The Role of Leadership in Fostering Psychological Safety in Healthcare: Protocol for a Systematic Review of Qualitative Studies

Abstract

Psychological safety, a shared belief held by members of a team that the team is safe for interpersonal risk-taking, is a critical factor in healthcare team performance and patient safety. Leadership plays a crucial role in creating psychologically safe environments that encourage open communication, problem-solving, and innovation. This qualitative evidence synthesis aims to synthesize the evidence on the role of leadership in fostering psychological safety in healthcare settings. The synthesis will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines and will include qualitative studies that explore leadership behaviors, strategies, and interventions that promote psychological safety in healthcare teams. The synthesis will search multiple electronic databases (PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, and Scopus) from inception to December 2024. Two reviewers will independently screen and select studies, extract data, assess methodological quality using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist, and assess confidence in the findings using the Grading of Recommendations Assessment, Development, and Evaluation - Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. A thematic synthesis will be conducted to identify key themes related to leadership behaviors, strategies, and interventions that promote psychological safety. This synthesis will provide valuable insights into the role of leadership in creating psychologically safe environments and inform the development of evidence-based leadership interventions to enhance healthcare team performance and patient safety.

Introduction

Psychological safety has emerged as a key factor in understanding the performance of teams in various settings, particularly in healthcare where the work is complex, dynamic, and high-stakes (Edmondson, 1999). Psychological safety refers to the shared belief among team members that the team is safe for interpersonal risk-taking, such that individuals feel comfortable speaking up, asking questions, raising concerns, and admitting mistakes without fear of negative consequences (Kahn, 1990). In psychologically safe teams, members are more likely to engage in learning behaviors, such as seeking feedback, experimenting with new approaches, and discussing errors, which are essential for continuous improvement and innovation (Edmondson & Lei, 2014).

In healthcare, creating a psychologically safe environment is crucial for ensuring high-quality, safe patient care. Healthcare teams face numerous challenges that require effective communication, coordination, and problem-solving among team members with diverse backgrounds, expertise, and hierarchical status (Nembhard & Edmondson, 2006). However, studies have shown that healthcare professionals often face significant barriers to speaking up and raising concerns, such as fear of retribution, lack of efficacy, and power differentials (Okuyama et al., 2014). These barriers can lead to communication breakdowns, medical errors, and suboptimal patient outcomes (Weaver et al., 2013).

Leadership has been identified as a critical factor in creating and maintaining psychologically safe environments in healthcare teams (Frazier et al., 2017). Leaders, whether formal or informal, set the tone for the team culture, model desired behaviors, and create the conditions that enable or hinder interpersonal risk-taking (Edmondson, 2018). Effective leadership has been associated with higher levels of psychological safety, team learning, and performance in various healthcare settings, including operating rooms (Edmondson et al., 2001), intensive care units (Nembhard & Tucker, 2011), and primary care teams (Nembhard & Tucker, 2016).

However, the specific leadership behaviors, strategies, and interventions that foster psychological safety in healthcare teams are not well understood. While there is a growing body of literature on psychological safety in healthcare, much of this research has focused on the antecedents and consequences of psychological safety at the individual and team levels (Newman et al., 2017), rather than the role of leadership in shaping these dynamics. Moreover, the existing research on leadership and psychological safety in healthcare is largely quantitative, focusing on testing hypothesized relationships between variables (O’Donovan et al., 2020), rather than exploring the lived experiences and perspectives of healthcare professionals.

Qualitative research is particularly well-suited for understanding complex social phenomena such as psychological safety and leadership in healthcare teams. Qualitative methods, such as interviews, focus groups, and ethnography, allow for a deep exploration of individuals’ experiences, perceptions, and behaviors in their natural context (Creswell & Poth, 2016). Qualitative research can generate rich, nuanced insights into the factors that contribute to or hinder psychological safety, the strategies that leaders use to promote it, and the challenges and facilitators to implementing these strategies in practice.

