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Key tips to providing a psychologically safe learning environment in the clinical setting

Abstract

Having psychological safety embedded in preceptorship relationships facilitates positive interpersonal and educational experiences for students. Psychological safety refers to a student’s belief as to whether or not it is safe for them to take interpersonal risks, such as asking questions, sharing an idea for improvement or speaking up to maintain patient safety. Having psychological safety leads to collaboration, positive student learning experiences and effective patient care. This article presents key guidelines for preceptors to provide a psychologically safe learning environment for their students. Guidelines fall under four categories 1) before meeting students, 2) first meeting students, 3) continued relationship with students, and 4) general rules. These guidelines are informed by current literature on psychological safety and preceptorship and the author's clinical expertise in nursing preceptorship. We conceptualise psychological safety in a nursing preceptorship for preceptors to denote the experience of inclusivity, empowerment, and well-being of students within the social, cultural and physical clinical learning environment. A crucial attribute to cultivating a psychologically safe environment involves being an accessible and approachable preceptor.

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Background

Learning in the clinical environment is a cornerstone of healthcare education [1]. An effective and supportive clinical learning environment (CLE) provides trainee healthcare professionals with an opportunity to develop professional behaviours, link the theoretical aspect of their studies with clinical practice and strongly influence students' achievement of their programme learning outcomes [2, 3].

Central to the learning in the CLE in nursing education is preceptorship. Preceptorship has been defined as: 'an approach to the teaching and learning process within the context of the practice setting which allows students to develop self-confidence while increasing their competence as they become socialised into the profession of nursing' [4, pg.259]. A fundamental component of preceptorship is the 'preceptorship relationship', a triadic professional relationship between the preceptor (experienced staff nurse) and the preceptee (nursing student), centred on the delivery of patient care within a clinical environment [5]. With 50% of the undergraduate nursing curriculum in a higher education institution and the other 50% in the clinical environment, preceptors play a pivotal role in educating student nurses in the clinical environment. It is widely acknowledged that the quality of the preceptorship relationship can significantly influence the student's integration into the nursing profession and the clinical environment and can affect the student's professional development and delivery of patient care [6].

A productive clinical learning environment for students depends on positive interpersonal relations. When preceptors take an interest in the supervision of students, are easy to approach, and engage and collaborate with students and patients, it positively influences the students learning experience [7]. Nursing students have also reported that when preceptors create an atmosphere of respect and recognition of the students' work, it positively impacts their learning, creating an inclusive and psychologically safe learning experience [1].

What is psychological safety?

Psychological safety was initially defined as a "shared belief that the team is safe for interpersonal risk-taking" [8]. These interpersonal risks include open communication, voicing concerns, asking questions and seeking feedback without fear of judgment [9]. In other words, psychologically safe environments allow individuals to be their authentic selves, improve individuals’ well-being, and reduce work-related stress, leading to increased engagement and learning. Within hierarchical healthcare teams, individuals in more junior positions often find it difficult to speak up against the status quo and this reduces opportunities for collaborative learning [10]. Therefore, psychological safety required that deliberate efforts are made to reduce the professional hierarchy often observed in healthcare teams and clinical education [11].

Seminal work by behavioural psychologist Amy Edmondson [8, 10] established that when leadership and interpersonal climate support candour, humility, learning from error, and an appreciation of input from everyone on the team, psychological safety can occur. Moreover, essential work carried out by Clark [12] in the field of psychological safety illustrates four stages of psychological safety; 1) feel included; inclusion safety, (2) feel safe to learn; learner safety, (3) feel safe to contribute; contributor safety and (4) feel safe to challenge the status quo; challenger safety. Clark [12] argues the four stages of psychological safety are a universal pattern that reflects the natural progression of human needs in social settings. In the context of learning, Clark [12] highlights the importance of learner safety in asking questions, giving, and receiving feedback, experimenting, and making mistakes when learning. The innovative and seminal work of Edmondson [8, 10] & Clark [12] has pioneered effective practices to creating psychological safety.

Methods

We provide an argument that a preceptor's ability to provide a psychologically safe learning environment for their students can significantly impact the students learning experience. Therefore, the authors set out to examine the available literature on psychological safety in a clinical learning environment, particularly in the context of a nursing preceptorship. This review aimed to establish what is known about psychological safety in a clinical learning environment. From this evidence base the authors set out to establish key tips for preceptors to create a psychologically safe learning environment for students in a nursing preceptorship review sought to address the following research question:

  • What is known about psychological safety in a clinical learning environment?

A comprehensive literature search was employed to inform the development of the innovative tips for providing a psychologically safe learning environment in the clinical setting.

The search was conducted within the following databases:

  • CINAHL, PsycINFO and PubMed.

