Psychological safety and well-being

Abstract Purpose Psychological safety is essential for creating equitable surgical training environments that support resident well-being and performance. This narrative review examines the intersection of diversity, equity, and inclusion (DEI) with psychological safety in surgical education, identifying barriers and facilitators to creating supportive learning environments for all trainees, particularly those who are underrepresented in medicine (URiM). Methods We conducted a narrative review of the US-based literature published between 2014 and 2026 using a three-phase PubMed search. Studies were included if they examined psychological safety, DEI initiatives, and their impact on surgical training environments. Quantitative and qualitative original research, reviews, and perspective papers were included. The synthesis followed SANRA guidelines. Results Fifty-four articles met inclusion criteria. Key themes were identified related to barriers and facilitators of psychological safety for surgical residents. Multiple barriers to psychological safety exist in surgical training, including hierarchical culture, harassment and discrimination, and structural inequities that disproportionately affect the well-being of URiM trainees. URiM residents experience higher rates of microaggressions, social isolation, and attrition compared to their peers. Facilitators of psychological safety include culturally concordant mentorship, diverse and inclusive leadership, institutional support through formal curricula and reporting mechanisms, and targeted interventions that address bias and microaggressions. Conclusions Creating psychologically safe learning environments requires deliberate institutional support that addresses systemic barriers while actively promoting inclusion. Programs must prioritize recruitment and retention of diverse trainees and faculty, provide robust mentorship opportunities, and implement frameworks to combat microaggressions.