medical
individual influences would impact the relationship with the clinician teachers, school. Participant demographics are
results, and therefore, used a maximum the social power structures within presented in Table 1. Twelve students
variation sampling approach to guarantee medical education, and the way that team (66%) identified as female, and 5 students
a variation in students’ professional leader and member behaviors impact of (27%) in our sample stated that they
and personal identities. For example, them. 24–28 We conducted interviews until identify with a racial or ethnic group that
after interviewing our initial list of reaching a point of thematic sufficiency. is underrepresented in medicine. 29
respondents, we intentionally scheduled After 12 interviews, the developed
further interviews to ensure a diversity of coding framework seemed to sufficiently Students described several team leader
participants and perspectives. represent the data we had gathered from behaviors that impacted medical student
our participants. We continued our PS in clinical teaching environments.
We sent an email invitation to all fourth- analysis beyond thematic sufficiency and Overall, we found that many of the
year medical students at each institution to purposefully explored counter examples. clinical teacher behaviors that students
participate in a semistructured interview. We conducted another 6 interviews reported could be characterized within 1
The lead investigator (A.H.M.) conducted to interrogate our coding framework of the 3 PS leadership tasks, and also fell
all the 1-hour semistructured interviews in relation to a wide variety of lived within a spectrum of the 3 key domains
with participants between October 2020 experiences in our students and to ensure of SDT: relatedness, autonomy, and
and February 2021. Participation was the framework was not institution-specific. competence (Table 2). Figure 1 is
Academic Medicine, Vol. 97, No. 11S / November 2022 Supplement S47
feeling like I can fully express myself

or my thoughts and opinions without
Table 1 fear of retribution, or even if someone
Participant Characteristics disagrees, they would do so in a positive,
tactful kind of way. So, safe means I can
Demographic Number (SD or %) learn and it’s less performative. Instead
Mean age 28 (+/− 1.8) of someone kind of judging my ability
to do something, it’s more about adding
Gender identity
to my ability to already do certain things
Male 6 (33%) that I can do, or adding to my ability to
Female 12 (66%) do things that I might not be able to do.

—Participant 14
Racial or ethnic background underrepresented in medicine
Yes 5 (27%) Team leader behaviors that promote

