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Psychological Safety

By Kate Cozart, M.Ed., Pharm.D., BCPS, BCGP, BCACP

Code Blue MICU. You hear the call overhead. You sprint two flights of stairs. You follow the crowd and take your place at the crash cart. You pass syringes of epinephrine and flushes every few minutes. “Should we try vasopressin?” You are only in your second week working as a “full fledged” PharmD but everyone is looking at you.

You are a P2 student on an IPPE rotation shadowing in an outpatient PharmD clinic. One of today’s patients is being started on Trulicity, and the preceptor turns to you during the visit when it is time to educate the patient on administration. You’ve never seen this device in person before now.

Do these scenarios bring an emotional response? That feeling in your stomach – especially if you’re thinking “I’ve been in ambulatory care for the last decade” – is driven by your amygdala.

When we think about psychological safety, we have to think about our specific learners. Let’s look at two learners. One enters residency with a strong background in pharmacokinetics and critical care. This learner is immediately ready to start answering consults independently from a knowledge standpoint. This learner was accustomed to responding to codes while on rotations. Another learner took mostly rotations in ambulatory care and community pharmacy, with minimal experiences in acute care. The thought of taking consults for critically ill patients causes significant stress for this learner. Which of these learners will likely excel in a weekend staffing experience that includes hospital-wide pharmacokinetic consults and response to any code blue events without an on-site preceptor?

As practitioners, we all want our patients to receive care that is high quality, safe, and effective. For this to be possible, we need to ensure the safety of our learners. Amy Edmondson, a pioneer in the field of psychological safety, reports that a safe environment is one of the keys to effective teamwork, and when we apply this to the medical field the psychological safety of the learner is extremely important for the physical safety of the patient.

When a learner feels unsafe, this typically leads to amygdala activation, a phenomenon that for most is hard to overcome. Once the amygdala is activated, the learner tends to have inadequate self-regulation, over-interpretation of emotion as truth, a flawed metabolism for criticism and praise, and often a negative self-image results from these processes.

Psychological safety for learners depends on both the environment and the learner. A psychologically safe learning environment should allow the learner to feel safe to admit a mistake, ask questions, share ideas, and grow from failures. When the environment is unsafe, however, learners become less likely to ask questions or admit mistakes and often this often results in blaming others. Safety can be achieved in many ways; making uncertainty safe by avoiding single right answers, using effective and learner-specific feedback methods, promoting a growth mindset, and modeling inclusivity are among the ways we can improve the safety of our learning environments.

The environment also needs to be tailored to the learner to allow the most of the experience. When an environment is psychologically safe but expectations are low, the learner may be comfortable but not growing into the independent practitioner we hope they can become. In contrast, the optimal learning zone is the area where both psychological safety and accountability are high.

Let’s go back to our learner scenarios. For the new resident in the MICU and the student being asked to provide education on an unfamiliar device, high accountability and a perceived lack of psychological safety may easily result in amygdala activation and leave them in the “anxiety zone” instead of the “learning zone.” So let’s get to know our learners and create an environment where they feel open to communication and collaboration, and where they feel valued, trusted, and safe.


Kate Cozart, M.Ed., Pharm.D., BCPS, BCGP, BCACP

Clinical Pharmacist Practitioner, Primary Care

Department of Veterans Affairs

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