Breathing Easy: Building Psychological Safety for Respiratory Therapists and Healthcare Teams

The following is an edited transcript of the course, Breathing Easy: Building Psychological Safety for Respiratory Therapists and Healthcare Teams, presented by Gabrielle Davis, MPH, MA, RRT, RRT-ACCS, RRT-NPS, TTS, LPC, NCC, FAARC.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Define psychological safety and explain its significance in healthcare settings, particularly for respiratory therapists and interdisciplinary teams.
• Identify common barriers to psychological safety in the workplace and their impact on communication, decision-making, and patient care.
• List strategies to cultivate a psychologically safe environment that encourages openness, collaboration, and continuous learning among healthcare professionals.

Psychological Safety

Psychological safety is the shared belief that individuals can speak up, take interpersonal risks, and voice concerns without fear of blame, ridicule, or retaliation. It is critical in complex, multidisciplinary settings such as healthcare, where open communication and trust are essential for effective teamwork and patient safety. Psychological safety allows us to ask questions, report errors, and share new ideas, fostering an environment where everyone feels valued and supported in contributing to high-quality care.

In simpler terms, psychological safety is the ability to speak up without fear of punishment. It encompasses the encouragement of varying ideas and feedback when appropriate, and places an emphasis on learning from mistakes rather than assigning blame. Punishment, it is worth noting, does not only mean formal consequences. It can also take the form of ridicule, embarrassment, or social exclusion.

I have thought about psychological safety in different contexts over my years as a respiratory therapist (RT), but I could not fully conceptualize it until I went to school to become a mental health therapist. Bridging the gap between healthcare and mental healthcare brought a great deal into focus.

Real-World Examples from Clinical Practice

To illustrate what psychological safety looks like in practice, I want to share a few scenarios from my own career.

The last time I worked bedside was in 2021. I was in a PICU helping out at a new hospital. The person assigned to orient me had been a therapist for about three or four years. At that point I had been a therapist for approximately ten years and had worked in multiple states. There was a child, twelve or fourteen years old, on the ventilator. The report indicated ventilator settings that I was unsure were appropriate, so I asked my preceptor whether we should speak with the physician.

She agreed it was a good idea. I approached the doctor, explained what I had observed, and said that in my experience those settings had not worked before and sounded potentially dangerous. I asked if he could say more about his reasoning. The doctor was visibly surprised that I was questioning him. He ultimately defended his position, but the next day the settings had been changed to what I had suggested. I found myself wondering: what if we could have had that conversation twenty-four hours earlier? Could we have mitigated harm more quickly?

What I also noticed in that moment was that my preceptor had privately agreed with my concern but was not comfortable voicing that agreement in front of the physician. She did not feel psychologically safe enough to speak up. That gap matters.

A second scenario involved me, a student, in 2008 during my final clinical rotation in the emergency room. A trauma came in, and the patient was a young woman who so closely resembled my sister that I froze. I could not function. My preceptor had to redirect me to the head of the bed by calling out to me. What brought me back was seeing the patient's mother enter the room, which reminded me that this was not my family.

After the patient was stabilized, my preceptor immediately moved on to the next room as if nothing had happened. I asked to use the restroom, went in, cried, and called my family. When I returned, my preceptor was irritated. There was no debriefing, no checking in, no acknowledgment of what had just occurred. What if there had been a psychologically safe space to say, "Do you want to talk about what just happened?" That conversation does not have to happen before the next patient. It can happen after. Any event can be debriefed at any time.

A third scenario took place during medical rounds. I was the only person of color in a group of ten medical professionals. The physician made a racially derogatory comment about the patient, who was also a person of color, and nobody responded. I asked the physician directly whether he had meant to say that aloud. He seemed surprised that anyone had challenged him. He eventually apologized. But I want to highlight something: nine other professionals were present, and not one of them said anything. Some were visibly uncomfortable and knew the comment was wrong. What would have happened if even one of them had felt safe enough to speak up?

These examples illustrate that psychological safety reaches beyond patient safety metrics and anti-bullying policies. It shapes every interaction in the clinical environment.

Outcomes of Psychological Safety

When healthcare teams operate in psychologically safe environments, the outcomes are significant. According to the Joint Commission, approximately 70% of medical errors are communication errors. If we create safer spaces for communication, we create safer outcomes for patients.

