Fostering Psychological Safety From Unsafe Ground: Professional Identity and the Leadership Paradox in NHS Nursing and Midwifery

This is the authors' abstract. We don't add key points for this paper.

AIM: To explore how nursing and midwifery (N&M) leaders draw on professional identity to navigate their role in relation to workforce wellbeing and psychological safety, and the consequences of this work when conducted within hostile organisational cultures. DESIGN: Constructivist Grounded Theory. METHODS: Eighteen participants holding current or recent formal leadership and management responsibilities within United Kingdom NHS settings were recruited via purposive sampling. Intensive semi-structured interviews were conducted and analysed using initial and focused coding, constant comparative analysis and memo writing. RESULTS: Three interconnected themes were generated: (1) professional identity as the foundation for psychological safety work, with participants drawing on values of care, integrity and advocacy to build trust-based team cultures; (2) professional credibility as the currency of trust, with leaders' demonstrable connection to frontline practice acting as the primary mechanism translating professional identity into team trust; and (3) the paradox: professional identity under threat, whereby the same professional values driving participants' commitment to psychological safety placed them at risk within their own organisational contexts, generating cumulative moral distress. This is conceptualised as the leadership and wellbeing paradox: fostering psychological safety from unsafe ground. CONCLUSION: N&M leaders cannot sustainably foster psychological safety when they are operating on unsafe ground. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Healthcare organisations must actively protect the psychological safety of N&M leaders for safe, compassionate care cultures. Failure to address the leadership and wellbeing paradox will continue to drive moral distress and attrition across the professions. IMPACT: Professional identity was found to motivate and endanger leaders' psychological safety work, generating a paradox in which cumulative moral distress damages wellbeing and threatens retention. The findings have direct relevance for N&M leaders, healthcare organisations and policymakers addressing workforce attrition and culture change. NO PATIENT OR PUBLIC CONTRIBUTION: This study did not involve patient or public contribution. The research focused exclusively on the professional experiences and perceptions of nursing and midwifery leaders as study participants. Given the study's focus on leadership practice and workforce wellbeing from the perspective of professionals in leadership roles, patient, service user or public involvement in the design, conduct or analysis of the research was not applicable.