No 13 (72%) safety
Many of the behaviors reported by
students that helped to establish safety
could be classified according to PS’s
Table 2 established leadership tasks.
Exemplary Quotes of Clinical Teacher Behavior Within the Self-Determination
Theory Framework That Contribute to Students’ Psychological Safety Setting the stage: Building relatedness
and setting them up for success in
Behavior Quote learning. Setting the stage arose from
Relatednessa I felt like I had a lot of really interesting insights to share for the team, and that students’ descriptions of having clear
it would be well received. I felt like I had a lot of great questions to ask and work expectations and the expected level
I could just really express my curiosity, and that I learned a lot of things that
day. I think when I felt really positive patient interactions or had been dealing of mastery. This also included clinical
with something difficult in terms of working with the patient and it ended up teachers explicitly stating a team focus on
resolving or going positively. I think when I felt like I emotionally connected with learning. A sense of team cohesion as well
the people on my team. (Participant 14) as collegial and supportive team member
Autonomyb Giving autonomy shows trust and makes you feel like the environment is safe. relationships helped build a sense of
Because obviously the person giving the trust knows that you might make a belonging and relatedness.
mistake. But I think that that autonomy also shows that they trust that if you
make a mistake, you will own up to it, and you will come and seek help when The very first thing is just someone’s
needed. Because I think that when you’re not given enough autonomy, you overall presentation of how eager they
don’t learn as much. (Participant 9) are to be there, if they have a positive
Competencec Even though they have high expectations or if like if you do something like attitude, and that they care about the
wrong or you have like the wrong differential or something like that like it team that is there if they want to get
didn’t feel like they were coming at you specifically. It felt like they genuinely to know us. I would say someone that
want you to learn which is like why I’m there. Like I genuinely want to learn and kind of sets expectations at the first
like get better and like get as much exposure as I wanted. (Participant 4) interaction and talks about what they’re
a
Relatedness is the need for a sense of belonging with teachers and the team.
looking for, what they’re not looking
b
Autonomy is the need to feel empowered in decision making. for, and is also very much into being
c
Competence is the need to feel capable of learning. able to ask and answer questions. So
just basically explicitly stating that it’s
a learning experience that they want
a conceptual model of clinical teaching questions or express a concern to foster for everybody involved. —
behaviors that impact students’ without fear of judgment, public Participant 9
perception of PS and influence learning humiliation, or retaliation; (2) a
behaviors. Results are presented below flattened hierarchy; and (3) supportive Inviting participation: Encouraging
according to the PS leadership tasks. The team member relationships. Simply students’ engagement in learning. This
PS of the learning environment affected being acknowledged and addressed included team leader humility and
students’ willingness to initiate learning by name was frequently cited as a student autonomy. Leadership humility
behaviors, impacted their cognitive behavior that made students feel that in the form of acknowledging one’s own
load, and was associated with student environments were safe and welcoming. gaps in knowledge or seeking input from
focus on image and assessment. Students Going beyond simple acknowledgment, junior team members was described
diagnosed their environments early on in teams with a flattened power structure, as a way clinical teachers built safe
team formation. First impressions of the where team leaders and senior environments. Humility normalized the
environment were formed quickly, were residents approached students as equal learning process and modeled lifelong
relatively durable, and had a powerful participants in teamwork and learning, learning. Students described autonomy
impact on trainee experience. were often described as places where as a form of inviting participation in
students felt safe. patient care and described how their
perception of autonomy demonstrated
Features of safe learning environments What does safe mean? I think it’s
physical safety, feeling like I can inhabit supervisor trust in them and gave them
Student definitions of safety included the space that I’m in physically, but a legitimate role on the team and in
3 key themes: (1) the ability to ask also emotionally. I think it means patient care. Students often described
Figure 1 Conceptual model of clinical teaching behaviors and impacts on psychological safety.
a sense of belonging and engagement rather than image or grading. Students wrong. But otherwise, I’m going to
when they were given autonomy. described a sense of agency in their own have no interaction with you at all.” —
Participant 6
I think that just that sense of we are here
learning process, a sense of purpose
doing this together kind of also made that within the team, and the ability to gain
a deeper understanding of medical Team leader behaviors that threaten PS
sense. I can trust you. We are doing this
