Psychological Safety and Support: Assessing Resident Perceptions of the Clinical Learning Environment

Psychological safety and perceived organizational support in emergency medicine residencies

Background

The clinical learning environment (CLE) is a key focus of the Accreditation Council of Graduate Medical Education. It impacts knowledge acquisition and professional development. A previous single-center study evaluated the psychological safety and perceived organizational support of the CLE across different specialties. Building on this work, we explored and evaluated psychological safety and perceived organizational support across multiple heterogeneous emergency medicine (EM) residencies to identify trends and factors affecting perceptions of the CLE.

Methods

Using the Psychological Safety Scale (PSS) and Survey of Perceived Organizational Support (SPOS), residents from seven U.S. EM residencies were surveyed using REDCap software from September through November 2021, with 300 potential respondents. As an adjunct to these surveys, three open-ended questions were included regarding features of their learning environments.

Results

A total of 137 out of 300 residents completed the survey. The overall response rate was 45.7%. There was a variable response rate across programs (26.0%-96.7%). Pooled results demonstrate an overall positive perception of CLEs, based on positive mean responses (i.e., "Members of my department are able to bring up problems and tough issue" had a mean of 4.2 on a 5-point Likert scale). Open responses identified teaching, collegiality, and support from program leadership as supportive features of the CLE. Confrontational interdisciplinary communication, a sense of being devalued, and off-service rotations were identified as threats or areas for improvement to the CLE.

Conclusions

PSS and SPOS scores were generally positive in this multi-institution study, consistent with the prior single-institution study indicating that EM is often considered psychologically safe and supportive. EM training programs can consider using the PSS/SPOS to audit their own programs to identify areas for improvement and foster supportive features already in place.

Psychological safety in the perioperative environment: a cost-consequence analysis

INTRODUCTION

Psychologically unsafe healthcare environments can lead to high levels of staff turnover, and unwanted financial burden. In this study, we investigate the hypothesis that lower levels of psychological safety are associated with higher levels of turnover, within an anaesthesiology department and we estimate the cost attributable to low psychological safety, driven by turnover costs.

METHODS

Psychological safety was measured in one academic department. The psychological safety score was correlated with 'intention to leave' using linear regression and Pearson correlation and a cost-consequence analysis was performed.

RESULTS

One hundred and thirty-eight physician anaesthesiologists (MDs) and 282 certified registered nurse anaesthetists (CRNAs) were surveyed. The response rate was 67.4% (93/138) for MDs and 60.6% (171/282) for CRNAs. There was an inverse relationship between psychological safety and turnover intent for both MDs (Pearson correlation -0.373, p value <0.0002) and CRNAs (Pearson correlation -0.486, p value <0.0002). The OR of intent to turn over in the presence of low psychological safety was 6.86 (95% CI 1.38 to 34.05) for MDs and 8.93 (95% CI 4.27 to 18.68) for CRNAs. The cost-consequence analysis demonstrated the cost of low psychological safety related to turnover per year was $337, 428 for MDs and $14, 024, 279 for CRNAs. Reducing low psychological safety in CRNAs from 31.6% to 20% reduces the potential cost of low psychological to $8 876 126.03.

CONCLUSION

There is a cost relationship between low psychological safety and turnover. Low psychological safety in an academic anaesthesiology department may result in staff turnover, and potentially high financial costs.

'We were treated like we are nobody': a mixed-methods study of medical doctors' internship experiences in Kenya and Uganda

OBJECTIVE

Medical interns are an important workforce providing first-line healthcare services in hospitals. The internship year is important for doctors as they transition from theoretical learning with minimal hands-on work under supervision to clinical practice roles with considerable responsibility. However, this transition is considered stressful and commonly leads to burn-out due to challenging working conditions and an ongoing need for learning and assessment, which is worse in countries with resource constraints. In this study, we provide an overview of medical doctors' internship experiences in Kenya and Uganda.