The search strategy was deployed in Jun 2022 to identify the most up-to-date literature. See Table 1:

Table 1 Key search terms for literature review

Studies eligible for inclusion were peer-reviewed or opinion pieces from any country, published between 2000 and 2022 and explored the development, implementation and/or evaluation of interventions relevant to psychological safety in a clinical learning environment. Given the limited number of interventions targeting psychological safety in nursing education, the search was expanded to include medical education. The grey literature was examined to identify professional guidance on learning in the clinical environment.

Studies were excluded if they were not available in English or if they reported on interventions conducted outside healthcare settings.

The initial electronic database searches retrieved 1127 references. Search results were uploaded to Mendeley reference management system (https://www.mendeley.com) to aid screening. Duplicates were removed (n = 371). The lead author carried out title and abstract screening. Common reason for exclusion (n = 700) was the focus was not on psychological safety in a clinical education setting. 56 full screen papers resulted in inclusion of two review papers, two case studies, five empirical papers, three commentary papers and three professional guidance documents (n = 13).

This review used a deductive thematic synthesis (Braun & Clarke, 2022) to combine the studies examining psychological safety in a clinical learning environment to a) examine psychological safety in clinical education b) examine psychological safety in the context of a nursing preceptorship. Furthermore, a content analysis was carried out on empirical research and professional guidance documents to identify universal themes for creating psychological safety so that they could then be applied to a nursing preceptorship scenario based on the authors clinical expertise in nursing preceptorship.

Psychological safety in clinical education

There is growing body of conceptual and empirical work focusing on understanding the nature of psychological safety, identifying factors that contribute to it, and examining its implications for individuals, teams, and organizations within healthcare clinical education. According to Edmondson et al. [10], psychological safety is critical in enabling individuals to overcome barriers to learning in interpersonally challenging environments. In a psychologically safe clinical learning environment, students feel safe to take risks, make mistakes, and ask for help or support when needed. Furthermore, this creates a safe environment where students can identify what skills they lack and wish to improve without judgment. The feeling of safety is an essential element in learning environments, where students are expected to take risks [13].

Psychological safety has been seen as an important element underpinning learning behaviours. Current literature reports that when students feel psychologically unsafe, they tend to refrain from doing or saying something that might suggest incompetence [14]. An unsafe psychological environment can also raise anxiety and lead to avoidance and disengagement of students' clinical education and patient care [15, 16]. Students can find it challenging to think clearly, retain information or perform clinical skills they previously felt competent in [14]. Psychological safety also plays a vital role in students speaking up for patient safety or questioning nurses when they observe inconsistencies between what is taught at university and what is performed in practice [17].

Psychologically safe learning environments permit students to seek clarification or help to answer questions or demonstrate skills workout fear of judgement or humiliation [18]. It is important to highlight that while preceptors should create an environment where students can make mistakes without being judged or punished, they must ensure patient safety throughout their practice placement [19]. Having a psychologically safe environment does not mean that there is a lack of accountability [10]. In fact, accountability and psychological safety are both required in order to students to operate within the “learning zone” [10]. Furthermore, students are expected to engage at a supernumerary level, adhering to established professional guidelines and code of conduct and only performing tasks they have learned and are competent to perform [20].

To contextualise the principles of psychological safety and learning in the clinical environment, it is important to consider Kolb's experiential learning theory. Due to its interpersonal and practical nature, experiential learning is critical for nursing skill development [21]. According to Kolb's experiential learning theory, learning is a process through which experience is transformed into new knowledge [22]. Kolb's learning cycle involves four stages: concrete learning, reflective observation, abstract conceptualisation and active experimentation [23]. More recently, Kolb and Kolb [24] acknowledge the importance of psychological safety in creating an effective learning space. Under this concept, the individuality of learners is faced and embraced by encouraging differences of expression. The learner and instructor can engage in fearless communication, i.e., express how they feel or their level of knowledge without fear of being reprimanded. In the absence of psychological safety, people do not share their unique knowledge, thus posing a threat to learning [8]. Furthermore, speaking to Kolb's experiential learning cycle principles, a factor in creating psychological safety in the clinical learning environment is identifying the learners' preferred learning style. Kolb postulated that a learning experience is maximised when the learner and facilitator consciously try to engage with the learner's learning style [25].

Psychological safety principles are also related to Maslow's (1943) hierarchy of needs. Maslow's (1943) hierarchy of needs [26]. Maslow highlights that our actions are motivated by particular psychological needs; 1) psychological needs, 2) safety needs, 3) love and belonging needs, 4) esteem needs, and 5) self-actualisation needs. A student can only move to address the higher-level needs when their basic needs are fulfilled. For example, once students feel safe, they seek social interaction and feel a sense of belonging followed by respect and achievement. Therefore, preceptors must allocate an appropriate level of time to establish psychological safety and maintain positive interpersonal relations within the preceptorship relationship to create a safe and inclusive learning environment for students from the outset of the professional relationship and throughout.