together. We are learning together. [The information and management when they Indifference: Unkind, avoidance. Team
attending] is learning with us. We are were in safe environments. leader indifference to students was a
learning. We are all working together to common reason students used to describe
care for these patients. That togetherness Features of unsafe environments feeling unwelcome, disconnected, and
I think made a big difference. — unsafe in the learning environment.
Participant 7 Conversely, students described
psychologically unsafe environments in Indifference took various forms including
similar terms, with behaviors that seemed not greeting or acknowledging students or
Responding productively: Reinforcing
to directly oppose the 3 core components addressing them by name, acting irritated
every effort as a learning opportunity.
of PS. Unsafe environments were or annoyed with students, providing brief
Responding productively was described
created by (1) team leader indifference “yes/no” answers to questions, not setting
as acknowledging student effort,
to students, (2) exclusion from patient any expectations for student work, unclear
providing frequent feedback, and always
care, and (3) responding to inquiry or learning objectives, or not providing
emphasizing learning. Reemphasizing
error with oppressive or dehumanizing adequate supervision for work that they
messages of learning, rather than
language or actions. did not feel prepared to take on. Body
shaming or ignoring, was particularly
language such as not looking at students
important when students gave wrong
Throughout nearly all student responses while speaking or presenting or being
answers or mistakes occurred. Learning-
were undercurrents of the power otherwise occupied (on their phone, for
centered responses reinforced a sense of
dynamics within medical teams and the example) when students were speaking
belonging and sense of competence in
ways that hierarchy negatively impacted was another common reason for feeling
their learning.
the student experience. Many students unwanted, unwelcome, and unsafe in
What makes me feel safe is, people that described their experiences as a function the learning environment. Educators
kind of respect different opinions and of their low position in the hierarchy, providing nonspecific feedback was
respond to different ideas in a supportive
or behaviors of attendings and senior also commonly viewed as indifference,
way. For example on clerkship, we’re
really pushed to come up with the plans residents as being understandable “given demonstrating that educators were not
on our own and propose those. And I their position,” as though it is an accepted invested in individual student growth and
feel like what makes me feel safe is when part of the culture to mistreat or ignore professional development (or had not
the attending acknowledged that. And if students. There were both implicit and been paying enough attention to students
they’re going to go with a different route, explicit ways that students were seen as to know what feedback to give).
explain why. Because I feel like it just being “at the bottom” of the hierarchy,
enables me to take a risk and commit to
something. So that makes me feel safe.
which often led to feelings of exclusion, or Like just not even looking in your
withdrawal. direction, not even … like there was no
—Participant 17 seat at the table for you, you had to stand
And I felt like when I introduced myself in the back or—I remember not having—I
Impact of safe environments as a medical student, they were very don’t know … yeah, it was just … they
In psychologically safe environments standoffish and really wanted nothing to didn’t even acknowledge you, they didn’t
do with a medical student. I feel like a talk to you unless they needed you to go
students reported that they were able lot of times we were kind of treated like check on a patient or something, and they
to ask questions at the point of care, children where it’s like, “If you’re doing didn’t want to walk up there themselves
disclose gaps in knowledge, seek out something wrong, I’m going to kind of or … just stuff that. It was just not a very
challenges, and focus on learning like tell you that you’re doing something good environment. —Participant 1
Exclusion: Not giving students a chance. kind of escalated from there because I misbehavior. A small number of students
Not inviting meaningful participation think they were having fun, and that day (2) could identify a time they had directly
was just a horrible feeling, like I felt really
in patient care or excluding students spoken up to their supervisor to improve
dumb and I felt like they were kind of
was another common way that PS was ganging up on me. —Participant 2 a negative learning experience.
impaired. This included examples such
One of the residents was not doing
as being placed in a part of the operating Impact of unsafe environments something correctly and the attending
room that did not allow them to see or got really mad and started yelling. And
Unsafe environments lead to loss of
follow a surgical case, or clinical teachers so that made the situation unsafe initially,
confidence and an increase in cognitive
taking over for them rather than helping but then, I don’t know, he was able to
burden. Students had to constantly acknowledge that he was angry. Maybe for
them learn something. Students felt
monitor the environment and manage me, this is really important when people
excluded and unsafe when they did not

