Stress and psychological safety in healthcare profesionals: current findings and intervention approaches

Abstract


Healthcare professionals face stress from many sources such as high workload, time pressure, emotional intensity and organizational stressors. In this review, the main factors that cause stress in healthcare professionals are discussed within the framework of workload and long working hours, relationships with patients and their relatives, institutional structures and the effects of crisis periods such as pandemics. The psychological effects of stress at the individual level are examined under the titles of burnout, anxiety, depression and decreased job satisfaction. The concept of psychological safety, which is one of the focal points of the study, is defined both theoretically and its importance in the field of healthcare is discussed. In addition, the relationship between psychological safety and stress levels is revealed and the role of this concept as a protective factor is emphasized. The last section includes suggestions to support the psychological well-being of healthcare professionals. In this context, suggestions are presented regarding the regulation of workload and working hours, provision of psychological support services, increasing education and awareness studies, supportive leadership practices, construction of safe working environments and improvements that can be made at the policy level. This review draws attention to the need to strengthen psychological safety for the protection of mental health of healthcare professionals and the provision of sustainable healthcare services.


Introduction

Healthcare professionals have one of the most stressful jobs due to the work they do and the hours/days they work. This situation brings with it intense job stress and general burnout (National Academies of Sciences, Engineering, and Medicine, 2019; Rink et al., 2023). The prevalence of this stress and burnout, especially in physicians and nurses, has been reported to be between 30-50% (Rotenstein et al., 2018). This global problem is not specific to certain countries or periods. For example, even before COVID-19, more than 60% of healthcare professionals reported high levels of stress (Boucher et al., 2025; National Academies of Sciences, Engineering, and Medicine, 2019). However, of course, the COVID-19 pandemic has made this situation worse, and many studies have shown that anxiety, depression, and burnout rates have increased significantly in healthcare professionals (Boucher et al., 2025; Pappa et al., 2020; Shechter et al., 2020). Working under chronic job stress not only negatively affects the mental and physical health of employees, but also threatens the quality and safety of patient care (Melnyk et al., 2018; Rink et al., 2023; Tawfik et al., 2019). Therefore, examining the sources and consequences of stress in healthcare professionals and determining protective factors for this stress are of vital importance.
The concept of psychological safety describes a climate in work environments where staff feel safe, share their thoughts, and are not afraid of making mistakes (Edmondson, 1999). In recent years, this concept has become a topic of interest in order to improve employee well-being and patient safety in the healthcare field. It is emphasized that employees feeling psychologically safe at work can reduce the negative effects of stress and enable teams to become more productive, innovative, and learn from mistakes (Edmondson et al., 2016; Frazier et al., 2017; Bahadurzada et al., 2024). Therefore, examining the relationship between stress and psychological safety is an important area of research in combating the burnout epidemic among healthcare professionals. In this context, the aim of this study is to examine the main factors that cause stress in healthcare professionals and the effects of stress on employees and patient care in the light of current scientific literature and to examine the role of the concept of psychological safety in this context. At the same time, it is aimed to present evidence-based suggestions for reducing stress and increasing psychological safety by presenting intervention approaches implemented or suggested at individual, organizational, and political levels.
1. Sources of stress in healthcare professionals
The stress experienced by healthcare professionals is multidimensional and has various sources ranging from workload to emotional strain and organizational conditions. In the literature, these stressors are frequently classified as work-related stressors, personal life stressors, and factors at the intersection of both (Silva et al., 2023; Turunç and Öğen, 2022). Within the scope of these classifications; the main sources of stress in healthcare professionals will be examined under four subheadings. These are:
  • Workload and time pressure,
  • Interaction with patients and their relatives,
  • Institutional and organizational factors, and
  • Additional stressors brought about by pandemic and crisis periods.  
1.1. Workload and time pressure
