Psychological Safety in Healthcare: The Complexity of Leading in Healthcare - Part 2 of 3

Denise Roistacher • January 26, 2026

So That Peole Can Speak Up Without Fear

Last year, I worked with a group of Chief Residents, and our conversation turned to coaching and feedback—specifically how it unfolds in real time as they oversee residents. One question sparked particularly rich dialogue:

“If we notice a resident is about to make a clinical misstep, do we stop and coach in the moment—especially when time is urgent?”

We acknowledged a familiar reality in healthcare: under intense pressure, guidance may emerge as a sharp directive—or even a “bark”—rather than a calm, supportive response. Patient safety must always come first. And because leaders are human—operating under stress, time pressure, and cognitive load—perfection is not the goal.

What matters most is what happens next.

When leaders intentionally circle back once things are calmer—to unpack what happened, name the learning, and repair the interaction—they reinforce trust, accountability, and psychological safety.

These moments reveal a pattern that extends far beyond isolated incidents—a pattern woven into the daily functioning of healthcare teams.

Psychological Safety as an Emotional Contract

Psychological safety is an emotional contract shaped over time through everyday interactions. People are constantly reading the environment, paying attention to:

How leaders respond to concerns
How feedback is delivered
Whether people feel heard
What happens when mistakes occur

When those signals reflect care and fairness, trust strengthens—even in demanding environments. When they do not, people become more guarded and less willing to take the risks necessary for learning and safety.

When Psychological Safety Erodes Quietly

Psychological safety also erodes in quieter, less visible ways—often outside moments of clinical urgency.

While these breakdowns may seem small, their ripple effects can be profound. When psychological safety is low, team members are less likely to speak up about uncertainties, near misses, or potential errors.

Research in critical care settings has shown that teams with higher levels of psychological safety experience fewer preventable adverse patient events, as clinicians feel more empowered to voice concerns before harm occurs. ¹ In other words, psychological safety is not a “nice-to-have.” It is directly linked to patient outcomes.

Let’s examine how small leadership behaviors contribute to such breakdowns—and what to watch for.

Where Psychological Safety Quietly Breaks

The Don’ts

Psychological safety rarely collapses in dramatic moments. More often, it erodes through small, repeated leadership behaviors that send unintended signals about what is safe—and what is not.

❌ Punitive responses to mistakes or near misses

When errors are met with blame, humiliation, or quiet punishment, people learn to hide problems rather than surface them.

❌ Poor timing and delivery of feedback

Feedback delivered when clinicians are depleted—between patients or late in the day—often lands as judgment rather than guidance.

❌ Mistaking silence for agreement

Silence is often self-protection, not alignment.

❌ Urgency without repair

Correcting quickly may be necessary. Failing to return afterward leaves people alone with the meaning they assign to the interaction.

❌ Blaming individuals for system failures

When gaps in onboarding, workflow, staffing, or training are treated as personal shortcomings, trust erodes—especially among high performers.

How Leaders Repair and Strengthen the Emotional Contract

The Do’s

Psychological safety is not built by avoiding pressure, being “nice,” or lowering standards. It is built by what leaders do after pressure-filled moments—especially when something goes wrong.

✅ Respond to mistakes with learning before judgment

After stabilizing the situation, explore what made sense at the time, what conditions contributed, and what can be improved. Accountability works best when paired with fairness.

✅ Deliver feedback as a constructive, collaborative conversation

Choose the right time and setting, invite dialogue, and focus on development rather than evaluation—so feedback supports learning instead of shutting it down.

✅ Practice active listening—really hear what people are saying

Listen without interrupting, without defensiveness, and without premature problem-solving. Reflect back what you hear, ask clarifying questions, and check for understanding so people know their concerns have truly landed.

✅ Circle back after high-stress moments

A brief follow-up to explain intent, acknowledge impact, and name learning helps repair trust after urgency-driven interactions.

Closing Reflection

Psychological safety is not about being nice or avoiding correction. It’s about urgency followed by repair, authority explained, and mistakes leading to learning.

Mistakes and near misses are often the ultimate test of the emotional contract. People decide whether honesty is safe based on what happens when something goes wrong.

Pressure is inevitable in healthcare. Silence does not have to be.

Psychological safety is built—and rebuilt—in the moments that follow.

Call to Action for Healthcare Leaders

As you reflect on your leadership, consider:

Where have I listened to my team’s ideas and solutions?
How is feedback delivered to my team—developmental or shutting down dialogue?
What happens when mistakes or near misses occur—learning or blame?

Reference

¹ Edmondson, A. Learning from Mistakes in Hospitals: A Multilevel Study of Error Reporting and Psychological Safety. Harvard Business School; The Role of Psychological Safety in High-Performing Medical Teams. The Joint Commission Journal on Quality and Patient Safety (2017).

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