Think Safety First when Precepting
Revisiting “Precepting 101” – Part 3
Cultivating Psychological Safety in the Clinical Rotation
As a preceptor, you likely have asked learners "What areas of weakness do you need to improve?" In my experience, responses range between two possible extremes: 1) something vague, generic, and obvious or 2) something thoughtful, specific, and reflective. When learners respond with self-awareness, I know I’m doing my job as a preceptor well. I know my student trust me enough to show-up as their authentic self.
Think about this simple question about areas of weaknesses. The range of responses to this question may reflect the range of environments in which it is posed. During a job interview, which is a high-stakes environment where you know your answer is being judged and may determine if you'll earn an income, your response will likely to be a safe one. "I tend to take on too many projects. It can be hard to say no sometimes with so many good opportunities for involvement!" But if asked by a trusted professional mentor, you may choose to disclose something more authentic. "I become so disorganized that I mess up big projects. I get overwhelmed with too many deadlines and when I become too stressed, I lose track of information. I need to learn how to manage deadlines better." The truth is that getting anyone to disclose a truly challenging or embarrassing professional deficit requires psychological safety. Fortunately, preceptors can cultivate the sense of safety needed to make a truly effective learning environment.
Why is Psychological Safety important in the education and clinical environment?
Sensing a healthy amount of psychological safety results in the ability to speak up, question, show concern, or make mistakes without fear of judgment, humiliation, or risk. Psychological safety is incredibly important in high-risk professional settings. I'm grateful for the psychological safety I have found among my current clinical teams since my job as a pharmacist requires me to question their clinical decisions while also serving as a trusted resource. Those of us who have worked on teams with low psychological safety understand how fear and anxiety can be a barrier to patient safety.
Just as with clinical practice, psychological safety is critical to the learning environment. When students experience judgment for inadequacies associated with their lack of experience, they begin to hide their deficiencies rather than engage in growth. Self-confidence gives way to self-consciousness. Hope for success turns into self-doubt. Simple risks feel too risky. Students disengage in the hopes of "playing it safe" rather than being caught making an avoidable mistake. This puts students in the worst possible position to demonstrate what they are truly capable of achieving.
How Preceptors can create psychological safety on their rotation
As a preceptor, you can influence how authentically your student engages with you (and their learning) during the rotation by promoting a psychological safe learning environment. Here's some practices you can adopt right now to communicate your learning environment values psychological safety.
Create the expectation of mutual constructive feedback. Do this work outside of your formal feedback to learners. Student will rarely give impromptu thoughtful direct feedback. I ask for feedback casually, routinely, at the end of the day or during downtime, just to establish the culture of we value and participate in feedback here.
Demonstrate how you use resources and how you ask for help from others. Make it clear you know your own limitations and it is okay to acknowledge inadequacies. This will give your learners a road map to asking you for help when they truly need it rather than hiding a deficiency that could lead to a mistake or a bigger problem.
Be inclusive as possible. Check for biases and keep biases in-check. Learners coming from diverse backgrounds may have experienced environments where psychological safety was undermined by discrimination. Make it clear to them that this is not one of those environments!
View learners as people with lives outside of school/work. They have other demands for time and unique obligations in addition to their training. They cannot easily ignore these demands, nor should they sacrifice self-care for the sake of a rotation. You do not have to cross professional boundaries or pry into their personal lives – simply don’t assume all time outside of the rotation is available to support their work while on the rotation.
Stop compromising psychological safety with outdated training philosophies
Below are a few precepting strategies that may undermine psychological safety during a rotation. Some of these approaches do have value, but I worry when these are employed without adequate psychological safety established.
The Sink or Swim approach. I strongly discourage this philosophy. First, it encourages a preceptor to be passive which rarely serves students well. Precepting is a verb, whereas this approach is a wait-and-see. Second, just as in a swimming pool, it can be difficult to recognize someone is drowning until it is too late. Even high achieving students can be sinking, though they may be able to mask it better than other students. I’ve found this strategy creates missed opportunities to engage proactive before problems become too big. In psychologically safe environments, students can proactively seek help when appropriate.
The Treat Rotations like a Job Interview expectation. Students who are risk-adverse may hold back during a rotation, fearing the possibility of jeopardizing a potential job opportunity by making unnecessary mistakes. A student once told me, "It is better to be silent than wrong." By holding back, not taking risks, and not engaging, students miss valuable learning opportunities. Many students may not be ready to impress or meet expectations of job candidates, after all, they are on your rotation to learn and grow. I have found that taking off the pressure of an imaginary job interview can greatly improve the student’s capacity to engage and learn.
Just asking “Why?” This is not about pimping. You should be prompting students often with questions. However, you can make questions more effective by avoiding a “why” questions. These questions often trigger anxieties and insecurities within the respondent because the question implies you did something unagreeable or incorrect. Instead of "why", preceptors can prompt with questions such as "Tell me your thought process," "What alternatives did you consider?" "What would have made you choose a different option?" There are endless options for exploring someone’s decision, but none will trigger defensiveness as much as “Why did you do that?”
Holding students to a higher standard. I believe that any behavior that a preceptor demonstrates in front of a student is fair game for the learner to adopt. It is easy to say that students need to be more professional than preceptors because they are students and learning, or that they don't have the rapport or credibility established to be "less professional." I think this is an unhelpful double standard, especially if it is being used to justify a poor student evaluation. If preceptors are missing deadlines, showing up late, or not being responsive, you're telling students this is the normalized expectation in this environment. Calling out students via a double standard creates uncertainty in the environment making it difficult for students to truly understand your expectations.
My Advice. . .
If I had just one piece of advice for a new preceptor, it would be to lean into the concept of psychological safety for learning. Creating and maintaining a psychologically safe learning environment will set you and your learners up for success.