METHODS

Using a convergent mixed-methods approach, we collected data from a survey of 854 medical interns and junior doctors and semistructured interviews with 54 junior doctors and 14 consultants. Data collection and analysis were guided by major themes identified from a previous global scoping review (well-being, educational environment and working environment and condition), using descriptive analysis and thematic analysis respectively for quantitative and qualitative data.

FINDINGS

Most medical interns are satisfied with their job but many reported suffering from stress, depression and burn-out, and working unreasonable hours due to staff shortages. They are also being affected by the challenging working environment characterised by a lack of adequate resources and a poor safety climate. Although the survey data suggested that most interns were satisfied with the supervision received, interviews revealed nuances where many interns faced challenging scenarios, for example, poor supervision, insufficient support due to consultants not being available or being 'treated like we are nobody'.

CONCLUSION

We highlight challenges experienced by Kenyan and Ugandan medical interns spanning from burn-out, stress, challenging working environment, inadequate support and poor quality of supervision. We recommend that regulators, educators and hospital administrators should improve the resource availability and capacity of internship hospitals, prioritise individual doctors' well-being and provide standardised supervision, support systems and conducive learning environments.

Critical care medicine training in the age of COVID-19

CONTEXT

The COVID-19 pandemic caused the largest disruption to graduate medical education in modern history. The danger associated with SARS-CoV-2 necessitated a paradigm shift regarding the fundamental approach to the education of medical residents and fellows. Whereas prior work has examined the effect of the pandemic on residents' experiences during training, the effect of the pandemic on academic performance of critical care medicine (CCM) fellows is not well understood.

OBJECTIVES

This study examined the relationship between CCM fellow's lived experiences during the COVID-19 pandemic and performance on in-training examinations.

METHODS

This mixed-methods study consisted of a quantitative retrospective analysis of critical care fellows' in-training examination scores and a qualitative, interview-based phenomenological examination of fellows' experiences during the pandemic while training in a single large academic hospital in the American Midwest. Quantitative: Prepandemic (2019 and 2020) and intrapandemic (2021 and 2022) in-training examination scores were analyzed utilizing an independent samples t test to determine whether a significant change occurred during the pandemic. Qualitative: Individual semi-structured interviews were conducted with CCM fellows exploring their lived experiences during the pandemic and their perception of the effect on their academic performance. Transcribed interviews were analyzed for thematic patterns. These themes were coded and categorized, and subcategories were developed as indicated during the analysis. The identified codes were then analyzed for thematic connections and apparent patterns. Relationships between themes and categories were analyzed. This process was continued until a coherent picture could be assembled from the data to answer the research questions. Analysis was performed from a phenomenological perspective with an emphasis on interpretation of the data from the participants' perspectives.

RESULTS

Quantitative: Fifty-one in-training examination scores from 2019 to 2022 were obtained for analysis. Scores from 2019 to 2020 were grouped as prepandemic scores, while scores from 2021 to 2022 were grouped as intrapandemic scores. Twenty-four prepandemic and 27 intrapandemic scores were included in the final analysis. A significant difference was found between mean total prepandemic and intrapandemic in-service examination scores (t 49=2.64, p=0.01), with mean intrapandemic scores being 4.5 points lower than prepandemic scores (95 % CI, 1.08-7.92). Qualitative: Interviews were conducted with eight CCM fellows. Thematic analysis of the qualitative interviews revealed three main themes: psychosocial/emotional effects, effects on training, and effects on health. The factors that most effected participants' perceptions of their training were burnout, isolation, increased workload, decreased bedside teaching, decreased formal academic training opportunities, decreased procedural experience, a lack of an external reference point for normal training in CCM, fear of spreading COVID-19, and neglect of personal health during the pandemic.

CONCLUSIONS

In-training examination scores decreased significantly during the COVID-19 pandemic for CCM fellows in this study. The fellows in this study reported perceived effects of the pandemic on their psychosocial/emotional well-being, medical training, and health.

"I never should have been a doctor": a qualitative study of imposter phenomenon among internal medicine residents

INTRODUCTION

Imposter phenomenon is common among medical trainees and may influence learning and professional development. The authors sought to describe imposter phenomenon among internal medicine residents.