The benefits of psychological safety include:

• Safer patient care through reduced communication errors
• Enhanced collaboration and team learning, including input from dietary, environmental services, and other non-clinical roles
• Decreased errors and near misses
• Decreased compassion fatigue, which is the stress that comes from chronically caring for others, and is something every clinician experiences, whether they name it or not
• Decreased burnout

It is also worth noting that medical professionals are less likely to report their own mental health struggles. They may acknowledge that mental health challenges exist in the medical field broadly, but are far less likely to speak about their own. When the environment is not psychologically safe, this silence is reinforced.

Barriers to Psychological Safety

Several factors commonly work against psychological safety in healthcare settings.

Hierarchical Structures

Healthcare is structured around clear hierarchies: physicians, nurses, respiratory therapists, dietary staff, environmental services, and so on. These hierarchies affect who feels entitled to speak. In 2008, when I began my career, I lacked the confidence to challenge physicians. By 2021, after working in multiple states and building a reputation, I had more latitude. But that latitude came from privilege accumulated over time, not from a change in the hierarchy itself. Those structures exist whether we acknowledge them or not.

Fear of Blame or Punishment

Fear of blame or punishment does not always involve formal disciplinary action. It can be as simple as fearing ridicule, embarrassment, or a tense interaction with a colleague. If someone forgot to document a call-off and is afraid to admit it, the solution is not to hide the mistake. What would happen if the environment normalized saying, "I forgot to write that down"? Learning cannot happen in an environment of fear.

Time Pressures and High Workload

In the ER example I described earlier, there was almost certainly time to check in with me briefly after that traumatic event, but it was not prioritized. We tend to deprioritize emotional processing in favor of the next task. That breathing treatment for a patient could have waited a few minutes so we could have done a brief debrief. Beyond time, workload is an ever-present barrier. In my career, I have never worked at or consulted for a hospital without open positions. Short staffing makes everything harder, including creating space for psychological safety.

Bias, Discrimination, and Cultural Norms

Bias and discrimination within teams are real barriers. So are cultural norms that discourage vulnerability. Early in my career, I was taught to keep my feelings outside of the patient's room. For a while that seemed to work. Over time, I noticed that when I showed authentic emotion, it actually brought me closer to patients and families. Vulnerability in appropriate measure is not a weakness. Saying "I do not know" when you genuinely do not know is a form of professional integrity.

Power Distance, Privilege, and Intersectionality

Power distance refers to the degree to which societally perceived "less powerful" individuals accept and expect an unequal distribution of power. In healthcare, this concept is highly relevant. Those with high power distance have often been conditioned to know their place or have been minoritized by society. Those with lower power distance tend to be more comfortable addressing authority. If you are in a position of lower power distance, meaning you have more privilege in a given space, I encourage you to use it. If a colleague feels afraid to raise a concern because they fear losing their job, ask for their consent to raise it on their behalf.

Intersectionality, a term coined in the 1980s by Professor Kimberly Crenshaw, is a lens through which we can see where power comes and collides, where it interlocks and intersects. It is not simply that there is a race problem here, a gender problem here, and a class or LGBTQ+ problem there. Many times, that fragmented framework erases what happens to people who are subject to all of these things simultaneously.

I spent five years working in Idaho, where I was the only Black respiratory therapist in a seven-hospital system. Patients sometimes questioned whether I was really the person on my business card. Some asked if I was sure. I had to navigate, in real time, decisions about authenticity: when asked what brought me to Idaho, I had to decide whether to reveal that I had moved there because my wife had taken a job. I had already been asked to leave rooms because of my race. If I added being a queer person to that disclosure, what would happen? These are decisions people with marginalized identities make constantly. If that is the calculation someone must run in every interaction, it is not a psychologically safe environment.

Identity dimensions that can affect psychological safety include, but are not limited to: race and racism, sexual identity, gender identity, body size, ageism, educational background (both formal and experiential), geographic location, visible and invisible disability, socioeconomic status, literacy, mental wellness and access to resources, and personal history. These factors compound and intersect in ways that affect every interaction in a clinical setting.

