How Psychological Safety Impacts Student Clinicians and Patient Safety

In this special guest episode, Danielle Duffy, graduate student in the College of Health Professions Department of Nurse Anesthesia, shares reflections on her doctoral project. Danielle explores the concept of psychological safety, what it is, how it presents itself in the clinical setting, and how it can influence actions taken by student clinicians. She also looks at the impact of these decisions and psychological safety in general on patients and patient safety.

Research references



For more information on the DNAP program at VCU visit the Department of Nurse Anesthesia website.

Transcript

Hi everyone. My name is Danielle Duffy and I'm a Nurse Anesthesia graduate student at Virginia Commonwealth University. I'm here to discuss with you some of the findings from my doctoral project, which is about how psychological safety may impact learning for student clinicians and how psychological safety may impact the safety of our patients. I'm going to talk about what got me interested in this topic and share some of my own clinical experience that I think many of my fellow SRNAs can relate to. What is psychological safety? I was introduced to this term during nurse anesthesia school while I was attending a lecture at one of my clinical sites. The speaker on this particular day was discussing provider wellness and briefly touched upon the topic of psychological safety. It piqued my interest, so I decided to do a little bit of digging on my own. And what I learned through my review of the literature is that psychological safety is defined as a subjective feeling by an individual or group that a situation or environment is safe to express thoughts, raise concerns, ask questions, and offer suggestions without the fear of shame or embarrassment. Essentially, it's about feeling safe. This definition really resonated with me because I immediately understood how much it related to my experience as a student registered nurse anesthetist, and how it could have widespread implications within anesthesia and healthcare. I'd like to disclose that as I looked into the literature, there was a huge variety of information that surrounded psychological safety. And there's a lot that can be discussed here. But today I'm going to focus on two specific areas. One being, how does psychological safety impact learners in the clinical environment? And how does psychological safety impact patient safety? How did I become interested in psychological safety? As I just mentioned, I was first introduced to the concept of psychological safety during a lecture at one of my clinical sites. But it was actually a very uncomfortable clinical experience that really inspired me to tackle this as my doctoral project. I'm going to tell you more about that in just a minute. But it was after learning more on my own that I really became interested in this concept. As students in the clinical environment, we are constantly interacting with a variety of people. From surgeons to preceptors, anesthesiologists, nurses, surgical technicians, anesthesia techs, and of course, our patients. We rotate through new clinical sites every couple of months. Our clinical environments and the people in it are constantly changing. Similar to our interactions with patients. We need to be able to demonstrate our capability, build rapport, and build trust with those we are working with. When it comes to our preceptors, we really need to be able to communicate clearly, acknowledge our own limitations, ask for help, and receive feedback in order to be successful and grow as learners. It is so important that we have a good working professional relationship. I believe psychological safety is a core component of this that I feel should be talked about a lot more. Now, I'll tell you about my own clinical experience that helped me truly understand what feeling psychologically unsafe meant and how it can impact patient safety. I'm going to keep some details here private as I want to protect the privacy of the clinical site. I also want to disclose that I in no way have hard feelings about this experience. I'd like to say that the vast majority of my preceptors have been absolutely fantastic. But this outlier experience really left an impact on me. This was relatively early on in my clinical experience. I was preparing for a day with a variety of cases. And as you do, as all of my SRNA is out there know, you go into the OR you prepare your machine, your drugs, your airway, all the things that you're going to need, and you try to have pretty much all of that done before your preceptor gets there. I had all that completed and my preceptor comes into the OR I
introduced myself and they replied by saying, “Okay”, not making eye contact with me, didn't tell me their name, even though I, of course, knew what their name was. I found that introduction to be a little bit curt, but I continued with the task at hand. I then explained my anesthesia plan to my preceptor for the cases that we had. My preceptor didn't acknowledge my plan that I had presented. They didn't give me positive or negative feedback. They just began to question me about complications that I might see during the case. I named a few that I had looked up the night before, but my preceptor just kept saying what else repeatedly until I had essentially named all the ones that I could think of. I explained that that was all I had found in my care planning and they began to ask me to list the sources that I had used and said things like, well, it sounds like if you had done the work, you would have found this. In my defense, the complication they described was highly unusual and not in the text that I had care planned with. As I went home and looked it up later, I brushed the interaction off and noted that I should go back and look over the possible complications later. We continued on with our day. Later, I asked my preceptor a question about something and they responded with, “You should already know that.” I can't remember what the question was exactly, but I remember thinking that it was a valid question for a student at my level of clinical experience to be asking this left me feeling like, okay, I cannot ask person questions because I'm going to be shamed for not already knowing what the answer is. Later on, my preceptor put me through what they called