METHODS

In 2020, using emailed invites we recruited a convenience sample of 28 internal medicine residents from a teaching hospital in Baltimore, Maryland to participate in an exploratory qualitative study. In one-on-one interviews, informants described experiences of imposter phenomenon during residency training. Using thematic analysis to identify meaningful segments of text, the authors developed a coding framework and iteratively identified and refined themes. Informants completed the Clance Imposter Phenomenon Scale.

RESULTS

Informants described feelings and thoughts related to imposter phenomenon, the contexts in which they developed and the impact on learning. Imposter phenomenon has profound effects on residents including: powerful and persistent feelings of inadequacy and habitual comparisons with others. Distinct contexts shaping imposter phenomenon included: changing roles with increasing responsibilities; constant scrutiny; and rigid medical hierarchy. Learning was impacted by inappropriate expectations, difficulty processing feedback, and mental energy diverted to impression management.

DISCUSSION

Internal medicine residents routinely experience imposter phenomenon; these feelings distort residents' sense of self confidence and competence and may impact learning. Modifiable aspects of the clinical learning environment exacerbate imposter phenomenon and thus can be acted upon to mitigate imposter phenomenon and promote learning among medical trainees.

How I Teach: Ultrasound-guided Peripheral Venous Access

Ultrasound-guided peripheral intravenous (IV) placement is often required for patients with difficult IV access and is associated with a reduction in central line placement. Despite the importance, there is no standardized technical approach, and there is limited ability to attain mastery through simulation. We describe our step-by-step approach for teaching ultrasound-guided IV placement at the bedside using short-axis dynamic guidance, with emphasis on advancing the needle and catheter device almost entirely into the vessel before threading the catheter. Our teaching approach allows the opportunity for trainees to maximize the learning potential of a single insertion experience, which includes focused preprocedure hands-on practice, instruction with real-time feedback at the bedside, and a post-procedure debrief with reinforcement of concepts.

Educational Safety for the Surgical Learner

Psychological safety is known to improve team performance and organizational learning. The related concept of "educational safety" has recently emerged to describe an environment in which learners can unreservedly focus on learning and professional growth, without worrying about the potential repercussions of interpersonal risk-taking. Educational safety is crucial for optimal learning in clinical environments, and yet is difficult to establish due to constant performance assessment, fear of failure, and pervasive hierarchies. In this perspective, we propose a framework for conceptualizing educational safety in surgical learning environments, and explore current threats to educational safety. We also discuss strategies for combating these threats, as well as the importance of further research to evaluate the impact of educational safety on surgical learning outcomes.

It's a 'two-way street': resident perspectives of effective coaching relationships in the clinical learning environment

BACKGROUND

Coaching has gained traction in postgraduate medical education to enhance interactions between residents and clinical teachers, but these relationships present unique challenges and tensions. In order to realize the promises of coaching in medical education, we must understand how coaching relationships can be enacted to optimize resident development. The purpose of this study was to explore residents' perceptions of key characteristics for effective clinical teacher-resident (CT-R) coaching relationships.

METHODS

We conducted four focus groups and eight interviews with residents at a Canadian academic center. Using a social constructionist approach, focus groups and interviews were audio recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Residents described three main characteristics that contributed to effective CT-R coaching relationships: safe, meaningful, and collaborative. Residents emphasized that these characteristics needed to be bidirectional in nature to be most effective, in that both the resident and clinical teacher embodied these characteristics.

CONCLUSIONS

Residents identified that effective coaching relationships were shaped not only by clinical teacher behaviours, but importantly, the quality of the interpersonal relationship that was fostered. Thus, it is imperative to consider the bidirectional nature of the CT-R coaching relationship when striving to enhance resident development.

