Clinician Teacher as Leader: Creating Psychological Safety in the Clinical Learning Environment for Medical Students

Psychological safety is the perception that a group environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of negative consequences. The presence of psychological safety has been tied to wellness, retention, and inclusiveness. National data demonstrate that many of the fundamental components of psychological safety are lacking in clinical learning environments. There is evidence that leadership behaviors can create psychological safety in traditional work environments. The authors sought to understand how clinical teachers' leadership behaviors can create, destroy, and rescue psychological safety in the clinical learning environment.

This was a multicenter, cross-sectional, qualitative study of fourth-year medical students from 2 institutions using semistructured interviews. Verbatim transcripts underwent constant comparison and iterative data reduction and analysis, continuing beyond thematic sufficiency.

Eighteen students participated in interviews. Participants described key themes of relationships, an emphasis on learning, clear expectations, autonomy, and frequent feedback as promoting psychological safety. Safe environments lead to a sense of belonging and agency. They reported educator disinterest in students, dismissal of questions, lack of autonomy, and unclear expectations as destructive of psychological safety. Unsafe environments lead to withdrawal and a high extraneous cognitive load. Most students were unable to describe a time psychological safety was restored if lost.

Clinical teachers' leadership behaviors can directly impact students' perception of psychological safety in the clinical learning environment. Psychological safety increases students' sense of belonging, self-efficacy, and engagement. The findings demonstrate that while it is difficult to repair an atmosphere that is psychologically unsafe, there are several 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.