drills, which was them asking me about what I would do in certain emergency scenarios. I thought that this would actually be great because I had not seen many emergencies in the operating room. However, even when I responded to their scenarios with appropriate interventions, they told me you had to think about that for too long, or they would simply not respond to my answers at all. It made me feel very defeated. It was early in my clinical experience and I was truly doing my best. I had been getting really positive feedback from my other preceptors. It felt unusual to be getting feedback like this, but these series of interactions left me feeling extremely uncomfortable. I felt that they didn't want to have a student with them and that they really just wanted to put me down. They even told me not every day is going to be a good day. I think that's really a shame. Later, we were doing a case under general anesthesia and the patient was paralyzed. I needed to reverse the patient before we were emerging. Which for those of you that are not in anesthesia, that just means to give a drug to reverse the paralyzing agent that we had on board. I had a question about how to time giving this reversal agent for this surgery because I didn't want to delay the wake up, but I, of course, wanted to be doing what was safe for the patient. I was just too afraid to ask my preceptor when I should be giving it because I thought that the response I was going to get was going to make me feel shameful or embarrassed. I made the decision on my own to give the reversal when the surgery was nearly complete, but as a new SRNA, I didn't know that for this particular surgery, I should have waited until the surgeon was completely done as the patient could cough or move and injure themselves with the surgical equipment. Well, the patient coughed and the surgeon politely asked me to deepen them. Fortunately, the patient did not have an injury from their cough and the surgery went fine. But it was my fault for not asking. I really wanted to ask. I was just under so much psychological stress at that moment, and I was afraid to communicate with my preceptor out of fear of their reaction, even though I really wanted to. It was later that I was able to identify that I had low psychological safety in this moment. And while everything ended up okay for this patient, there was a real potential for harm there. And that is the consequence of low psychological safety. Not only did I not learn effectively that day, but I almost caused a patient injury, all because I felt completely psychologically unsafe. This experience also taught me an important lesson about what an effective and ineffective preceptor looks like. And I have no hard feelings towards this preceptor. I don't know their background or their experiences that led them to interact with students in that way. I am fortunate to have a great support system among my fellow classmates, and I know in comparison to some of the days my classmates have had, this experience could be considered mild. But I share all of this to give a personal example of how impactful psychological safety can be regarding learning and patient safety. Next, I'll be discussing the four stages of psychological safety. Timothy Clark wrote a book titled The Four Stages of Psychological Safety. In this book, he describes four stages in which teams or individuals move through to achieve psychological safety. With each of these stages, I'll be discussing vulnerabilities clinician learners may have. Stage one is described as inclusion safety. This means that individuals feel safe and they feel that they belong to a team. They're comfortable being present, they don't feel excluded, and they feel wanted and appreciated as it relates to students and specifically students in the clinical environment. I think this stage is extremely important. As I mentioned earlier, SRNA's move through a variety of different clinical environments with different people every few weeks to months. And it can be challenging to immediately feel comfortable or even feel that you're a part of that team. Sometimes it can feel like you're an outsider, since you're only there for a defined period of time. This definition also includes feeling wanted and appreciated. Often, I think as students we can feel like a burden. We're not yet as skilled as our CRNA is to work at the pace that the operating room teams are used to. It can sometimes feel like you're slowing things down. For example, maybe you're placing a spinal anesthetic for the first time. Any SRNA or CRNA that has done this in the operating room can tell you that the team is waiting on you to complete this successfully before the surgery can proceed. That can feel like a lot of pressure. If it's taking longer than it normally does for an experienced provider, it's easy to see that this can decrease your sense of security and belonging within a team. Stage two is described as learner safety. This means that individuals are able to learn through asking questions, making mistakes, and asking for help. I think this stage is perhaps the most important for a learner in the clinical environment, whether it be anesthesia, or nursing, or medicine. The ability to ask questions and ask for help is absolutely crucial to our learning. Every time someone asks a question, whether they are a learner or not, they are offering a sense of vulnerability. That vulnerability can either be met with reward or punishment. Let me give you an example to explain what I mean. Recently I was doing a 13 level scoliosis repair with a neurosurgeon. As anesthesia providers know some of the neuromonitoring that the neuromonitoring techs do to ensure the safety of the patient during the case requires that the patient not have paralysis on board as this can interfere with their readings. However, sometimes the surgeon want the patient to be paralyzed in order to get good exposure at the start of the case. Before the surgery started, I asked the surgeon what his preference was for paralysis. He explained that he wanted the patient to have baseline readings after inductions, so no paralysis on board, and then have a small time with paralysis on board so that he could get exposure. This response served as a reward to my question because not only did it give me the answers I was looking for, it gave me a sense that this surgeon appreciated my inquiry