To date, there has been no comprehensive synthesis of the qualitative evidence on the role of leadership in fostering psychological safety in healthcare teams. Previous reviews have examined the antecedents and consequences of psychological safety in healthcare (O’Donovan & McAuliffe, 2020b) and the interventions designed to promote it (O’Donovan & McAuliffe, 2020a), but have not focused specifically on leadership or synthesized the qualitative evidence. This represents a significant gap in the literature, as understanding the leadership behaviors and strategies that foster psychological safety is critical for designing effective interventions and training programs to support healthcare leaders in creating safe and supportive team environments.

Therefore, the purpose of this qualitative evidence synthesis is to systematically review and synthesize the qualitative research on the role of leadership in fostering psychological safety in healthcare teams. The synthesis aims to address the following research questions:

1. What are the leadership behaviors, styles, and practices that promote or hinder psychological safety in healthcare teams?

2. What are the strategies and interventions that leaders use to foster psychological safety, and how are they perceived and experienced by team members?

3. What are the contextual factors that influence the effectiveness of leadership approaches to fostering psychological safety in different healthcare settings?

4. What are the barriers and facilitators to implementing leadership strategies and interventions to foster psychological safety in healthcare organizations?

By answering these questions, this synthesis will provide a comprehensive understanding of the role of leadership in creating psychologically safe environments in healthcare. The findings will have important implications for healthcare leadership practice, education, and research, and will inform the development of evidence-based interventions and training programs to support healthcare leaders in fostering psychological safety in their teams.

The rest of this protocol outlines the methods that will be used to conduct the synthesis, including the search strategy, selection criteria, data extraction, quality appraisal, and synthesis approach. The protocol follows the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement (Tong et al., 2012), which provides guidelines for reporting the synthesis of qualitative research in a transparent and reproducible manner.

Methods

Search Strategy

The search strategy for this synthesis will be developed in consultation with a health sciences librarian to ensure a comprehensive approach to identifying all relevant qualitative studies on the role of leadership in fostering psychological safety within healthcare teams. Electronic databases to be searched from inception to December 2024 will include PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, and Scopus.

The search will use a combination of keywords and controlled vocabulary terms (e.g., MeSH terms) related to psychological safety, leadership, healthcare teams, and qualitative research. The search strategy will be adapted for each database and will include both free-text and controlled vocabulary terms. An example search string for PubMed is:

(“Psychological Safety”[Mesh] OR “psychological safety”[Title/Abstract] OR “psychologically safe”[Title/Abstract] OR “interpersonal risk taking” [Title/Abstract] OR “speaking up”[Title/Abstract]) AND (Leadership [Mesh] OR leader*[Title/Abstract] OR “management”[Title/Abstract] OR “supervision”[Title/Abstract]) AND (“Patient Care Team”[Mesh] OR “healthcare team*”[Title/Abstract] OR “health care team*”[Title/Abstract] OR “medical team*”[Title/Abstract] OR “nursing team*”[Title/Abstract] OR “interprofessional team*”[Title/Abstract] OR “interdisciplinary team*”[Title/Abstract] OR “multidisciplinary team*”[Title/Abstract]) AND (“Qualitative Research”[Mesh] OR qualitative[Title/Abstract] OR “mixed method*”[Title/Abstract] OR interview*[Title/Abstract] OR “focus group*” [Title/Abstract] OR ethnograph*[Title/Abstract] OR “grounded theory”[Title/Abstract] OR phenomenolog*[Title/Abstract] OR “content analysis”[Title/Abstract] OR “thematic analysis”[Title/Abstract] OR “constant comparative”[Title/Abstract] OR “field notes”[Title/Abstract] OR “semi-structured”[Title/Abstract] OR narrative[Title/Abstract])

In addition to the electronic database search, the reference lists of included studies and relevant reviews will be hand-searched to identify any additional studies. Gray literature sources, such as conference proceedings, theses, and dissertations, will also be searched to minimize publication bias.

Selection Criteria

Studies will be included in the synthesis if they meet the following criteria:

1. Qualitative study design: The study uses qualitative methods for data collection and analysis, such as interviews, focus groups, ethnography, or qualitative case studies. Mixed methods studies that include a qualitative component will also be included.

2. Focus on leadership and psychological safety: The study explores the role of leadership in fostering psychological safety in healthcare teams, including leadership behaviors, styles, practices, strategies, or interventions that promote or hinder psychological safety.