their image, both of which detract acknowledge the feelings in the room
feel like they had autonomy and found
from learning. Students in unsafe at the time. He acknowledged he was
themselves only shadowing or having angry and then he said something along
environments often reported withdrawal
their work micromanaged. the lines of like, “It’s okay. Let’s just keep
and disengagement from the learning
moving forward,” and his tone got a little
Just that feeling of you’re not really environment, trying to avoid drawing any bit more calm. So, that was a situation
welcome here, or I know that you’re attention to themselves, and described maybe where it changed the feeling and
expendable, so I don’t really care to either “just waiting for it to be over.” the feelings in the room made me feel
teach you or to help you out because I safer as a student. —Participant 14
have my own responsibilities to get done.
Some of them are even just resistant to In unsafe environments, students
you helping them at all, because they feel described the use of less efficient learning Discussion
like you’ll just mess things up or do things strategies, like going home and reading This study identifies clinical teacher
wrong. So, they don’t teach you at first on their own, which they described as leadership behaviors that directly
and then they never teach you in the end, “missed opportunities” to learn from
which is kind of sad. —Participant 13 promote or hinder PS in naturally
experts at the point of care through occurring undergraduate clinical learning
dialogue. environments. While much of the existing
Responding unproductively:
Oppressive, dehumanizing, and First impressions: How students literature on the learning environment
hierarchy-reinforcing responses to diagnose the learning environment tends to focus on what faculty should
students. Environments with rigid avoid doing to enhance the environment
Students diagnosed their environment for students, our findings identify simple
hierarchy were often cited as places through interpretations of direct
that felt unsafe to students. Similarly, and concrete ways that educators can
interpersonal interactions with team create supportive and inclusive clinical
behaviors that students perceived as members, and through monitoring of
reminding them of their low position in learning experiences for students.
team members interactions with others, Students’ decisions about whether the
the hierarchy were commonly mentioned including other students, residents,
as behaviors that reduced safety in the learning environment was safe or unsafe
nonphysician care team members, and were often made through monitoring of
learning environment. One often cited patients. Additionally, students noted
behavior was repeatedly asking questions specific clinical teacher behaviors and
that their decisions about safe or unsafe their interpersonal interactions with
of students when they had already environments occurred very quickly
demonstrated a lack of knowledge about students, underscoring the significant
and were relatively durable within influence of clinical teachers in building
a topic. This was seen as highlighting a given team or relationship with a
how little students knew compared with safe or unsafe environments, and the
supervisor. amount of power that they possess in the
more senior members and was often
cited as a form of public humiliation and Day one. Definitely on the first day. I eyes of students.
mean, the first day of meeting people.
highlighting power dynamics within a
team. Responses that compared students
Because on some rotations the people Medical students in psychologically safe
stayed fairly constant, and then there were clinical learning environments described
with one another was another common other rotations where every few days the
source of feeling dehumanized and reduced extraneous cognitive load, and
team was like changing, and the attending
embarrassed publicly, while also creating and the residents were kind of like a stronger sense of belonging, self-
competition between peers. Students shifting. But I felt like on the first day in efficacy, and engagement. SDT describes
reported that these responses often lead interacting with any given team member, the psychological needs necessary to
to self-isolation and disengagement.
I could get a sense of like if I’m going to create an environment that promotes
feel comfortable or not. —Participant 4 intrinsic motivation, deep learning, well-
He asked me a specific question and I was being, and better performance. 28 The 3
Repairing an unsafe environment psychological domains that contribute
on the tip of my tongue and I couldn’t
remember the exact word and he kept Most students were unable to think of a to SDT are relatedness, autonomy,
pressing, and kept pressing, and kept time when a safe environment became and competence. 28 Our corresponding
pressing, and I started kind of freaking unsafe, or an unsafe one became safe findings to each domain of SDT include:
out, and I said the word … it was the again. Of the few students who could Relatedness—students’ perception of
platysma muscle, I said “platysmus” and
then the second attending came in and
identify when unsafe environments their clinical teachers level of interest
just they started making fun of me for were returned to safe, it was typically in them as a person and the perceived
that. And so the rest of the case, I felt through behaviors such as acknowledging power difference between one another;
awful for that reason, and the pimping and apologizing for team member Autonomy—students’ perceived level of
autonomy from their clinical teachers; giving them an active role in patient and isolation, rather than engagement
Competence—students’ perception of care can create safety. It is especially and learning.
their effectiveness in learning and patient surprising given how seemingly simple
care based on their clinical teacher’s these are, that there are still many Some of the behaviors identified by
responses. In psychologically safe learning environments where these students, such as frequent feedback and
environments, students felt welcome and are not done and students feel unsafe. making learning relevant to individual
wanted, rather than “tolerated.” They had Additionally, while relationships were learners, 39 have already been described
more agency, could focus on learning, important, they were not always time as best practices in clinical teaching
safely disclose knowledge gaps, and ask dependent. Establishing PS could and simulation. 39–41 Our study fits
questions or seek help. still be accomplished using the same these well-known teaching habits into
behaviors in settings where there was a greater framework to help educators