Growth, Engagement, and Belonging in the Clinical Learning Environment: the Role of Psychological Safety and the Work Ahead

Psychological safety is the perception that an environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of being shamed, blamed, or ignored. The presence of psychological safety has been associated with improved team learning and innovation, leader inclusivity, and team members' sense of belonging. In medical education, psychological safety has additional benefits: it allows learners to be present in the moment and to focus on the tasks at hand, and reduces trainee focus on image. Several key features of psychologically safe environments have already been described, including the presence of high-quality relationships, the absence of social positioning, a learner-driven and flexible learning agenda, the lack of formal assessment, and time for debriefing. However, many of the structures and cultural traditions in medical education are in clear opposition to these features. This paper describes the current barriers to psychological safety in medical education, and sets out an agenda for change. In accordance with benefits seen in other sectors, we anticipate that an emphasis on relationships and psychological safety will support the learning, inclusion, and success of medical trainees.

Influence of Psychological Safety and Organizational Support on the Impact of Humiliation on Trainee Well-Being

OBJECTIVES

To develop physicians who can practice safely, we need better understanding of how the clinical learning environment affects trainee well-being. Two psychosocial constructs may help us understand the context: psychological safety (belief one can speak up without concerns) and perceived organizational support (degree to which members feel that their organization cares for them and values their contributions). The objective of this study is to test a moderated mediation model to determine how humiliation (X) impacts trainees' well-being (Y) while taking into account psychological safety (mediator) and organizational support (moderator).

METHODS

Between May and June 2018, a single health system recruited resident physicians across 19 programs to complete an anonymous electronic survey to assess facets of the clinical learning environment, well-being, and experiences of humiliation. In a moderated mediation analysis, mediation helps explain how a predictor variable (X) impacts an outcome variable (Y) through a mediating variable, whereas moderation helps explain under what conditions such a relationship exists.

RESULTS

Of 428 residents, 303 responded (71%) to the survey across 19 training programs. The effects of humiliation on well-being were mitigated by psychological safety, which varied depending on the levels of perceived organizational support. Environments rated 1 SD below the mean on perceived organization support by residents had a stronger negative impact of public humiliation on psychological safety.

CONCLUSIONS

The findings suggest that humiliation is associated with well-being through the effects of psychological safety and influenced by organizational support. Further work might explore the relationship by investing resources (e.g., faculty development, mentorship) to increase psychological safety and reduce humiliation during training, especially within environments prone to be perceived as unsupportive of trainees.

Residents as Research Subjects: Balancing Resident Education and Contribution to Advancing Educational Innovations

BACKGROUND

Research in education advances knowledge and improves learning, but the literature does not define how to protect residents' rights as subjects in studies or how to limit the impact of their participation on their clinical training.

OBJECTIVE

We aimed to develop a consensual framework on how to include residents as participants in education research, with the dual goal of protecting their rights and promoting their contributions to research.

METHODS

A nominal group technique approach was used to structure 3 iterative meetings held with the pre-existing residency training program committee and 7 invited experts between September 2018 and April 2019. Thematic text analysis was conducted to prepare a final report, including recommendations.

RESULTS

Five themes, each with recommendations, were identified: (1) Freedom of participation: participation, non-participation, or withdrawal from a study should not interfere with teacher-learner relationship (recommendation: improve recruitment and consent forms); (2) Avoidance of over-solicitation (recommendation: limit the number of ongoing studies); (3) Management of time dedicated to participation in research (recommendations: schedule and proportion of time for study participation); (4) Emotional safety (recommendation: requirement for debriefing and confidential counseling); and (5) Educational safety: data collected during a study should not influence clinical assessment of the resident (recommendation: principal investigator should not be involved in the evaluation process of learners in clinical rotation).

CONCLUSIONS

Our nominal group technique approach resulted in raising 5 specific issues about freedom of participation of residents in research in medical education, over-solicitation, time dedicated to research, emotional safety, and educational safety.