Recognizing Safe and Unsafe Environments

Signs of a Safer Environment

In psychologically safe environments, staff feel comfortable raising concerns without fear of retaliation. Constructive feedback is both given and received. Diversity of thought is welcomed and encouraged rather than suppressed. For example, in my COPD and nicotine cessation program, I built a team primarily composed of students and newer RTs, despite pressure from colleagues to use only senior staff. Those newer voices brought value. Diversity of thought is not just about demographics. It includes professional experience, clinical setting, and role.

Red Flag Environments

Several behaviors and patterns can signal that an environment is not psychologically safe:

• Unusual silence during meetings and huddles, particularly from team members who are normally engaged
• Defensive responses when concerns are raised, which make it unlikely that the person will raise a concern again
• Chronic interruptions, particularly affecting women, younger professionals, and newer clinicians. I spoke with one department in which the women tracked how often they were interrupted over an hour and found that, collectively, they completed only 6 sentences during that period.
• Lack of accountability: a culture where errors are attributed to others rather than owned
• Changes in nonverbal communication, which I consider the most immediately observable signal

Nonverbal Communication as a Signal

Nonverbal cues can tell you a great deal about whether someone feels safe. Crossed arms, leaning away, creating physical distance, and shifts in posture all indicate disengagement or discomfort. Facial expressions such as frowns, pursed lips, eye rolls, or a head shaking with disappointment signal that something is wrong. Gestures like fidgeting, foot tapping, or clenching hands can indicate anger or anxiety.

Eye contact is culturally variable and should not be used as a universal marker. However, if someone who previously made eye contact suddenly stops, that shift is meaningful. Similarly, a sudden drop in vocal tone, giving only short responses, or the absence of minimal encouragers all suggest a person has withdrawn from the interaction.

Minimal Encouragers

Minimal encouragers are verbal and nonverbal cues that signal to a patient or colleague that you are actively listening and that they can continue sharing. Most people use them instinctively without knowing there is a name for them. They foster an environment where patients feel safe to tell their story, and stories yield more clinically useful information than closed-ended yes-or-no questions.

Verbal minimal encouragers include phrases such as "I see," "Go on," "That sounds difficult," "Mhm," and "Tell me more." These signals communicate that you are present, that you hear what is being said, and that the person should continue. The specific phrasing can be adjusted for the audience. With a pediatric patient, "That is tough" may feel more natural than "That sounds difficult." The goal is authenticity, not formula.

Nonverbal minimal encouragers include nodding, maintaining eye contact (where culturally appropriate), leaning forward slightly, and using facial expressions that convey concern or empathy. I have found in my mental health practice that allowing myself to have genuine reactions, including surprise or visible concern, actually helps patients open up more than a trained neutral expression does. People need to see that you are human.

Minimal encouragers help patients feel heard and understood, promote sharing of critical health information, demonstrate genuine care and attentiveness, lead to better understanding of patient needs, and contribute to more accurate diagnoses and treatment plans.

Case Study: Minimal Encouragers and COPD Management

I had a patient with COPD, whom I will call Mary, who had been managing well through a program we developed together with her daughter. She had stopped coming in. Then, shortly before COVID emerged, she was readmitted and described by staff as non-compliant with her medication regimen.

Because I had a relationship with her, I asked simply: what was going on? She mentioned that her daughter was not with her. I asked where her daughter was. Through that conversation, I learned that her daughter had fractured her femur and had been bedridden for forty days. Her daughter's husband, overwhelmed by caring for everything, had not been getting Mary's medications to her. She was not non-compliant. She did not have access to her medication.

The fix was simple: arrange for the medication to be mailed. But we never would have reached that solution without asking open-ended questions and listening for the story behind the symptom.

Case Study: A Patient Refusing Discharge

Another patient was ready for discharge but was refusing to leave. Staff were frustrated and described her in negative terms. Because I had an established relationship with her, I approached her directly and asked why she wanted to stay. In conversation, it came out that her daughter would be paroled in two weeks and released to her home. She was afraid.

All it took was a conversation with the social worker. The social worker contacted the parole officer, the daughter was discharged to a halfway house instead, and the patient went home the next day. Relationships built on genuine listening and rapport resolve problems that checklists and protocols cannot.