Unsafe environments led to high minimal continuity between educators understand why these behaviors work,
extraneous cognitive load and were often and students. Effective leadership was by highlighting the experience of the
associated with exclusion from learning not a matter of time but of behavior. students and demonstrating how they
and withdrawal. Prior studies have linked “diagnose” the learning environment.
exclusion in learning environments to Using a lens of Critical Theory, 27 our PS, in a sense, represents what Kim and
learners experiencing hostile treatment, findings highlight the role of power and colleagues termed “the engine, rather than
and ultimately to higher drop/push-out hierarchy in creating or diminishing PS the fuel” 42 that drives the learning and
rates, specifically in students who are in the clinical learning environment. skill acquisition for doctors in training.
underrepresented in medicine. 30 The Academic medicine has a powerful Teaching behaviors, patient exposure,
finding of belonging, then, is especially hidden curriculum of hierarchy and and learner enthusiasm/engagement are
notable, and suggests that building PS in power differentials. 18 At best, these all necessary for fuel to create growth
learning environments may be one way differentials in status can facilitate but cannot even begin to occur in a
to support inclusion and belonging for organizational structure and clear psychologically unsafe environment. Said
all students, an important step toward communication. They can also lead to another way, PS represents the system
building and retaining a more diverse social control by using humiliation, in which teaching occurs, and in which
physician workforce. fear, and shame to maintain the power students learn medicine. What we found
differential. 35 Students often learn the is that it has a wide spectrum ranging
Our data support a growing body of rules of hierarchy through teaching from a place where students feel like
research on the importance of trust by humiliation 36 and intimidation, 35,37 they belong and are welcome to a place
and relationships for high-quality practices that maintain the hierarchy where students feel rejected, fear shame,
learning. 25,31–33 Clinical teachers are and the power of those at the top. The and ultimately seek to avoid. These
ultimately team leaders, and as such, social constructs related to status of outcomes are felt most intensely by the
can have an outsized impact on team members played a significant group with least amount of power and
students’ experiences in the learning role in how students experienced and the entire existence of the system often
environment. Students who perceive a were treated within the environment. goes unnoticed by those at the top. Prior
sense of safety and trust in their clinical Flattened hierarchies improved safety. studies support this by showing that
teachers are able to more fully focus Clinical teachers who aspired to build perception of a team leader in medical
on their learning and operating in relationships with students, include education is likely more important to the
their zone of proximal development. 34 them in patient care, and demonstrate an presence of PS than actual team leader
Interactions and relationships that were investment in student growth were seen behaviors or team leaders’ perceptions of
perceived as transactional, without as building safe environments that lacked their own behavior. 18 Additionally, while
true investment in the learning and traditional hierarchy and dismissiveness prior studies have demonstrated the ability
growth of the student, tended to reduce of students. Rigid hierarchy can to “focus on learning” in psychologically
perceptions of PS. be a hindrance to PS and optimal safe learning environments, 12,13 our data
learning. Hierarchies that highlighted are the first to describe the contents of
Our findings also demonstrate that power differentials and distance were the competing cognitive load in unsafe
students often make quick and durable experienced as unwelcoming and unsafe environments, and the learning-related
assessments of the environment, environments. While it can be tempting consequences of the experiences of
making it difficult to repair an to associate humiliation and intimidation exclusion and withdrawal from the clinical
atmosphere that has been deemed with effective teaching, these instances learning environment.
psychologically unsafe. However, are powerful emotional memories that
simple actions can be put into motion actually hinder long-term memory Our study is limited by the geographic
early on by clinical teachers to ensure retrieval and development. 38 These distribution of participants, which
the learning environment is safe and behaviors more quickly teach learners included medical schools in Western and
remains so. The degree to which small to avoid engaging than they do actual Central United States only. As a result,
behaviors by clinical teachers can medicine. Clinical teachers who used transferability to different institutions
build PS was an unexpected finding. oppressive, dehumanizing, or belittling may be limited if regional or institutional
Behaviors as simple as acknowledging behaviors as “teaching tools,” or were cultures differ from our sample. Our
students, calling them by name, indifferent to the presence or learning research team also did not include
inviting them to ask questions, and needs of students, promoted withdrawal any medical students, and a member
check was difficult to complete because A.H. McClintock is assistant professor of medicine, 14. Hylton J, Karjane N, Santen S, Rigby F,
many students left their institutions for University of Washington, Seattle, Washington. Appelbaum N. Keeping residents well:
How important are perceptions of program
residency by the time we had completed T.L. Fainstad is associate professor of medicine, support and psychological safety to resident
our analysis. Finally, the USMLE Step University of Colorado Anschutz School of Medicine, wellness? Obstet Gynecol. 2019;134:49S.
1 exam is changing to pass/fail in the Aurora, Colorado. 15. Keitz SA, Aron DC, Brannen JL, et al. Impact
future. This is likely to create an additional J. Jauregui is associate professor of emergency of clinical training on recruiting graduating
health professionals. Am J Manag Care.
emphasis placed on clerkship grades for medicine, University of Washington, Seattle,
Washington. 2019;25:E111–E118.
residency applications. This may change 16. Nembhard IM, Edmondson AC. Making it
the context in which our data could safe: The effects of leader inclusiveness and
be translated into practice. However, References professional status on psychological safety