and didn't dismiss it or make me feel as though I should already know the answer to that question. On the contrary, I've had experiences where I asked a question and the response was, you should already know that. This does just the opposite. It decreases one's sense of psychological safety. This question or moment of vulnerability was met with punishment. It created a space where I felt I could not freely ask questions, which in turn creates withdrawal. I once had a preceptor asked me, do you have any questions about anything that you've been too embarrassed to ask anyone else about? This small gesture really provided me with a sense of psychological safety. While this person had done many other things to make me feel comfortable asking them questions, this gesture really spoke to not only the safe space they were creating for me and my learning, but their invested interest in my learning. Stage three is described as contributor safety. This means that individuals feel safe to contribute their own ideas without fear of embarrassment or ridicule. For example, say you're in a clinical situation where suddenly your patient's blood pressure drops. Maybe you call for help and someone comes by and starts trying to troubleshoot what could be going on in this situation. It's so important that team members feel safe to contribute their own ideas of what could be happening. If someone is afraid to share their idea because they're worried that they could be wrong or look silly and feel embarrassed, it could be a missed opportunity or delay finding the cause to the patient's low blood pressure. This is just a hypothetical scenario, but it's easy to imagine why it's important. We all feel safe to contribute our ideas. Stage four is described as Challenger Safety. This means that individuals can question others, even those with authority, and suggest their own ideas or plans or way of doing things. It's similar to stage three, but it involves challenging others ideas. Early during my clinical rotations, I was doing outpatient surgery cases and I was caring for a patient that disclosed they did not have transportation home that day. The patient was getting a large but superficial mass removed on their side.
Originally, the anesthetic plan was to this patient under what we call monitored Anesthesia care. Where you give them like a Propofol drip and local anesthetic at the site. And after this patient told us that he didn't have a ride home, the anesthesiologist said, well, I think we need to cancel the case. But the patient expressed that they were having some financial troubles and they said it was really difficult for them to get the day off of work to even get this procedure done. Knowing all of this, my CRNA suggested to the anesthesiologist and the surgeon to simply use local anesthetic at the site of the mass and provide verbal anesthesia, which just means giving the patient coaching and reassurance during the case. This would mean that the patient would be awake for the procedure but would then be able to drive themself home safely. The CRNA discussed this idea with the patient, with the surgeon, and with the attending anesthesiologists, And everyone agreed that this would be the only safe way to proceed and have the patient drive themself home. This is what we did. The patient was appreciative of the out of the box thinking and the surgeon was glad to be able to get the case done for the patient. But had the CRNA not had a sense of psychological safety, perhaps they would not have felt comfortable suggesting that plan at all. Of course, that’s hypothetical. But you can see the implications of potentially not sharing ideas out of fear that they may be met with criticism or ridicule. Now that we have given a background on what psychological safety is, I'm going to discuss how psychological safety impacts learners in the clinical setting. Clinician learners, such as nursing students, medical students, physician residents, and student registered nurse anesthetists, must complete a portion of their education in the clinical environment. The clinical portion of their education involves applying theoretical knowledge to real life patient situations. For example, as an SRNA, we learn in the classroom the conceptual knowledge required to successfully intubate a patient. However, you only learn to perform this skill through repeated engagements in the clinical setting. This portion of the learning experience is essential in the process of becoming a competent and skilled clinician. There was a study done conducted by McClintock in which they interviewed medical students regarding their experience in the clinical environment as it related to psychological safety. Study participants were asked to describe their experiences in the clinical environment that impacted their sense of psychological safety, both positively and negatively. Participants noted behaviors by team leaders, such as ignoring students, repeatedly asking students questions that expose their lack of understanding on a subject. Yelling and responding to a question with oppressive language as examples of behaviors that negatively impact their sense of psychological safety. While these examples may seem overtly inappropriate to those that are not in health care, these experiences are not all that uncommon. Participants explained that these behaviors were distracting from their learning experience because they felt they needed to focus their attention on their own self-preservation rather than engage with their clinical environment. Participants noted that when psychological safety is low, it increases the cognitive load on them. This increase in cognitive load decreases the learner's capacity to focus on the task at hand, thus detracting from their learning experience. Study participants also noted that once psychological safety was lost, it was nearly impossible to restore. Considering clinician learners are often in the same facility with the same preceptors for weeks or months at a time. A large portion of their learning experience can be wasted if they're unable to engage properly. I love this quote by Johnson, which states, only when the brain is satisfied with, I am safe with these people does it switch to utilizing its full capacity for engagement, creativity, and learning. I think from experience that this is remarkably true. When I'm working in an environment