The principles of psychological safety also speak to Mezirow’s theory of transformative learning [27]. Mezirow & Cranton [28,pg74] defined transformative learning as “the process of using prior interpretation to construe a new or revised interpretation of the meaning of one’s experience as a guide to future action”. Constructs of critical reflection, dialogue, and experience are considered central to transformative learning theory [25]. Psychological safety creates an environment where the learner is comfortable embracing feelings of uncertainty associated with learning new skills in the clinical environment. Psychological safety permits the learner to feel safe to openly admit if they do not know something or are unsure of how to complete a particular skill, thus facilitating a positive learning experience and, most likely, a productive learning experience for the learner. Like Kolb’s experiential learning theory, critical reflection also plays a central role in Mezirow’s transformative learning theory. Psychological safety creates a safe environment for learners to critically reflect and discuss experiences within the clinical learning environment to generate a new understanding of the experience.

Psychological safety in nursing preceptorship

As discussed in the previous section psychological safety plays a central role in education in the clinical setting. The authors argue that psychological safety also plays a crucial role in a nursing preceptorship, where students' clinical placement outcomes rely heavily on the interpersonal dynamic and assessment associated with the preceptorship relationship. Preceptors are responsible for teaching and assessing students using a competency assessment criteria [29, 30]. Preceptors are also responsible for ensuring they provide a supportive culture for students [29]. Students’ perception of psychological safety is likely to mediate the relationship between preceptor-to-student interactions and students’ perceived quality of their learning experience [18]. The current literature suggests a lack of guidelines for preceptors to address the psychological safety needs of their students. Current guidelines for psychological safety are typically focused at an organisational and team level [31]. The guidelines presented in the next section are targeted at individual preceptors who aim to provide a psychologically safe learning environment for their students.

Guidelines to providing psychologically safe learning environments for students

In the following section, the authors will describe key recommendations to fostering psychological safety for students in clinical learning environments based on Edmondson's [8, 10] and Clarke's [12] seminal work in psychological safety, the available literature on psychological safety in clinical education, international professional guidance documents [29, 32, 33] and the author's expertise in the field of preceptorship. Table 2 below presents guidelines for creating a psychologically safe learning environment in the context of a nursing preceptorship under four categories 1) before meeting students, 2)first meeting students, 3) continued relationship with students and 4) general rules. It describes each of the individual steps, providing a rationale and example for each.

Table 2 Guidelines to providing a psychologically safe learning environment for students

Lyman and colleagues’ recent study [18] examining new graduate nurses' experiences of psychological safety found four main themes emerged, including: building credibility (building the trust of others in their capabilities), making personal connections, feeling supported and seeking safety. Similarly, a more recent concept analysis of the application of psychological safety to health care found five attributes: perceptions of the consequences of taking interpersonal risks, strong interpersonal relationships, group-level phenomenon, safe work environment for taking interpersonal risks and non-punitive culture to influence psychological safety [34]. In addition, a systematic review of factors that enable psychological safety in healthcare teams found five broader themes: priority for patient safety, improvement of learning orientation, support, familiarity with colleagues, status, hierarchy and inclusiveness and individual differences impacted psychological safety [11].

Collectively the evidence above suggests the critical role making strong interpersonal connections plays in initiating a psychologically safe environment for students. It lets preceptors connect with their students beyond surface-level greetings or small talk. Identifying students preferred names creates an atmosphere of respect [35]. On the other hand, a lack of openness or personal engagement from preceptors has resulted in negative learning experiences for students [36]. Therefore, the authors recommend to “Identify how the student likes to be addressed and how to pronounce their name” and “Build a rapport by sharing appropriate background and experiences about yourself; Ask students questions to discover their interests” (Table 2).

Moreover, international guidance documents for nurses on learning in the clinical environment [29, 30, 37] recommend that all students are made aware of the supports and opportunities available to them within the clinical environment. This includes students clearly understanding the purpose of the professional relationship preceptorship offers, your role as their preceptor, and how it will work. Therefore, the authors recommend “Define and communicate the purpose of the professional relationship and your role as their preceptor”(Table 2).

Inclusivity is another fundamental component of creating a psychologically safe learning environment [10, 20]. Without addressing social and cultural aspects of the clinical learning environment, there is a risk that students may feel excluded from the ward resulting in students feeling a lack of belonging or value to the team [20]. Social acceptance and feeling part of the team have led to motivation to provide care and clinical learning amongst students [38]. Therefore, the authors recommend to “Express gratitude and appreciation towards students for their input to the team” and “Avoid exclusive patterns of social interaction” (Table 2).