and improvement efforts in health care
if anything, we anticipate this change 1. Cook AF, Arora VM, Rasinski KA, Curlin
FA, Yoon JD. The prevalence of medical teams. J Org Behav. 2006;27:941–966.
would more likely create additional 17. Appelbaum NP, Lockeman KS, Orr S, et
student mistreatment and its association with
stress for students in the clinical al. Perceived influence of power distance,
burnout. Acad Med. 2014;89:749–754.
learning environment, emphasizing the 2. Mavis B, Sousa A, Lipscomb W, Rappley psychological safety, and team cohesion
importance of our findings even further. MD. Learning about medical student on team effectiveness. J Interprof Care.
mistreatment from responses to the medical 2020;34:20–26.
school graduation questionnaire. Acad Med. 18. Appelbaum NP, Dow A, Mazmanian PE,
Conclusions 2014;89:705–711. Jundt DK, Appelbaum EN. The effects of
3. Buery-Joyner SD, Ryan MS, Santen SA, power, leadership and psychological safety
Clinical teachers’ leadership behaviors on resident event reporting. Med Educ.
Borda A, Webb T, Cheifetz C. Beyond
can directly impact students’ mistreatment: Learner neglect in the 2016;50:343–350.
perception of PS in the clinical learning clinical teaching environment. Med Teach. 19. Roussin CJ, Larraz E, Jamieson K, Maestre
environment. Specific behaviors such as 2019;41:949–955. JM. Psychological safety, self-efficacy,
4. Wolf TM, Randall HM, von Almen K, and speaking up in interprofessional
greeting students by name, asking them
Tynes LL. Perceived mistreatment and health care simulation. Clin Simul Nurs.
about their lives outside of medicine, and attitude change by graduating medical 2018;17:38–46.
emphasizing learning and professional students: A retrospective study. Med Educ. 20. Lateef F. Maximizing learning and creativity:
development as a common underlying 1991;25:182–190. Understanding psychological safety in
goal in patient care and teaching can be 5. Sheehan KH, Sheehan DV, White K, simulation-based learning. J Emerg Trauma
Leibowitz A, Baldwin DC, Jr. A pilot study of Shock. 2020;13:5–14.
employed early on in team formation 21. Turner S, Harder N. Psychological safe
medical student “abuse”: Student perceptions
to create PS for medical students. of mistreatment and misconduct in medical environment: A concept analysis. Clin Simul
PS can increase students’ sense of school. JAMA. 1990;263:533–537. Nurs. 2018;18:47–55.
belonging, self-efficacy, and engagement. 6. Vanstone M, Grierson L. Medical student 22. Bergman E, de Feijter J, Frambach J, et al.
Our findings also demonstrate it is strategies for actively negotiating hierarchy A guide to research paradigms relevant to
in the clinical environment. Med Educ. medical education. Acad Med. 2012;87:545.
difficult to repair an atmosphere that is 2019;53:1013–1024. 23. Charmaz K. Constructing Grounded Theory.
psychologically unsafe, but that there 7. Edmondson AC. The Fearless Organization: Los Angeles, CA: SAGE; 2014.
are several simple actions that can be Creating Psychological Safety in the Workplace 24. Telio S, Ajjawi R, Regehr G. The
put into motion early on to ensure for Learning, Innovation, and Growth. “Educational Alliance” as a framework
Hoboken, NJ: John Wiley & Sons; 2018. for reconceptualizing feedback in medical
the learning environment is safe and education. Acad Med. 2015;90:609–614.
8. Edmondson AC, Roloff KS. Overcoming
remains so. Future research should barriers to collaboration: Psychological 25. Telio S, Regehr G, Ajjawi R. Feedback and the
investigate whether psychologically safety and learning in diverse teams. In: educational alliance: Examining credibility
safe environments lead to meaningful Salas E, Goodwin GF, Burke CS, eds. Team judgements and their consequences. Med
differences in assessments of student Effectiveness in Complex Organizations: Educ. 2016;50:933–942.
Cross-Disciplinary Perspectives and 26. Sandars JE. Critical theory and the
learning and effective cultural change. Approaches. New York, NY: Routledge; scholarship of medical education. J Int Assoc
2009:183–208. Med Sci Educ. 2016;7:246–247.
Acknowledgments: The authors wish to thank 27. Chow CJ, Hirshfield LE, Wyatt TR.
9. Harvey JF, Johnson KJ, Roloff KS,
Lynne Robbins, PhD, and Janneke Frambach, PhD, Sharpening our tools: Conducting medical
Edmondson AC. From orientation to
for their review and feedback before publication. behavior: The interplay between learning education research using critical theory.
orientation, open-mindedness, and Teach Learn Med. 2022;34:285–294.
Funding/Support: This study was funded by the 28. Ryan RM, Deci EL. Self-determination
psychological safety in team learning. Hum
Center for Leadership and Innovation in Medical Relat. 2019;72:1726–1751. theory and the facilitation of intrinsic
Education (CLIME) Small Grants Program at the 10. Edmondson AC. Teaming: How motivation, social development, and well-
University of Washington. Organizations Learn, Innovate, and Compete being. Am Psychol. 2000;55:68–78.
in the Knowledge Economy. Hoboken, NJ: 29. Association of American Medical Colleges.
Other disclosures: None reported. John Wiley & Sons; 2012. Underrepresented in medicine definition.
11. Edmondson AC. The Fearless Organization: https://www.aamc.org/what-we-do/equity-
Ethical approval: This study was deemed exempt Creating Psychological Safety in the Workplace diversity-inclusion/underrepresented-in-
by the institutional review board of the University for Learning, Innovation, and Growth. medicine. Accessed October 20, 2021.
of Washington. Hoboken, NJ: John Wiley & Sons; 2018. 30. Amayo J, Heron S, Spell N, Gooding H.
12. Tsuei SH, Lee D, Ho C, Regehr G, Nimmon Twelve Tips for Inclusive Teaching [version 1].
Previous presentations: The abstract of an earlier L. Exploring the construct of psychological MedEdPublish. 2021;10:81. doi: https://doi.
version of this article was presented at Learn safety in medical education. Acad Med. org/10.15694/mep.2021.000081.1
Serve Lead 2021: The Virtual Experience, 2019;94:S28–S35. 31. Hauer KE, ten Cate O, Boscardin C, Irby
November 2021, and published in “Association 13. Johnson CE, Keating JL, Molloy EK. DM, Iobst W, O’Sullivan PS. Understanding
of American Medical Colleges Learn Serve Lead: Psychological safety in feedback: What trust as an essential element of trainee
Proceedings of the 60th Annual Research in does it look like and how can educators supervision and learning in the workplace.
Medical Education Presentations and Medical work with learners to foster it? Med Educ. Adv Health Sci Educ Theory Pract.
Education Abstracts.” 2020;54:559–570. 2014;19:435–456.
32. Hauer KE, O’Brien BC, Hansen LA, et al. in doctors’ narratives of power relations Teaching and Learning in Medicine. 2nd ed.
More is better: Students describe successful in specialist training. Soc Sci Med. Edinburgh, UK: Elsevier; 2016.
and unsuccessful experiences with teachers 2017;186:70–77. 40. Haydar B, Charnin J, Voepel-Lewis T,
differently in brief and longitudinal 36. Lempp H, Seale C. The hidden Baker K. Resident characterization of
relationships. Acad Med. 2012;87:1389–1396. curriculum in undergraduate medical better-than- and worse-than-average
33. Albritton JA, Fried B, Singh K, Weiner BJ, education: Qualitative study of medical clinical teaching. Anesthesiology.
Reeve B, Edwards JR. The role of psychological students’ perceptions of teaching. BMJ. 2014;120:120–128.
safety and learning behavior in the 2004;329:770–773. 41. Curry SE, Cortland CI, Graham MJ. Role-
development of effective quality improvement 37. Lempp H. Medical-school culture. In: modelling in the operating room: Medical
teams in Ghana: An observational study. BMC Handbook of the Sociology of Medical student observations of exemplary behaviour:
Health Serv Res. 2019;19:385. Education. New York, NY: Routledge; Student observations of OR behaviour. Med
34. McKimm J, Swanwick T. Educational 2009:85–102. Educ. 2011;45:946–957.