where I don't feel psychologically safe, I feel that not all of my attention is focused on the clinical situation at hand. It might be focused on thoughts like, if I decide to give this medication, will my preceptor be okay with that? Or I think it might be time to turn down my anesthetic gas. But will my preceptor think it's too early to do this? McClintock also noted that students experiencing low psychological safety and exclusion in the clinical environment ultimately had higher dropout rates. And this is particularly noted in underrepresented groups of medical students considering the importance of diversity and inclusion among health care providers, it's clear that this consequence of low psychological safety can have major implications. Often in the clinical environment, learners may encounter methods of teaching that border on shame and humiliation. An example of this might be pressing a learner on a subject they have demonstrated a knowledge gap in, in order to further highlight that knowledge gap. These experiences can lead to feelings of disgrace and embarrassment. Learners can often remember these scenarios well. It's then reasonable to question if these scenarios lead to effective teaching. When I began to look into this topic, this exact question came to mind. During my time in clinical, I've had experiences where I was not as knowledgeable on a certain subject and subsequently received significant questioning on that subject. It can be very nerve racking, and I certainly remember those experience as well. Of course, I ask myself, this is an unpleasant experience, but if I remember it well, doesn't that mean it was an effective method of teaching? But McClintock argues that while these scenarios do create powerful emotional memories, they're not effective at long term information retention. Said another way, learners will remember the emotional experience well, but not necessarily the clinical information. After reading this, I thought back to the subject that I was being pressed on and certainly remember how I felt in that moment. But in terms of the actual clinical information being discussed, I can't say I recall it that well. This surprised me. I'd like to say that this is different than learning through experience. For example, say hypothetically, you are moving an intimated patient from the OR bed to the stretcher and you don’t hang on to the endotracheal tube securely enough and it comes out. From then on you are going to be sure that you hang onto the endotracheal tube securely. This is different than someone pressing you want information and shaming you for not knowing it. Furthermore, these teaching styles teach learners to avoid engaging in their clinical environment. This further promotes withdrawal and isolation for the learner. Unfortunately, clinical learners often frequently encounter scenarios that decrease their sense of psychological safety. Because of the commonplace of such scenarios, learners often accept this as a part of their process of becoming a clinician. That's quite unfortunate because as we now understand, these teaching styles are not effective. They increase the cognitive load on the learner and they're not necessary for a successful clinical environment. With all of that being said, I think it's important to acknowledge here the responsibility of the learner in the clinical environment. While it may not be appropriate for someone to press you about obscure information to shame you, it's also not appropriate for someone like an SRNA to have a blatant knowledge gap in something that requires them to be fully prepared for their clinical day. I think ultimately, it's a balance of acknowledging that students are not going to know everything, but they need to know enough to provide safe care and demonstrate that they have done their due diligence to prepare for their clinical experience. In 2019, the World Health Organization said that the incidence of being harmed while traveling by plane was around one in 1 million. In contrast, the World Health Organization reports that the chance of being harmed while receiving medical care is one in 300. They also stated that patient harm is the 14th leading cause of morbidity and mortality across the world. Clearly, patient safety is a growing concern, and there's a multitude of factors that play into patient safety. Presence of psychological safety in the workplace is correlated with creativity, critical thinking, team performance, wellness, and retention. But the presence of psychological safety is still lacking within health care organizations. The absence of psychological safety can prevent individuals from expressing themselves freely. Torrabla describes how individuals in the workplace perform a careful and tactful calculation before speaking up to determine the level of risk their statement may pose. Said another way, people are thinking really hard before they say something to make sure that the statement isn't going to be met with embarrassment or ridicule. As I stated before, this is an act of being vulnerable. Arad states that teamwork can be inhibited by low levels of psychological safety. As we know, teamwork is absolutely crucial in health care. Theoretically, this decrease in health care workers being able to speak freely and decrease in their ability to work well as a team
as a result of low psychological safety can result in missed opportunities to catch potential errors. An example of a patient safety error impacted by low psychological safety was described by Arad. In this study, an operating room nurse was interviewed about their experience with communication in the operating room. One nurse described a scenario where psychological safety was impaired during a routine surgical count. The nurse informed the surgeon that the surgical count was incorrect, but the surgeon insisted otherwise. The nurse described how the surgeon bullied them and told them to go to school and learn to count, and continued to close the case. Later, the nurse pushed for an x ray to be performed and the missing surgical instrument was discovered in the patient. This error may have been missed. The nurse not insisted on the surgical count being incorrect. Certainly the surgeon, acting as team leader, could have better handled the scenario to preserve psychological safety of the team and safety of the patient. Another study among critical