Barriers and Facilitators to Surgical Trainee Psychological Safety.

Importance: Although psychological safety has been shown to be imperative for effective learning, specific factors associated with its presence in surgical training have not been well characterized. Objective: To identify barriers and facilitators to psychological safety for surgical trainees in the clinical learning environment. Design, Setting, and Participants: This qualitative study was conducted from February 20 to May 2, 2024, among 25 trainees in general surgery and 3 surgical subspecialty programs at 9 teaching hospitals-4 university-based, 3 community-based, and 2 community-based, university-affiliated hospitals. Exposure: Participation in surgical training. Main Outcomes and Measures: Participants were asked to share their perspectives and experiences in training in association with psychological safety in the learning environment. Purposive sampling was used to recruit for semistructured interviews. Transcripts were coded inductively using an interpretive description method. Results: Of 25 surgical trainees (13 women [52%]), 13 (52%) were junior residents (postgraduate years 1-3) and 7 (28%) were members of racial and ethnic minority groups. Four barriers and 3 facilitators to psychological safety were identified. Trainees cited (1) public humiliation, (2) tension around questioning, (3) culture fostered by faculty, and (4) influence of flawed system factors as barriers to psychological safety. Learners described instances of mistreatment and public shaming as detrimental to establishing psychological safety. Although trainees expressed a desire to ask more questions, fear of judgment served as a major barrier to building psychological safety through question asking in the trainee-faculty relationship. Although faculty played a key role in dictating whether psychological safety was present, trainees also noted overarching system-level factors, such as understaffing and lack of resources, as obstacles to promoting psychological safety. Conversely, (1) the work involved in promoting psychological safety, (2) trust, and (3) normalizing vulnerability in the clinical learning environment were facilitators of psychological safety. Trainees highlighted intentionality of actions by chief residents and faculty that explicitly promoted psychological safety. Instances where trust was initially "on the line" (ie, at serious risk of being lost) but ultimately reinforced formed the basis for psychological safety. Furthermore, acknowledgment of shortcomings normalized open sharing of mistakes in a psychologically safe manner. Conclusions and Relevance: This qualitative study identified 7 key individual, interpersonal, and organizational factors associated with psychological safety for surgical trainees. These findings may help inform the future development of interventions aimed at promoting psychological safety in the learning environment for surgical trainees.