Psychological safety in postgraduate medical training: a systematic review of barriers and facilitators

Introduction Psychological safety allows healthcare workers to ask questions, acknowledge uncertainty and raise concerns without fear of interpersonal consequences. Junior doctors may face added risk because postgraduate training combines clinical responsibility, supervision and assessment. Evidence specific to this group has not been synthesised across individual, relational and organisational levels. Purpose This systematic review examined factors associated with psychological safety among doctors in postgraduate medical training and considered how the findings may inform supervision, leadership and training systems. Materials and methods Eight databases were searched for empirical quantitative, qualitative and mixed-methods studies. Findings were integrated using narrative synthesis and organised into intrapersonal, interpersonal and sociocultural levels. Methodological appraisal used the prespecified Risk Of Bias In Non-randomised Studies—of Interventions (ROBINS-I) framework. Because the included evidence did not evaluate assigned interventions and included qualitative studies, intervention-specific domains were recorded as not applicable and the remaining judgements were interpreted cautiously. Results 13 studies from four countries met the inclusion criteria. Under the prespecified design-limited ROBINS-I application, 11 studies received an overall judgement of moderate risk of bias and 2 received an overall judgement of serious risk. Reported influences included confidence, emotional vulnerability, supervisory hierarchy, peer relationships, communication and feedback, organisational culture, formal speaking-up systems, mistreatment, organisational support, leadership and responses to error. Conclusion Psychological safety in postgraduate medical training is shaped by interacting personal, relational and organisational conditions. The findings suggest prioritising approachable supervision, structured feedback, peer support, reliable speaking-up routes and non-punitive responses to error. Formal leadership and hierarchy-reduction programmes require prospective evaluation. PROSPERO registration number CRD42023417152.