This point of care tool can help preceptors promote psychological safety.

SEVERAL NURSING ORGANIZATIONS (including the American Nurses Association [ANA], the American Association of Colleges of Nursing, and the American Association of Nurse Practitioners in Women’s Health) have acknowledged the importance of increasing representation in the nursing workforce and improving access to care and outcomes. In 2024, ANA published a statement that articulates a clear vision for the nursing profession where every nurse has the equal opportunity to excel, and every patient receives the highest standard of equitable care. In response to these calls to action, Chicca and Shellenbarger and Warren and colleagues note that preceptors require tools that foster psychologically safe learning environments where all students can learn effectively.

As part of that effort, we developed five actionable steps (the Five Rs) that preceptors can use to ensure psychological safety, with attention to diversity and inclusion, as they cultivate a more diverse nursing workforce.

Psychologically safe learning environments

All learning involves risk-taking and a willingness to experience growth. According to Chicca and colleagues and Turner and Harder, primary components of a psychologically safe learning environment include permission to make mistakes, a supportive preceptor, orientation to the setting, and clear expectations for performance. In this environment, students have the opportunity to practice clinical decision making with the support of their preceptor so that they can make errors without compromising patient care. In contrast, a psychologically unsafe environment may include the presence of biases and microaggressions that inhibit learning. (See Definitions)

Weiss and colleagues describe psychological safety as supporting student retention and progression. It functions as a foundational component of student well-being, a proxy for satisfaction with the clinical learning environment, and a hallmark of effective supervision—all factors closely linked to persistence and on-time completion. These supervisory behaviors (modeling fallibility, inviting questions, and providing constructive feedback) signal safety and are consistently associated with better learning experiences and sustained engagement.

In contrast, as noted by Dong and colleagues, a psychologically unsafe environment may include the presence of biases and microaggressions that inhibit learning. Global perspectives in health professions education underscore that such threats to inclusion and learner safety suppress voice, reduce willingness to contribute to or challenge problematic practices, and thereby diminish learning opportunities and the equality of patient care.

Although the evidence base is heterogeneous, studies (including by Montgomery and colleagues) have demonstrated significant associations between higher psychological safety and objective patient safety outcomes (increased error reporting and reduction in certain adverse events), reinforcing the idea that the same conditions that enable learners to grow also contribute to safer care. At the same time, measuring patient safety solely as an absence of harm can complicate the interpretation (higher reporting may reflect more safety, not less), underscoring the importance of cultivating psychologically safe environments while refining outcomes assessment.

Mitigating barriers

Preceptors guide APRN students in the integration of didactic learning, hands-on skills, and decision making in the clinical setting. They adapt to students’ different personalities, cultures, and learning styles. Preceptors may face obstacles to effectively modeling psychological safety within this diversity. For example, they may work in systems that don’t support or aren’t conducive to students’ psychological well-being. Several factors can lead to this type of unsupportive environment, including work hours, patient volume and resources, and lack of respect for the APRN role.

Preceptors can mitigate barriers to implementing psychological safety by intentionally cultivating a supportive learning environment within their own clinical interactions, regardless of broader system constraints. Employing concise teaching strategies, such as debriefs and structured feedback, allows preceptors to promote safety despite high workload or limited resources. Clarifying expectations, inviting questions, and tailoring communication to students’ individual learning styles and cultural backgrounds further strengthen trust. Additionally, modeling professional role clarity and reflective practice helps students navigate environments where the APRN role may be undervalued. Through these focused strategies, preceptors can foster psychological safety even in settings that aren’t inherently supportive.

Preceptor reflection

To create a psychologically safe learning environment that facilitates success, the preceptor must engage in a process of self‑reflection about their own responses to bias and demonstrate empathy in their interactions with students. Although preceptors may experience their own emotional discomfort when bias occurs, briefly acknowledging these feelings can enhance their ability to remain present, supportive, and responsive to the learner’s needs. Having strategies to identify and respond to psychologically unsafe learning events can prove helpful.

Actionable steps

Many nurses find that they lack the ability to respond in the moment to uncomfortable situations. The American College of Nurse-Midwives + Shift Consulting advises nurses to address the witnessed words or behavior rather than the person who said them.

In an effort to follow that advice, we developed our Five Rs tool (Respond, Recall, Redirect, Relate, and Reflect). Based on our experience as student preceptors and faculty, the ideologies and concepts of researchers (including Effland and colleagues and the Josiah Macy Jr. Foundation), and the American College of Nurse Midwives Anti-Racism Toolkit for Midwives, the tool aims to promote actionable steps preceptors can take to promote psychologically safe learning environments. The steps described frequently flow in the order presented, but they can occur in a different order. (See Five actionable steps.)

Respond

Immediately bring attention to words or behavior that contribute to a psychologically unsafe learning environment. Responding exposes the offending words or behavior despite awareness or intent. Sue and colleagues note that depending on the environment, situation, and witnesses present, it may be appropriate to defer discussing the event in detail to a more appropriate time.