leadership and management. In: 38. Vogel S, Schwabe L. Learning and memory 42. Kim S, Lee H, Connerton TP. How
Understanding Medical Education. Hoboken, under stress: Implications for the classroom. psychological safety affects team
NJ: John Wiley & Sons, Ltd; 2018;549–568. npj Sci Learn. 2016;1:1–10. performance: Mediating role of efficacy
35. Crowe S, Clarke N, Brugha R. “You do 39. Harden RM, Laidlaw JM. Essential Skills and learning behavior. Front Psychol.
not cross them”: Hierarchy and emotion for a Medical Teacher: An Introduction to 2020;11:1581.

Clinician - Teacher - As - Leader - Creating Psychological Safety Environment

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Bias, Safety, and Intersectionality

Facilitator: Tasha R. Wyatt, PhD

Clinician Teacher as Leader: Creating

Purpose Method a high extraneous cognitive load. Most

to gather unique perspectives in a

feeling like I can fully express myself

Female 12 (66%) do things that I might not be able to do.

Yes 5 (27%) Team leader behaviors that promote

excluded and unsafe when they did not

behaviors in settings where there was a greater framework to help educators

be translated into practice. However, References professional status on psychological safety

34. McKimm J, Swanwick T. Educational 2009:85–102. Educ. 2011;45:946–957.

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