Psychological safety in the surgical learning environment
Psychological safety is a term that originated in the organizational research literature.1 It is a team-level phenomenon that creates an atmosphere of interpersonal trust and mutual respect and allows people to be comfortable being themselves. In this way, psychological safety reduces interpersonal risk. As described by Karlyn Borysenko,
Psychologically safe learning environments offer learners the freedom to be fallible and the support needed to succeed. For this reason, psychologically safe environments allow for learning behaviors, such as: seeking feedback, sharing information, asking for help, experimenting, and talking about mistakes.1 (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 trusts that the environment supports their individual learning needs. This sense of security gives learners the ability to take risks and learn from right and wrong decisions, which in turn promotes a growth mindset in learners, as it illustrates how skills can be developed through to hard work, good strategies and the contribution of others.4 In contrast, in psychologically unsafe environments, learners are less likely to take risks that make them vulnerable to criticism from others,seven which results in a reluctance to ask questions, try new skills, share concerns or express new ideas.
Fostering connection is central to building psychological safety in the surgical learning environment.8 This article offers a conceptual framework that educators can use to create psychological safety in the surgical learning environment through the use of specific behaviors (Table 2). These behaviors include:
- Establish a relationship
- Respect and Empowerment
- Recognize Vulnerability
Building a relationship means developing a connection and mutual trust so that both parties feel supported and understood. To build relationships, surgical educators can demonstrate to learners that they are an important and valued part of the surgical team. This process begins with learner engagement – asking learners about their goals for a rotation, clinic day, or even a particular operation forces them to invest in the process. It also demonstrates that as an educator, you care about their unique learning goals.
Establishing a relationship 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 may cause a learner to worry about the image they are projecting with their answer, especially in the hierarchical context of surgery. Instead, try asking a learner “Tell me something ordinary About you.” 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, may elicit a laugh and often lead to deeper conversation.
Asking learners questions is also an excellent tool to increase 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 depending on how the questions are phrased, the tone in which they are spoken, and the subsequent response to the learner’s response. Shaming a learner who doesn’t know the answer to a question or gives the wrong answerten is one of the fastest ways to reduce psychological safety in the surgical learning environment because it makes the act of vulnerability dangerous. If a learner is having trouble giving an immediate answer to a question, providing a series of multiple-choice options is a technique to help them make a choice, which you can then discuss. For example, you might ask, “What surgical excision margins are recommended for a 1 mm thick melanoma?” Is it 5mm, 10mm, 10-20mm or > 20mm? Recognizing 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 for learners, caring for them, appreciating them, identifying with 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 come up with new solutions to problems, 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 that you care enough to know who they are and respect them enough to recognize them as a person. It begins to break down the seemingly impenetrable hierarchy of surgery and can help reduce your psychological height as someone in a position of power. The use of titles demonstrates the valuable role of the learner as an active member of the team, for example, referring to a resident as “doctor” when interacting with a patient.
Encouraging learners to participate in the conversation about surgical planning and patient care also builds relationships and enables team members to innovate and engage more deeply in patient care activities. Recognizing that learners are on an equal footing within the team enables them to act as agents whose choices are meaningful.
Interruptions, such as during learner presentations during morning rounds, may appear to be benign and time-saving 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 have to 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 bit” – and allow the learner the benefit of your full attention in the future.
Getting learner feedback is a great way to build respect and empowerment, as it makes learners feel seen and heard. This practice also emphasizes the importance of feedback as a two-way process. Modeling seeking and receiving feedback from colleagues shows learners how to develop a growth mindset.4
Recognizing vulnerability means recognizing that personal risk is an integral part of learning and interacting with a team. In surgery, learning also takes place in a public forum, which can seem particularly risky. Being open to the fact that learning inherently involves not knowing is a good way to begin to recognize vulnerability. It can be as simple as telling 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 knowledge gaps are so we can work together to fill them. »
Another way to recognize vulnerability is to share your own limitations. When a learner asks a question you don’t know the answer to, instead of telling them to research it and report back, consider saying “I’m not sure, let’s research together.” This not only models your own growth mindset, but can also provide the learner with access to a new resource to answer their future questions.
Invite team members to freely raise issues, questions, and concerns. This may be related to patient care, workflow, or specific surgical techniques. When they do, praise learners for being vulnerable and take this as a sign that you are creating a psychologically safe learning environment.
Setting expectations means providing clarity to 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: “During morning rounds, you will be responsible for assisting the intern by gathering supplies for shift changes. bandages”. This centers the learner as a member of the community of practice, an essential part of professional identity formation.12
Monitoring and feedback are essential parts of setting expectations. Giving feedback to learners involves the intersection of psychological safety and responsibility.13 By providing accountability in a psychologically safe environment, surgical educators inspire learners to grow. Selecting the appropriate setting and time to give feedback can affect perceived psychological safety. Difficult comments are often best given in a private, planned and unhurried manner. Comments must correspond to previously defined expectations by being specific, objective, relevant, timely and balanced.14