An Institutional Approach to Harassment

Harassment is commonly experienced within the hierarchical world of medicine by both learners and faculty. There are different types of harassment; however, all types of harassment have a negative impact on individuals professionally and personally. Harassment also negatively impacts groups, by impacting team dynamics, perceptions of leaders, and upon workplace psychological safety and wellness. To address harassment, the Faculty of Medicine and Dentistry (FoMD) at the University of Alberta (UAlberta) has developed a structured institutional response to harassment through: (1) providing institutional members and leaders with explicit expectations of behaviour, outlining types of harassment, and starting to integrate psychological safety priorities at all levels of the institution; (2) through aiding, training, selecting, and evaluating workplace leaders in psychological safety, workplace wellness, and harassment interventions, guiding leaders through options of: coaching types of interventions, investigations, and when there is a duty to report to formal bodies; (3) educating and providing tools for workplace members to deal with harassment situations either; directly or by reporting; and (4) being aware of, and addressing, unique aspects of: racial, sexual, and online harassment. Through such iterative institutional process improvement and reflection, we are moving towards effectively addressing harassment within all learning and working environments. Our ultimate institutional goal is to eradicate harassment occurrence within our institution, thus creating a psychologically safe, transparent, and accountable culture for individuals, workplaces, and groups.

A concept analysis of psychological safety: Further understanding for application to health care

AIM

To clarify the concept of psychological safety in a healthcare context and to provide the first theoretical framework for improving interpersonal relationships in the workplace to better patient care.

DESIGN

A Rodgers' concept analysis.

METHODS

The concept analysis was conducted using a systematic search strategy on PubMed, CINAHL, PsycINFO and Ichushi-Web.

RESULTS

An analysis of 88 articles studying psychological safety in health care identified 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. The antecedents included structure/system factors, interpersonal factors and individual factors. The four consequences included performance outcomes, organizational culture outcomes, and psychological and behavioural outcomes.

Tools for measuring medical internship experience: a scoping review

BACKGROUND

Appropriate and well-resourced medical internship training is important to ensure psychological health and well-being of doctors in training and also to recruit and retain these doctors. However, most reviews focused on clinical competency of medical interns instead of the non-clinical aspects of training. In this scoping review, we aim to review what tools exist to measure medical internship experience and summarize the major domains assessed.

METHOD

The authors searched MEDLINE, Embase, PsycINFO, ERIC, and the Cochrane Library for peer-reviewed studies that provided quantitative data on medical intern's (house officer, foundation year doctor, etc.) internship experience and published between 2000 and 2019. Three reviewers screened studies for eligibility with inclusion criteria. Data including tools used, key themes examined, and psychometric properties within the study population were charted, collated, and summarized. Tools that were used in multiple studies, and tools with internal validity or reliability assessed directed in their intern population were reported.

RESULTS

The authors identified 92 studies that were included in the analysis. The majority of studies were conducted in the US (n = 30, 32.6%) and the UK (n = 20, 21.7%), and only 14 studies (15.2%) were conducted in low- and middle-income countries. Major themes examined for internship experience included well-being, educational environment, and work condition and environment. For measuring well-being, standardized tools like the Maslach Burnout Inventory (for measuring burnout), Patient Health Questionnaire-9 (depression), General Health Questionnaire-12 or 30 (psychological distress) and Perceived Stress Scale (stress) were used multiple times. For educational environment and work condition and environment, there is a lack of widely used tools for interns that have undergone psychometric testing in this population other than the Postgraduate Hospital Educational Environment Measure, which has been used in four different countries.

CONCLUSIONS

There are a large number of tools designed for measuring medical internship experience. International comparability of results from future studies would benefit if tools that have been more widely used are employed in studies on medical interns with further testing of their psychometric properties in different contexts.

Development and Validation of a Theory-Informed Group Learning Environment Assessment Tool for Graduate Medical Education Programs

BACKGROUND

Recent studies showed that psychological safety is important to resident perception of the work environment, and improved psychological safety improves resident satisfaction survey scores. However, there is no evidence in medical education literature specifically addressing relationships between psychological safety and learning behaviors or its impact on learning outcomes.

OBJECTIVE

We developed and gathered validity evidence for a group learning environment assessment tool using Edmondson's Teaming Theory and Webb's Depth of Knowledge model as a theoretical framework.