3. Healthcare setting: The study is conducted in a healthcare setting, such as a hospital, clinic, primary care practice, or long-term care facility.

4. Participants: The study participants are healthcare professionals who work in teams, such as physicians, nurses, allied health professionals, or support staff.

Studies will be excluded if they:

1. Do not use qualitative methods or do not report qualitative findings

2. Do not focus on leadership or psychological safety in healthcare teams

3. Are conducted in non-healthcare settings

4. Do not include healthcare professionals as participants

5. Are published as conference abstracts, editorials, commentaries, or opinion pieces

Two reviewers will independently screen the titles and abstracts of all studies identified through the search against the selection criteria. Studies that meet the criteria or are unclear will be retrieved in full text and reviewed independently by the two reviewers. Any discrepancies will be resolved through discussion or consultation with a third reviewer. The reasons for excluding studies will be recorded and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Booth et al., 2012) (S1 Checklist).

Data Extraction

Data will be extracted from the included studies using a standardized data extraction form developed for this synthesis. The form will be piloted on a sample of studies and refined as needed (S1 File). Two reviewers will independently extract data from each study, and any discrepancies will be resolved through discussion or consultation with a third reviewer.

The data extraction form will include the following information:

1. Study characteristics: authors, year of publication, country, study design, setting, aim/research question

2. Participant characteristics: sample size, profession, age, gender, years of experience

3. Leadership characteristics: leadership style, behaviors, practices, strategies, interventions

4. Psychological safety: definition, measurement, level (individual, team, organizational)

5. Findings: themes, categories, or theories related to the role of leadership in fostering psychological safety, with supporting quotes

6. Conclusions: authors’ interpretations and recommendations for practice, education, or research

Quality Appraisal

The methodological quality of the included studies will be appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist (Critical Appraisal Skills, 2018). The CASP checklist consists of 10 questions that assess the rigor, credibility, and relevance of qualitative research, covering issues such as the appropriateness of the research design, the sampling and data collection methods, the depth and richness of the data analysis, and the clarity and value of the findings.

Two reviewers will independently appraise each study using the CASP checklist, and any discrepancies will be resolved through discussion or consultation with a third reviewer. The appraisal results will be reported in a table, with each study rated as “high,” “moderate,” or “low” quality based on the number of criteria met. Studies will not be excluded based on quality, but the appraisal results will be used to inform the interpretation and synthesis of the findings, with greater weight given to higher-quality studies.

Data Synthesis

The data from the included studies will be synthesized using a thematic synthesis approach (Thomas & Harden, 2008). Thematic synthesis is a method for identifying, analyzing, and interpreting patterns or themes within qualitative data, which can generate new insights and theories that go beyond the findings of the individual studies.

The synthesis will involve three stages:

 1. Line-by-line coding of the findings of the primary studies

 2. Development of descriptive themes

 3. Generation of analytical themes

In the first stage, two reviewers will independently read and re-read the findings of each study, and code them line-by-line according to their content and meaning. The codes will be inductively generated from the data, rather than being pre-specified. The reviewers will compare and discuss their codes, and resolve any discrepancies through consensus.

In the second stage, the reviewers will work together to group the codes into descriptive themes that capture the key concepts and patterns across the studies. The themes will be refined and revised iteratively, with constant comparison between the themes and the original data to ensure that they are grounded in the evidence.

In the third stage, the reviewers will generate analytical themes that go beyond the descriptive themes to offer new interpretations and explanations of the data. The analytical themes will be developed through a process of conceptual mapping and abstraction, drawing on the reviewers’ expertise and the wider literature on leadership and psychological safety. The analytical themes will aim to provide a higher-order understanding of the role of leadership in fostering psychological safety in healthcare teams, and to generate new hypotheses and theories that can be tested in future research.

Throughout the synthesis process, the reviewers will maintain a reflexive stance, acknowledging their own backgrounds, perspectives, and assumptions, and considering how these may influence their interpretations of the data. The reviewers will also keep an audit trail of their decisions and rationales, and will engage in regular peer debriefing and member checking to enhance the trustworthiness and credibility of the synthesis.