Trust is a crucial aspect of psychological safety. Trust forms the foundation of psychological safety, acknowledging vulnerabilities and allowing reciprocal expectations and beliefs to rely on each other during the teaching and learning process [33]. Preceptors must create a trusting atmosphere for their students. Therefore, the authors recommend” Identity with your students each other’s strengths and weaknesses in areas of nursing” and “Demonstrate learning empathy”.

Unintentional bias is another factor that can result in a psychologically unsafe environment for students [39]. Preceptors must examine any bias or stereotypes they may have towards students to remove barriers to effectively communicating and engaging with students to promote belongingness in the preceptorship relationship. Therefore, the authors recommend to “Identify and reflect on any unconscious negative bias (towards students), so you can act to remove them” (Table 2).

Setting clear expectations and learning objectives is also a valued action to create a psychologically safe learning environment for students [14]. When clear learning objectives are set collaboratively, it is shown to positively influence the students learning experience [40]. Therefore, the authors recommend to “Communicate a vision of the student's potential” and “Collaborate with their student to set concrete and time-bound learning goals” (Table 2).

As previously outlined Edmondson [10] established creating an interpersonal climate that supports openness and honesty is central to psychological safety and learning. Therefore, in the context of providing a psychologically safe environments for students, the authors recommend preceptors take the following steps: “Identify with your students each other’s strengths and weaknesses in areas of nursing”, “Admit when you do not know something”, “Share past mistakes” (Table 2).

Equally, Clarke [12] established the importance of learner safety and psychological safety in one’s ability to ask questions. This speaks both to the preceptor and student in a nursing preceptorship. Therefore, the authors recommend that preceptors ask structured questions to spark students learning; “Formulate a set of questions specific to your area of nursing”. The authors also recommend “conducting frequent touchpoints” to create an atmosphere where students feel safe to ask questions (Table 2).

Another critical factor in creating a psychically safe learning environment is engaging students in collaborative and bidirectional feedback (30; 31,15]. Bidirectional feedback creates a collaborative environment and demonstrates a mutual respect [41]. Psychological safety makes it more likely that students will engage in safe clinical practice and collaborative discussions with their preceptors, thus supporting learning and helping develop a sense of teamwork and belonging. Therefore, the authors recommend to “ask the student for feedback and embrace it”. Furthermore Clarke [12] established the importance of making mistakes when learning and the importance of creating an environment in which there is fear or reprimand. Therefore, the authors recommend to “If a student makes a mistake, do not judge or reprimand them. Reinforce their effort into achieving the skill, highlight how it can be improved, and ask how you can help them achieve this” (Table 2).

Discussion

This paper outlines guidelines for preceptors to provide a psychologically safe learning environment for their students (Table 2). These guidelines were recently incorporated into an innovative preceptorship education programme accredited by the Nursing and Midwifery Board of Ireland (NMBI), focusing on developing preceptors' interpersonal and communication skills relevant to student teaching and learning [32]. Implementing these guidelines could help preceptors establish a standardised approach to providing a psychologically safe learning environment for their students. More research is required to determine the impact of implementing these guidelines from the perspective of preceptors and the perspective of students on creating a psychologically safe learning environment following completion of the new educational programme.

Conclusion

Psychological safety is an essential component of an effective nursing preceptorship. It is evident from the available literature that psychological safety plays an essential role in ensuring a positive and productive learning experience for students in the clinical learning environment. It is vital that students feel safe to ask questions and verbalise areas of clinical practice that require improvement without fear of judgment or repercussions for their clinical assessment documents. Key attributes preceptors must display are openness, inclusivity, effective interpersonal and communication skills, and a collaborative approach to creating a psychologically safe learning environment for students. Learning in a clinical context is foundational in training all health professionals. While the focus of this paper was applied to creating a psychologically safe learning environment within a nursing preceptorship, the authors argue that these principles and guidelines could be adapted and applied to suit different health professional training programmes.

Take-home message

  • Psychologically safe learning environments are essential for optimal learning in a nursing preceptorship.

  • Students' learning is enhanced when students perceive a psychologically safe learning environment in the clinical setting.

  • Preceptors defining attributes to creating a psychologically safe learning environment for students include openness, inclusivity, effective interpersonal and communication skills and collaboration with nursing students

  • Preceptors must allocate an appropriate amount of time to establish and maintain psychological safety within the preceptorship relationship.

Availability of data and materials

Not applicable.

Ethics approval and consent to participate.

Not applicable.

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PH & RD prepared the first draft of the paper and Tables. All authors read and approved the final manuscript.

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Hardie, P., O’Donovan, R., Jarvis, S. et al. Key tips to providing a psychologically safe learning environment in the clinical setting. BMC Med Educ 22, 816 (2022). https://doi.org/10.1186/s12909-022-03892-9

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Keywords

  • Psychological Safety
  • Clinical Learning Environment
  • Nursing Education
  • Nursing Preceptorship