Psychological safety was initially defined as a "shared belief that the team is safe for interpersonal risk-taking" [9]. These interpersonal risks include open communication, voicing concerns, asking questions and seeking feedback without fear of judgment [10]. 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 [11]. Therefore, psychological safety required that deliberate efforts are made to reduce the professional hierarchy often observed in healthcare teams [12].
Psychological safety in nursing preceptorship.
The concept of psychological safety is not new to nursing education. In a psychologically safe 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]. It is particularly important 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 national clinical assessment document (NCAD) [14]. Preceptors are also responsible for ensuring they provide a supportive culture for students [14].
Current literature reports that when students feel psychologically unsafe, they tend to refrain from doing or saying something that might suggest incompetence [15]. An unsafe psychological environment can also raise anxiety and lead to avoidance and disengagement of students' clinical education and patient care [16; 17]. Students can find it challenging to think clearly, retain information or perform clinical skills they previously felt competent in [15]. 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 [18].
Psychologically safe learning environments permit students to seek clarification or help to answer questions or demonstrate skills workout fear of judgement or humiliation [19]. 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 [20]. Having a psychologically safe environment does not mean that there is a lack of accountability [21]. In fact, accountability and psychological safety are both required in order to students to operate within the “learning zone” [21]. 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 [22].
To contextualise the principles of psychological safety and learning in the clinical environment, it is important to consider Maslow's (1943) hierarchy of needs [23]. 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.
Guidelines to providing a psychologically safe environments for students.
Lyman and colleagues’ recent study [19] 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 [24]. 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 [12].
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 [25]. On the other hand, a lack of openness or personal engagement from preceptors has resulted in negative learning experiences for students [26]. 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 1).
Inclusivity is another fundamental component of creating a psychologically safe learning environment [22]. 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 [22]. Social acceptance and feeling part of the team have led to motivation to provide care and clinical learning amongst students [27]. 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 1).
Unintentional bias is another factor that can result in a psychologically unsafe environment for students [28]. 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 1).
Setting clear expectations and learning objectives is also a valued action to create a psychologically safe learning environment for students [15]. When clear learning objectives are set collaboratively, it is shown to positively influence the students learning experience [29]. 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 1).
Another critical factor in creating a psychically safe learning environment is engaging students in collaborative and bidirectional feedback (30; 15]. Bidirectional feedback creates a collaborative environment and demonstrates a mutual respect [30]. 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” and “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 1).
Based on the current guidelines from other disciplines [31], professional guidance documents [14] and the literature described above, as well as the author's clinical expertise in a nursing preceptorship. Table 1 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.