A critical review of psychological safety in clinical learning environments

BACKGROUND: In recent years the perceived need to ensure the psychological safety of learners has become an imperative. A range of conceptualisations appear to be in use, which could create confusion among medical educators and undermine the learning outcomes psychological safety is meant to improve. METHODS: In this critical literature review, we investigated how the concept of psychological safety is used, identifying the various appeals to the safety of learners in clinical environments. The search was conducted spanning January 2019 to January 2025 with the term 'safety' as pertains to learners then narrowed to 'psychological safety'. We used Bacchi's 'What's the problem represented to be' analytic method. FINDINGS: We analysed 46 papers and identified four functions that psychological safety served: (1) as a solution to a wide range of problems, (2) an achievable goal, (3) a way to manage hierarchical power, and (4) a substitute for attending to emotions. We critique each, demonstrating how psychological safety is often treated as a state that individuals can achieve. CONCLUSIONS: This review offers a reframing of safety, as an ongoing, negotiated process among all those involved rather than an endpoint. This focus on psychological safety as a process could guide practitioners, learners and researchers to contribute to more inclusive learning environments.