So far, in the current blog series, I have explained why I have changed my mind about resident progress and evaluation transparency. I have also offered a series of questions programs can utilize to improve the gaps (as I see them) that may exist. Today I want to provide a reminder of why it matters – which boils primarily down to psychological safety.
Psychological safety is a concept that gets more attention than it once did, and rightly so. A psychologically safe environment “encourages, recognizes, and rewards individuals for their contributions and ideas by making them feel safe when taking interpersonal risks. It’s one that is built on respect and permission” (Definition from Psych Safety)
Dr. Timothy Clark, an Oxford-trained social science expert, and author of the Four Stages of Psychological Safety, lists the progressive stages. In order, they are:
When trainees don’t feel they belong, they must keep the impostor mask of perfection up for self-protection. It causes undue stress.
What can you do as individual upper-level residents and attendings do to create a culture of connectedness and belonging? What can the program offer to foster the same? What must change?
When it’s not perceived as safe, the mask stays up. They fear speaking up on rounds for fear of “looking stupid,” having a knowledge gap, or perhaps saying anything about an issue or situation they perceive as harmful. This impacts not only their education but team dynamics and patient safety.
How do you and your program normalize varying knowledge gaps from person to person? What approaches may exist within your program that could lead trainees to hold back? How will you change those?
This is where we, as supervising clinical educators, allow for progressive autonomy with guidance and encouragement in exchange for the effort and growth of the individual. While still occurring in many venues, micromanaging, dismissing ideas, or publicly embarrassing residents and fellows are damaging. Micromanaging leads to stunted independent growth and learned helplessness. Whereas, healthy guidance leads to self-efficacy and competent clinical independence.
How do you decide when to direct your accountability at the task, process, or outcomes level? What processes are you and your colleagues using to guide progressive autonomy? A coaching approach can help trainees realize how much they know (because many, by default, dismiss the knowledge they’ve gained), augment their clinical connections, and highlight knowledge gaps to fill. And you, as the supervisor, can use this information to determine the level of accountability. Whether you prescribe the exact medication, route, and dose or if you say, “let’s get their blood pressure down to more appropriate levels” or somewhere in between. If it feels unsafe for knowledge gaps to exist (no learner safety), then the attending’s questions can be perceived as “digging to find the weakness” instead of highlighting how far they’ve come. I wrote more about this subject of balancing autonomy with supervision HERE.
How do you support trainees to speak their opinions without fear of retribution? In what ways is meaningful consideration given to those ideas? And in what ways can you encourage and provide opportunities for such? Many of you likely offer the opportunity through the ongoing program evaluation committee. In what ways are dissenting opinions handled and considered? Is there room for improvement? What approaches may exist to discourage trainees from sharing their views and questioning clinical decisions or system processes? What adjustments could be made?
Psychological safety takes attention at all levels. Lack of it creates a culture of emotional exhaustion, fear, and disengagement. When it does exist, our trainees are more fulfilled, engaged, and confident and perform at higher levels to reach their potential.
Next week, I’ll offer concrete steps for mitigating implicit bias in reviewing trainees for remediation, extension, promotion, and graduation.
Until then, Have a Joy-filled day!
Tonya
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