The synthesis findings will be presented in a narrative form, with a rich description of the themes and sub-themes, supported by illustrative quotes from the primary studies. The findings will be organized around the research questions, and will highlight the key similarities and differences between the studies, as well as any gaps or inconsistencies in the evidence. The confidence in each synthesized finding will be assessed using the GRADE-CERQual approach (Lewin et al., 2018), which considers the methodological limitations, relevance, coherence, and adequacy of the supporting evidence.

Reporting

The protocol for this qualitative evidence synthesis, including any amendments, will be registered in PROSPERO, the international prospective register of systematic reviews (Booth et al., 2012). The final synthesis will be reported in accordance with the ENTREQ guidelines (Tong et al., 2012), which provide a 21-item checklist for reporting the synthesis of qualitative research. The ENTREQ items cover issues such as the research question, search strategy, selection criteria, appraisal methods, synthesis methods, and limitations.

The synthesis report will include a detailed description of the methods used, the characteristics of the included studies, the quality appraisal results, the synthesized findings, and the limitations and implications of the synthesis. The report will also include a discussion of the potential impact of the findings on healthcare leadership practice, education, and research, and will make recommendations for future research directions.

The synthesis findings will be disseminated through multiple channels, including peer-reviewed publications, conference presentations, and stakeholder engagement activities. The synthesis team will work with healthcare leaders, educators, and policymakers to translate the findings into practical strategies and interventions that can be implemented in healthcare organizations to foster psychological safety and improve team performance and patient outcomes.

Discussion

This protocol outlines a comprehensive and rigorous approach to synthesizing the qualitative evidence on the role of leadership in fostering psychological safety in healthcare teams. The synthesis will use a systematic search strategy, clear selection criteria, standardized data extraction, quality appraisal, and a thematic synthesis approach to identify and interpret the key themes and patterns in the literature.

The synthesis will make several important contributions to the field of healthcare leadership and psychological safety research. First, it will provide a comprehensive and up-to-date review of the qualitative evidence on this topic, which has not been previously synthesized. Second, it will generate new insights and hypotheses about the specific leadership behaviors, strategies, and interventions that promote psychological safety in different healthcare contexts, which can inform future research and practice. Third, it will identify the barriers and facilitators to implementing these strategies in healthcare organizations, which can guide the development of more effective and feasible interventions.

The synthesis will also have important implications for healthcare leadership education and training. By identifying the key competencies and skills that leaders need to foster psychological safety in their teams, the synthesis can inform the design of leadership development programs and curricula. The synthesis findings can also be used to create practical tools and resources for healthcare leaders, such as self-assessment instruments, action planning guides, and case studies.

However, the synthesis has several potential limitations that should be acknowledged. First, the scope of qualitative studies on leadership and psychological safety in healthcare may be limited, potentially affecting the comprehensiveness of our findings. Second, the synthesis will rely on the quality and richness of the primary studies, which may vary in their methodological rigor and depth of analysis. Third, the synthesis will involve some level of interpretation and abstraction by the reviewers, which may be influenced by their own backgrounds and perspectives, despite our planned measures to enhance trustworthiness.

To mitigate these limitations, the synthesis team will use a rigorous and transparent methodology, following established guidelines for qualitative evidence synthesis and reporting. The team will also engage in regular reflexivity and peer debriefing to challenge their assumptions and interpretations, and will seek feedback from stakeholders and experts in the field to ensure the relevance and credibility of the findings.

Supplemental Material

Supplemental Material - The Role of Leadership in Fostering Psychological Safety in Healthcare: Protocol for a Systematic Review of Qualitative Studies

Supplemental Material for The Role of Leadership in Fostering Psychological Safety in Healthcare: Protocol for a Systematic Review of Qualitative Studies by Ravi Shankar, Fiona Devi, and Amartya Mukhopadhyay in International Journal of Qualitative Methods

ORCID iDs

Ravi Shankar https://orcid.org/0009-0005-5578-3481

Fiona Devi https://orcid.org/0000-0001-9367-5258

Statements and Declarations

Ethical Approval

This protocol has been registered with PROSPERO (CRD42024617856). As this is a systematic review protocol, ethical approval was not required. However, the review itself will only include studies that have received appropriate ethical approval, and this will be assessed during the quality appraisal process using the CASP checklist.