Best Practices for Using Minimal Encouragers

Be fully present during patient and colleague interactions. Avoid overusing verbal encouragers, as they can feel like interruptions when used excessively. Combine verbal and nonverbal cues for greater impact. Avoid colloquialisms and euphemisms, which can mean different things to different people or fall into unintended meanings. One time I returned to a patient's room and said "I am back like a bad rash," and the patient was startled because she was covered in a rash. We cannot always anticipate every context, but we can be thoughtful.

Creating Safer Environments

Creating a psychologically safe environment involves four interconnected practices: building trust, reducing fear, promoting openness, and fostering mutual respect.

Building Trust

Trust is built through consistent communication using varied formats, demonstrating humility and integrity, showing care and empathy, and checking in proactively rather than only reactively. You do not have to wait for a death or a critical incident to check in with a colleague. You can check in about everyday stressors, organizational changes, or just how someone is doing.

Do what you say you will do. If you cannot, be honest about it. Shift the idea of 'leader' to 'leadership': leadership is not a title. Everyone has the capacity to practice leadership behaviors. When people understand that leadership is a practice available to all, it creates a safer environment because the hierarchy feels less absolute.

There is no such thing as cultural competency, despite how often the term is used. We only know what we know. We should always be on a path toward learning more. Humility is the posture; cultural humility is the ongoing practice.

Reducing Fear

One of the most powerful fear-reducing practices is normalizing "I do not know." In healthcare, where knowledge is associated with authority and credentialing, admitting uncertainty is difficult. But it is far better to say "I do not know" electively than to pretend you know emergently. I have even said "I do not know" when I did know, specifically to invite a patient or colleague to teach me something. It creates space for others to contribute.

Encourage question-asking and model it yourself. When someone asks me a question in a group setting, I sometimes answer and then turn it back to the group: what do others think? This moves away from the idea that one person holds all the answers and toward a shared learning environment.

When errors occur, the response should focus on learning rather than on admonishment, where appropriate. This is why near-miss reporting programs exist. Refraining from mistakes as learning opportunities rather than grounds for punishment encourages team members to report issues promptly.

Promoting Openness

Be mindful of your tone when collecting information after a mistake is made. An interrogative tone shuts people down. Be aware of your own nonverbal communication. Share your own stories about mistakes made. I tell my mentees about failing a certification exam by six points. That six-point margin stung more than the failure itself. Sharing that story out loud normalized failure for them in a way that abstract encouragement never could.

Active listening is the cornerstone of openness. One evidence-based framework for active listening is O.A.R.S., drawn from motivational interviewing. O.A.R.S. stands for:

• Open-ended questions, such as "Tell me how you believe your life is impacted by your smoking."
• Affirmations, such as "I appreciate you sharing that with me."
• Reflections, such as "It sounds like no one has really paid attention to this issue for you before."
• Summarize: briefly paraphrase what you have heard to confirm understanding. You do not have to repeat everything, but enough to demonstrate that you received what was said.

Fostering Mutual Respect

Avoid interrupting and dismissing. Recognize and celebrate contributions from all team members, particularly those from minoritized identities who may not have been recognized in similar ways before. Establish shared goals and values. Learn how teammates prefer to receive both feedback and recognition. Some people find public recognition mortifying. If you are in a leadership role, ask new hires early on: how do you want to receive feedback, and how do you want to be recognized when you do something well? Then honor that.

Clinical Scenarios

Scenario 1: Wrong Equipment During Emergency Intubation

During an emergency intubation, an RT notices that the wrong-sized endotracheal tube is being prepared but hesitates to speak up, fearing backlash from the lead physician. The patient develops complications, leading to more difficult airway management.

If the RT had felt secure enough to raise concerns, the appropriate equipment could have been used from the outset, avoiding complications and improving patient outcomes. Open communication in high-pressure scenarios is critical for effective teamwork and patient safety. This is exactly the kind of situation where pre-established psychological safety pays off. If a newer RT or younger clinician has been told that their voice matters, they are far more likely to speak up when it counts.

Scenario 2: Medication Protocol Error

An RT realizes they administered the wrong oxygen therapy protocol but avoids reporting the mistake due to fear of reprimand. This delay in addressing the error leads to prolonged hypoxia for the patient.