Recall

Discuss the event in an environment conducive to open communication and where parties feel comfortable and safe. The conversation shouldn’t incite blame or anger, which can close down effective communication. Using “I” statements rather than “you” statements avoids assigning guilt. Recalling events soon after they occur prevents preoccupation with the incident, which can increase anxiety and fear.

Redirect

Provide the opportunity to assign ownership in a nonthreatening manner and assist with establishing the intent of the offending statement, behavior, or event. After determining the intent, clarify the statements made. Without establishing intent and clarity, an enlightening conversation may prove impossible. Redirection allows the individual to explore possible beliefs or biases contributing to the statement or behavior.

Relate

Connect the event to tangible, real-life examples, emphasizing humanity and conveying the significance of the behavior or statement for all involved. The preceptor should invite questions, practice active listening, and validate feelings. Change requires admitting mistakes and knowledge gaps. Highlight areas that require self or institutional education. Normalize being wrong and emphasize that no one is immune to bias.

Reflect

Encourage those harmed by microaggressions, racism, or bias to prioritize both mental and physical well-being. Mentors, therapists, or peers can help create a safe space to work through events and interactions and explore feelings and reactions. If a psychologically unsafe environment persists for a student despite intervention, withdrawal from the clinical setting and reassignment to another for self-protection may be appropriate. For those who’ve made a biased statement or engaged in a microaggression, reflection provides an opportunity to explore their implicit biases and seek opportunities to self-educate.

Student/preceptor scenario

A nurse practitioner student reporting to the preceptor says, “This is a 17-year-old primigravida Native American client who presents to the clinic today at 38 weeks after missing several prenatal visits. She reports that the baby is moving fine. She plans to breastfeed and doesn’t want to discuss birth control.” A colleague in the clinic overhears the discussion and says, “I hope you discussed birth control because you know she’s one of those people and will probably be back again pregnant next year.”

Respond. The preceptor says to the colleague, “That statement, ‘She’s one of those people and will probably be back again pregnant next year,’ doesn’t sit well with me. I’d like to discuss this with you after I complete this next visit.”

Recall. The preceptor says to the colleague, “Now that we have a few minutes and privacy, can we discuss the statement made earlier using the words ‘those people’ in regard to a Native American client? When statements like that are made, I’m uncomfortable because I identify it as a microaggression.”
Redirect. The preceptor says to the colleague, “Can you explain what you mean when you say ‘those people’?”

Relate. The preceptor says to the colleague, “I previously had similar thoughts, but took the time to educate myself on the cultural practices of our Native American clients and realized I was wrong. I’m happy to share educational resources I used. I don’t want our students exposed to racism, bias, or misconceptions in our clinic.”

Reflect. The preceptor says to the student, “You witnessed an unfair comment based on the patient’s cultural background. As nurse practitioners, it’s important that we create an environment for our patients and for ourselves that’s safe and culturally appropriate. We also should take a leadership role in addressing these issues. I find reflection on thoughts and feelings surrounding such events helpful. Journaling and sharing the experience with a trusted peer, mentor, clinical faculty member, or counselor may help you with reflection.”

Practice

Chicca and Shellenbarger and Folkvord and Risa describe role-playing, simulation, and scripting as effective strategies for questioning assumptions, promoting self-efficacy, and engaging in reflection about cultural difference and its role in healthcare. Preceptors and students can verbally practice implementing the Five Rs via role-playing. In simulation, this might occur in the context of other aspects of simulated patient care, such as managing responses to bias while performing a physical assessment. Scripting offers the opportunity to prepare and practice responses to use in the moment when situations occur.

Learners and preceptors may experience discomfort when practicing responses to bias or cultural difference, and limited clinical time frequently restricts opportunities for extended engagement. In addition, without clear structure, these activities may elicit only superficial participation. These barriers can be reduced through brief, structured practice scenarios, integration of micro‑practice into clinical workflows, and focused debriefing that emphasizes reflective learning. Employing realistic cases and explicitly linking activities to the Five Rs further support meaningful, authentic skill development within constrained educational contexts.

Role modeling responsibility

Preceptors have a responsibility to role‑model responses to challenging clinical encounters, including bias, microaggressions, and racism. To succeed, preceptors must remain open to self‑reflection and continue interrogating their own biases and behavior. They should listen to their students to understand their perspectives and use the Five Rs, adapted to fit individual student needs, to foster psychologically safe learning environments.

By tailoring the approach to each learner’s communication style, prior exposure, and cultural lens, preceptors demonstrate their commitment to advancing a diverse, inclusive profession capable of delivering culturally appropriate, safe, unbiased care to those we serve.

The authors are faculty members at Frontier Nursing University in Versailles, Kentucky.

References

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Keywords: psychological safety, advanced practice, diversity, inclusion, cultural sensitivity