METHODS

In 2018, investigators developed the preliminary tool. The authors administered the resulting survey to neonatology faculty and trainees at Baylor College of Medicine morning report sessions and collected validity evidence (content, response process, and internal structure) to describe the instrument's psychometric properties.

RESULTS

Between December 2018 and July 2019, 450 surveys were administered, and 393 completed surveys were collected (87% response rate). Exploratory factor analysis and confirmatory factor analysis testing the 3-factor measurement model of the 15-item tool showed acceptable fit of the hypothesized model with standardized root mean square residual = 0.034, root mean square error approximation = 0.088, and comparative fit index = 0.987. Standardized path coefficients ranged from 0.66 to 0.97. Almost all absolute standardized residual correlations were less than 0.10. Cronbach's alpha scores showed internal consistency of the constructs. There was a high correlation among the constructs.

CONCLUSIONS

Validity evidence suggests the developed group learning assessment tool is a reliable instrument to assess psychological safety, learning behaviors, and learning outcomes during group learning sessions such as morning report.

Threats to Reliability and Validity With Resident Wellness Surveying Efforts

BACKGROUND

Residency programs and the Accreditation Council for Graduate Medical Education (ACGME) use survey data for the purpose of program evaluation. A priority for many programs is to improve resident wellness, often relying on self-reported surveys to drive interventions.

OBJECTIVE

We tested for result differences on wellness surveys collected through varying survey methodology and identified potential causes for differences.

METHODS

Aggregated results on the resident wellness scale for a single institution were compared when collected electronically through the ACGME Resident Survey immediately following the program evaluation survey for accreditation purposes and anonymously through an internal survey aimed at program improvement.

RESULTS

Across 18 residency programs, 293 of 404 (73%) residents responded to the internal survey, and 383 of 398 residents (96%) responded to the 2018 ACGME survey. There was a significant difference (P < .001, Cohen's d = 1.22) between the composite wellness score from our internal survey (3.69 ± 0.34) compared to its measurement through the ACGME (4.08 ± 0.30), indicating reports of more positive wellness on the national accreditation survey. ACGME results were also statistically more favorable for all 10 individual scale items compared to the internal results.

CONCLUSIONS

Potential causes for differences in wellness scores between internal and ACGME collected surveys include poor test-retest reliability, nonresponse bias, coaching responses, social desirability bias, different modes for data collection, and differences in survey response options. Triangulation of data through multiple methodologies and tools may be one approach to accurately gauge resident wellness.

Analysis of the Emergency Medicine Clinical Learning Environment

BACKGROUND

Residencies are grappling with ways to identify methods to internally monitor and improve their learning environments. Building on prior work, the objective of this study was to determine emergency medicine (EM) internal evaluations of perceived organizational support and psychological safety and compare to the results from the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey for the purpose of program improvement and to explore factors affecting residents' perception of their learning environment.

METHODS

In 2017, the Virginia Commonwealth University School of Medicine Office of Graduate Medical Education and Office of Quality and Safety conducted an in-person, anonymous safety survey of the residents across 19 residency programs on the Short Survey of Perceived Organizational Support (SPOS) and Psychological Safety Scale (PSS). These were compared to the ACGME Resident Survey for 19 programs. Resident interviews and open response evaluation data informed content analysis on program experiences.

RESULTS

Institutional response rates were 63% for the internal learning environment survey and 96% for ACGME Resident Safety Survey. EM residents responded positively on the SPOS and PSS compared to other programs (ranked second highest scores on both scales). One-hundred percent of respondents agreed or strongly agreed on SPOS items: "Help is available from my department when I have a problem." "My department really cares about my well-being." "My department values my contribution to its well-being." Furthermore, EM had the highest overall training experience score (mean = 4.83) on the ACGME survey compared to the 18 other training programs. Qualitative responses suggest program strengths included supportive program leadership, positive working relationships with faculty, and emphasis on trainee wellness.

CONCLUSIONS

Compared to other programs, EM has created a positive environment of safety and support as perceived by their residents. Internal surveys of the learning environment can help programs understand their culture for purposes of improvement and align with the ACGME survey.