In a psychologically safe environment, the RT could report the mistake promptly, allowing for a swift corrective response, minimizing harm, and framing the error as a learning opportunity for the team.

Scenario 3: Conflict Between Orders and Patient Directives

An RT is asked to continue aggressive ventilation on a terminally ill patient despite the patient's advanced directives. The RT feels conflicted but fears repercussions for questioning the order.

In a psychologically safe workplace, the RT could discuss their ethical concerns without fear, leading to a reassessment of the care plan in alignment with the patient's wishes and ethical practices. This is where leadership is especially important. People with formal titles have the responsibility to lead by example and demonstrate that ethical questions are welcome.

Strategies for Leaders and Teams

Leadership Strategies

Leaders set the tone for psychological safety. When you make a mistake in front of a group, correct it in front of the group. If you realize after the fact that you gave incorrect information, send a follow-up email to the whole team. When you make errors visible and correctable, you model that it is safe for others to do the same.

Create clear expectations for behavior and communication. Provide educational resources that support team development. Psychological safety resources are widely available, many of them free, and can be incorporated into huddles. The huddle does not have to be only about census and staffing. Small, consistent touchpoints around team culture accumulate over time.

Feedback Strategies

Use "I" statements when giving feedback. Ensure feedback is specific and actionable. If you are pointing out a missed step or a problem, pair it with a suggestion for what could be done differently. Do not deliver a complaint without a path forward.

If you are a colleague rather than a supervisor, ask for consent before offering feedback. I recently said to a colleague, "I have some feedback specific to you. Are you willing to hear it?" She said yes. I offered it. She received it well. But asking for consent is what made that possible. It shifts the power dynamic and demonstrates respect.

Addressing Challenges to Change

When organizations push back with "this is how it has always been done, and it has worked," I always ask: has it, though? If there is a need for this conversation, something has happened. The fact that something has persisted does not mean it is working well. Resistance to change is best addressed through gradual implementation rather than sweeping mandates.

Time constraints are real, but they can be addressed by integrating psychological safety practices into existing workflows rather than adding separate programming. Hierarchy concerns can be mitigated by intentionally involving leaders in modeling desired behavior so that change is visible at the top.

Takeaways

Psychological safety enhances patient outcomes. In environments where team members feel safe to speak, there are fewer medical errors, earlier identification of patient risk, and higher-quality care. Additionally, patients lose a sense of control when they enter the hospital. Building rapport early in a patient's stay is not just a relational nicety. It is a clinical strategy.

Leadership sets the tone. How leaders respond to questions, errors, and dissenting voices tells the entire team what is and is not safe to bring forward. Building trust is a deliberate act, not a passive outcome. It requires consistent communication, modeling of vulnerability, and follow-through.

Errors are opportunities for learning. Reframing mistakes in this way changes a team's entire culture. When people do not fear punishment for mistakes, they report them. When they report them, those mistakes can become the basis for improved protocols and processes.

Inclusion of all voices matters. Psychological safety relies on valuing every team member's contribution regardless of role, experience level, or identity. Inclusion is not passive. It is something you do on purpose. You have to actively invite voices in. I was not the most diverse hire at the Idaho hospital system, where I worked for five years, but I was included. My ideas were sought, heard, and sometimes acted upon. That distinction, between diversity and inclusion, is meaningful. Inclusion is the mechanism that creates the conditions for psychological safety to exist.

Questions and Answers

How do I recover mentally after making a mistake in patient care?

The first thing to recognize is that you are not the only person who has ever made a mistake. You are not alone, even though it feels that way in the moment. There is a model called the CLAIM model that can be helpful to review after a clinical error.

The most important step in the immediate aftermath is to own the mistake and apologize. Not a prolonged apology that shifts focus to your distress, but a clean one: acknowledge what happened, apologize, and ask if there is anything else the patient or colleague needs. Do not fill the apology with explanations. The explanation does not serve the person harmed in that moment.

Later, in private, reflect on what you can do differently in the future. The most important ongoing practice is to give yourself grace. A mistake is not the last mistake you will ever make. What changes over time is the rate and the severity, and your capacity to catch yourself earlier. Do not measure your career against other people's benchmarks. We set goals based on external comparisons that often do not serve us. You get to define what success means, and that definition can evolve.

References

References are provided in the course handout.