care nurses in the intensive care unit examined the impact of psychological safety and adherence to safety checklist during placement of central Ines. This study found that nurses with a higher sense of psychological safety were more likely to report nonadherence to safety checklists for centralized insertion. Meaning nurses that had a higher sense of psychological safety were more likely to speak up if they saw a breach in sterility. Clearly, this can have a huge impact on patient safety as we know the dangers of central line associated infections. This finding demonstrates how psychological safety can directly impact patient safety as central associated infections have detrimental effects on patient outcomes. A different study among ER nurses sought to examine the influence of psychological safety on teamwork and patient safety. This study identified that psychological safety was a key component of effective teamwork and communication. And since we know teamwork and communication are critical components to patient safety, it can be stated that psychological safety has an indirect effect on patient safety as well. Some of us may have heard about tools or algorithms used for speaking up that are suggested to help promote patient safety and recognizing unsafe patient situations. An example of this would be the use of cus words. This essentially says, to first express that you are concerned about a patient scenario, Then say you feel uncomfortable with a patient scenario. And finally, express that you feel a scenario is a safety issue if the previous statements were not regarded properly. While this algorithm may be helpful, Rudolph expresses that these tools and algorithms are simply not enough, and true psychological safety is needed for true open communication. What are the recommendations for leaders? With all the information I just covered in regards to why low psychological safety can be detrimental, not only to learners but to our patients. I'm going to cover some information on what leaders can do to create psychologically safe environments. And I'm using the term leader here as a generalization. This can mean the surgeon, a nurse preceptor, a CRNA preceptor, a fellow attending, et cetera. Really, anyone in the team can use these techniques to create psychological safety. The literature contains several recommendations that preceptors and team leaders can utilize to help cultivate a psychologically safe environment for their learners. Hardy outlined a set of guidelines that preceptors can use to provide a psychologically safe experience for their learners. And these guidelines begin as early as when the preceptor or the team leader meets their learner for the first time. Behaviors such as giving a proper introduction, clarifying the learner's preferred name, making eye contact, building rapport, and outlining learning goals set the stage for psychological safety. These behaviors convey a sense of respect for the learner as well as the preceptor's vested interest in their learning. Continued guidelines include giving frequent positive feedback, sharing personal limitations, and offering support foster a psychologically safe environment for the learner. Johnson echoed these findings describing how when preceptors or clinical leaders acknowledge their own limitations, display humility and offer their own vulnerability, they allow for learners to share their thoughts and ideas, even when potentially incorrect. Given the complex, ambiguous and dynamic nature of providing health care to patients, it's important that learners feel comfortable asking questions or sharing their thoughts. In this way, learners can correct mistakes, learn new information. While feedback cannot always be positive, negative feedback should be met along with examples of how to improve. For example, SRNA must master the task of mask ventilating a patient in order to administer anesthesia. Anyone that has mask ventilated, a real patient can tell you that it's a lot harder than it looks. It cannot be fully learned without performing it on an actual patient. Feedback that's specific to the technique in which a learner holds their hand or holds the mask is critical for the student to improve their technique. While it's a challenging task to master, preceptors that utilize these techniques can help students learn that skill without totally dismantling their confidence. It's also important that the preceptor acknowledge the learner's effort in achieving the skill. With this being said, the presence of psychological safety does not absolve the learner for their own accountability. Learners must be properly prepared and held accountable in order to properly engage with their clinical environment. In summary, psychological safety is a subjective feeling by an individual that an environment is safe to express thoughts, ask questions, and raise concerns without the fear of shame, humiliation, or embarrassment. The presence or absence of psychological safety among clinical learners can have a significant impact on their learning experience. The presence of psychological safety can have an impact on patient safety through the incidence of increased error reporting and psychologically safe environments. Preceptors can be instrumental in creating a psychologically safe environment for learners by displaying respect, engaging with students, and conveying a sense of investment in their learning experience. Further studies specifically on the impact of psychological safety for the student registered nurse anesthetist in the clinical environment would be helpful to expand these findings. I think introducing this concept to SRNA's before their clinical experience would also be really helpful to allow them to identify some of the feelings they may have in clinical and to give them tools on how to be resilient in psychologically unsafe situations. I think giving tools to preceptors on how to encourage psychological safety would be helpful as well. For those of you that have stuck around and tolerated my voice for this long, I thank you so much. I hope that you learn something about why psychological safety is important and how we can make the clinical environment more psychologically safe for the sake of each other and for our patients. Thank you. For those interested in looking at my sources, my references are listed in the show notes. Thank you so much.