#KeyLIMEPodcast 244: Safety Dance

This special live episode was recorded at the 2019 Association of American Medical Colleges (AAMC) Conference in Phoenix, Arizona.  Lara’s selection tackled (the lack of) formal literature on psychological safety in medical education. The authors delved in to the concept, examining its components across institutional, interpersonal, and intrapersonal levels in order to develop further insights, definitions and theories.

Listen in to hear their conclusions on the topic.


KeyLIME Session 244

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Hsiang-Te Tsuei, et. al. 2019. Exploring the Construct of Psychological Safety in Medical Education. Academic Medicine. 94


Lara Varpio (@LaraVarpio)


  • The authors tell us that there is little formal literature in medical education that defines or explores psychological safety in depth., that psychological safety has largely been explored as an absence. They explain that scholars have focused on situations and contexts where psychological safety is missing and on how medical learners face social, verbal, sexual, and physical mistreatment.
  • But just because we know what erodes psychological safety doesn’t necessarily mean that, if those factors are NOT in the context that psychological safety IS in the context. The authors contend that we need to compliment that research by exploring and defining what psychological safety IS, and not just study what actions to avoid.
  • The authors point out that other fields have examined psychological safety, originating in the seminal works of Edmondson and Kahn in management science where considerable research has defined and explored psychological safety, including ways of maximizing it. It has also been studied in the nursing literature. But medicine hasn’t done this foundational work, and so our understanding of how to build a safe learning environment for our learners is under developed.


  • This study seeks to inductively develop insights into the concept of psychological safety for medical learners which can then serve as a foundation for developing definitions and theories on this important concept.

Key Points on the Methods

  • The authors offer a strong justification for the study’s context. The study was conducted in a peer-assisted-learning program because the literature suggests that peer-assisted-learning fosters students’ psychological safety because it fosters a positive socio-emotional environment. Participants of the local peer-assisted-learning program were, therefore, a reasonable target population to participate in the study. It stands to reason that this population would have insights into what psychological safety is when it is present in a learning context
  • The authors explain that this is a descriptive and exploratory study, using semi-structured interviews for data collection. The authors describe the structure of the interview protocol, and they give us the interview guide as an Appendix
  • Another methods highlight to note in this paper is that the authors clearly described when theory was used to inform the research. The first stages of analysis were fully inductive — so no theory informed that analysis. But when the researchers moved from describing data themes to interpreting them, the authors used Brofenbrenner’s social ecological theory to inform that interpretation.

Key Outcomes

  • The authors describe the constituents of psychological safety, offering that description across institutional, interpersonal, and intrapersonal levels. The tie that binds them together is that these elements made the learners feel free to engage fully in the learning moment, without having to hold back or monitor themselves for fear of being judged
  • At an institutional level, that freedom was supported in the peer assisted learning program because there were no formal assessments and no formal structure to adhere to. That informal approach let the students engage in curiosity driven learning
  • At an interpersonal level, the psychological safety enabled by not needing to self-monitor was supported by strong relationships between the learners and between the learners and the faculty. Those relationships made the individual learners feel seen as a person, cared for — not just as a future clinician, but as a person with their own goals, aspirations, and fears. They also didn’t worry about asking questions that might reveal their ignorance on a topic.
  • At an intrapersonal level, psychological safety was present when the learner him/herself felt that they were meeting their own expectations in terms of performance, that they were keeping up with their peers.
  • The second part of the results talked about the consequences of feeling psychological safety. If that safety was absent, the learners engaged in social comparison to their classmates and talked about feeling anxious, ashamed or inadequate. They were reticent to engage in the learning activities. BUT, if psychological safety was present, they were freed from those comparisons and the associated negative feelings. In fact, the presence of psychological safety became a self-reinforcing structure that generated a stronger sense of psychological safety.

Key Conclusions

  • The authors conclude that educational safety is a relational product and that when a sense of safety is sufficiently strong, learners are liberated from constantly worrying about the consequences of their actions.


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