Leadership and psychological safety in healthcare: a qualitative evidence synthesis

Purpose This systematic review aims to synthesize qualitative evidence on the role of leadership in fostering psychological safety among healthcare professionals to inform evidence-based interventions and leadership development programs. Design/methodology/approach A systematic review of qualitative studies was conducted following established guidelines for qualitative evidence synthesis. Six qualitative studies from the USA, UK and Ireland were analyzed using thematic synthesis methodology. Studies examined psychological safety and leadership across diverse healthcare settings including hospitals, intensive care units, primary care practices and Veterans Health Administration facilities, with 854 total participants including nurses, physicians, allied health professionals and administrators. Findings Leadership influences psychological safety through multiple interconnected mechanisms operating at individual, team and organizational levels. Key facilitating behaviors include displaying openness and approachability, actively soliciting input, responding supportively to concerns, role modeling vulnerability, creating structured communication opportunities and establishing non-punitive cultures. Barriers include hierarchical structures, authoritarian leadership styles, negative responses to speaking up and lack of organizational follow-through. A critical finding is that supportive leadership, while necessary, is insufficient alone; individual characteristics, past experiences, interpersonal relationships and organizational context significantly moderate leadership effectiveness. Research limitations/implications The review included six studies, potentially missing relevant evidence. Most studies were conducted in Western healthcare systems, limiting generalizability to other cultural contexts where authority relations may differ. Heterogeneity of healthcare settings, participant types and methodological approaches presents synthesis challenges. Future research should test leadership-focused interventions through rigorous evaluation studies, examine the relative importance of factors and their interactions, explore cross-cultural applicability and investigate temporal dynamics through longitudinal research. Studies should examine how psychological safety develops over time within teams and whether findings apply across different organizational types. Research exploring psychological safety in non-Western healthcare systems would enhance understanding of cultural influences. Practical implications Healthcare organizations should invest in multilevel approaches addressing leadership behaviors alongside individual perceptions, team dynamics and organizational structures. Leaders should adopt inclusive practices, create structured voice opportunities, respond supportively, role model vulnerability and ensure organizational follow-through on concerns raised. Social implications Enhancing psychological safety in healthcare settings has profound implications for patient safety and care quality. When healthcare professionals feel safe speaking up, medical errors are more likely to be identified and prevented, potentially saving lives and reducing preventable harm. Creating psychologically safe environments promotes organizational learning, enabling healthcare systems to continuously improve. For healthcare workers, psychological safety contributes to wellbeing, job satisfaction and retention, addressing workforce challenges. The emphasis on flattening hierarchies and promoting inclusive leadership challenges traditional power structures in medicine, potentially transforming professional relationships toward more equitable, collaborative models. Ultimately, psychological safety supports the fundamental healthcare goal of patient-centered care delivered by engaged, empowered professionals. Originality/value This review illuminates mechanisms through which leadership influences psychological safety and demonstrates that leadership-focused interventions alone are insufficient without addressing individual, team and organizational factors simultaneously.