We saw the smile vanish from her face instantly. Our colleague, a zestful individual with a passion for obstetrical care, fell silent after our superiors met her ideas for improving her training experience with defensiveness and deflection. After the meeting, she confessed she was losing hope about getting robust enough exposure to delivering babies and managing laboring mothers prior to completing residency. For her, this was essential to her securing a job she desired after graduating. When we asked what caused her to become disconsolate immediately, she said it was the unwillingness to explore ideas and understand her concerns.
What our colleague experienced was a lack of psychological safety, which is defined as the perception of being safe from negative repercussions when sharing thoughts, ideas, opinions, and struggles with others. Deficient psychological safety in society causes individuals to fear expressing their authentic selves, which impedes open communication and collaboration. This lack of psychological safety perpetuates silence, suppresses creativity, and threatens well-being. It exacerbates social divisions, resulting in marginalized groups not voicing their concerns and deepening inequalities. Feeling psychologically unsafe contributes to a sense of isolation, eroding trust and empathy within communities.
Although many of us can acknowledge the value of psychological safety in our own lives, the concept is not without its criticisms. Some academics and other opponents have argued that creating psychologically safe environments can lead to no accountability for poor performance, consensus decision-making, groupthink, and excessive collegiality. Some fear all of this would suppress open and honest discussions about problems. While micromanaging work environments to ensure safety at all costs could produce these outcomes, psychological safety can exist in the same context as a fluid dialogue about unenviable situations.
Interestingly, psychological safety changes how different neurons in the brain fire, and recent neurobiology research has shown that social distress from deficient psychological safety produces similar brain activity to physical pain. Specifically, there is more activity in the dorsal anterior cingulate cortex and right vertical prefrontal cortex, which are associated with responding to both types of distress and regulating them, respectively. When people feel unsafe, they lose the ability to use other areas of the prefrontal frontal cortex responsible for attention, cognitive flexibility, and prospective memory. When we feel psychologically safe, the brain tends to produce more oxytocin, which is a neurotransmitter that suppresses the amygdala and other brain regions involved in survival and hyperreactivity to stress.
Creating a psychologically safe environment offers broad benefits for creating open, inclusive, and effective spaces. As such, encouraging an atmosphere where people feel safe to share their thoughts without fear of criticism has clear importance. When this happens, it helps teams share genuine interactions in order to work better together. When people share different ideas openly, it can lead to coming up with new and creative solutions to problems. It also builds stronger interpersonal relationships and lowers stress associated with interpersonal interactions. Feeling safe in a group makes individuals happier and more engaged. Overall, upholding psychological safety enables strong collaboration and creates a healthier and more supportive environment.
As evidence demonstrating the importance of psychological safety has grown, it has become clear that there are theoretical and practical overlaps between this phenomenon and concepts described in the field of positive psychology. For example, flow states are achieved when there is balance between the perceived challenge of a task and the skills necessary to complete it. When experiencing flow, people view challenges in a favorable light and are able to put in a lot of mental effort without distress. This phenomenon harkens back to psychological safety, enabling people to be vulnerable without fear of negative consequences. In fact, we argue that psychological safety is likely a prerequisite for humans to achieve what Martin Seligman has called “flourishing.”
While often discussed but rarely practiced, there is room for much improvement in psychological safety in professional settings, especially in health care. Typically based in dated, hierarchical structures, the nature of these workplaces is a major obstacle. Open disdain toward questions from junior resident physicians by more senior doctors discourages inquiry and impairs learning. These negative environments stifle the expression of concerns by the lower-ranking staff, creating hostile workplaces and poorer patient care. Fear of reprisal may create a culture of secrecy and insecurity, which tends to only perpetuate deep-seated issues.
Moreover, heavy workloads and having limited time only add to stress levels and beget general insecurity among staff. Certain populations struggle with these challenges more than others. The aforementioned issues are compounded by classic discriminatory behaviors in the workplace, which makes life even harder for employees of marginalized backgrounds. On top of that, some may worry about being judged for the way they speak or how they look, which further deteriorates the perceived safety of workplaces. Making changes to address these problems is critical to improving employee well-being and patient care in health care settings.
So, how can we nurture psychological safety in adverse environments? To start, leaders can encourage open communication, value diverse perspectives, acknowledge mistakes as opportunities for growth, cultivate a non-judgmental atmosphere, and promote trust and collaboration. Leaders should exemplify vulnerability, demonstrating that it is safe to express concerns and that “to err is human.” Other evidence-based strategies include emphasizing collective success over individual blame, regularly checking in on everyone’s well-being, and promoting a supportive culture that prioritizes mental health. By prioritizing empathy, understanding, and accountability, teams can navigate adversity together, all while building psychological safety as a steadfast foundation for growth and innovation.
Psychological safety is critical to individual and organizational growth. For our colleague, a lack of psychological safety led to disengagement from the people who had the power to change her professional training environment and caused others to remain silent on similar subjects. In our work to build a stronger culture of psychological safety in our program, we are optimistic that we can turn the tide on interactions like these and ensure that she does not stay resigned to a fate that others control. Much like burnout, psychological safety is not an individual responsibility; it takes adaptive leadership and commitment from teams to attain it.
Ashten Duncan and Isabel Diaz Morfin are family medicine residents.
