Psychological safety and shared decision-making for patient engagement in care quality

Patient engagement is increasingly recognised as a core component of healthcare quality and safety. However, many patients remain reluctant to voice concerns, ask questions or participate meaningfully in clinical decisions. While patient safety initiatives have traditionally focused on preventing errors through system-level controls, less attention has been paid to the relational conditions that enable patients to contribute actively to safety and quality in everyday care.

This narrative review aims to conceptualise psychological safety and shared decision-making (SDM) as interdependent mechanisms that enable patient engagement and shape patient experience and to examine how their absence contributes to defensive medical practices.

We conducted a narrative review of interdisciplinary literature spanning patient safety science, quality improvement, patient experience research and organisational psychology. Conceptual frameworks and illustrative clinical examples were synthesised to clarify how psychological safety and SDM function together within routine clinical encounters.

Psychological safety enables patients to express concerns, uncertainty and preferences without fear of dismissal or negative judgement, while SDM provides a structured process through which patient values and clinical evidence can jointly inform decisions. When these relational mechanisms are weak or absent, defensive medical practices-often framed as actions taken 'just to be safe'-may proliferate. Although intended to reduce risk, such practices can undermine patient engagement by limiting dialogue, increasing anxiety and reinforcing paternalistic decision-making. In contrast, integrating psychological safety and SDM reframes patient engagement as an active safety mechanism that supports learning, transparency and trust.

Reframing patient engagement as a core safety and quality mechanism highlights the importance of psychological safety and SDM in everyday clinical practice. Rather than treating patient experience as a downstream outcome, healthcare organisations should recognise it as an integral component of safe, high-quality care. Embedding psychologically safe communication and SDM into routine decision-making may reduce reliance on defensive medicine while promoting safer, more participatory and more respectful healthcare.