Excessive workload and insufficient time are one of the most common and obvious sources of stress in healthcare professionals (Starc, 2018; National Academies of Sciences, Engineering, and Medicine, 2019; Turunç and Öğen, 2022). Studies on nurses and physicians have shown that increasing patient numbers and intense work tempo significantly increase the risk of burnout in employees (Güdük, Vural and Güdük, 2022; Starc, 2018). Especially in cases of chronic staff shortages, a small number of healthcare professionals have to care for an excessive number of patients. This situation leads to a constant feeling of not being able to keep up and time pressure, paving the way for stress (Doğan, Ertuğrul and Akın, 2024; World Health Organization, 2022). In fact, evaluations conducted in European countries have shown that the high number of patients per nurse due to the shortage of nurses increases the workload of healthcare professionals, causing stress, illness cases, and absenteeism (Kinter and Kani, 2022; National Academies of Sciences, Engineering, and Medicine, 2019). Healthcare professionals working under intense work tempo and long working hours may experience serious psychological problems, in addition to not being able to find the opportunity to rest and recover, as well as the necessity to make critical decisions quickly (National Academies of Sciences, Engineering, and Medicine, 2019; West et al., 2016). As a result, high job demands and time constraints emerge as one of the most fundamental determinants of occupational stress in healthcare professionals.
1.2. Interaction with patients and relatives
Another important area affecting the stress level of healthcare professionals is the interactions established with patients and their relatives. The emotional demands and challenging interpersonal relationships that accompany patient care can put significant pressure on staff (Fu & Chen, 2011). In particular, situations that involve intense emotional load—for example, caring for critically ill patients, caring for dying patients, or witnessing people suffering—can lead to emotional exhaustion in healthcare personnel (Starc, 2018). A study conducted on nurses found that staff who are constantly confronted with death and pain can develop compassion fatigue over time, which increases their stress levels (Branch & Klinkenberg, 2015; Starc, 2018). In addition, conflicts with difficult patients or demanding/angry relatives are also significant sources of stress for staff. For example, a study conducted in intensive care units found that conflicts between the team and patients’ families regarding treatment plans were seen as a significant source of stress by nurses (Edwards et al., 2012; Okoli et al., 2019). Similarly, a study found that conflicts with family members create more stress for nurses than other team members (Edwards et al., 2012; Franza et al., 2020). Healthcare professionals may worry about receiving negative feedback, being exposed to violence, or not being able to meet expectations when communicating with patients and their relatives. The increasing focus on patient satisfaction, especially in healthcare services, can increase the stress load by creating pressure on employees to “please the patient in every situation” (Moll et al., 2015; O’Donovan et al., 2021). In the face of aggressive attitudes or threatening behaviors of the patient or relative, employees may develop both psychological stress and safety concerns. As a result, the emotional labor undertaken during patient care and the difficulties experienced in relationships with the patient/patient family are important components of the job stress of healthcare professionals.
1.3. Institutional and organizational factors
The organizational structure and characteristics of the work environment play a determining role in the level of stress experienced by healthcare professionals. Institutional factors such as unsupportive management style, insufficient resources, and work-role conflicts create stress by increasing employees' workload or reducing their sense of control (Karácsony, 2019; Starc, 2018). For example, in one study, participating nurses stated that inadequate supervision and lack of feedback were among the sources of stress; at the same time, it was emphasized that excessively strict supervision and micromanagement contributed to stress by undermining their sense of autonomy (Catapano et al., 2023; Starc, 2018). Hierarchical communication problems within the institution, employees not being included in decision-making processes, or not receiving sufficient appreciation from managers are also frequently reported stressors (Nembhard & Edmondson, 2006; Nicholas & Hilary, 2017). Conflicts regarding values and ethics are also among the sources of institutional stress. For example, healthcare professionals may experience significant stress when they feel that their ethical values regarding patient care conflict with institutional policies or when they are exposed to an unfair compensation/reward system (Catapano et al., 2023; Starc, 2018). Indeed, one study found that unfair compensation and promotion systems and limited career advancement opportunities contribute to the development of burnout in nurses (Karácsony, 2019; Starc, 2018). The length of working hours and the shift system are also organizational stress factors; irregular shifts and long hours increase stress by creating sleep disorders and conflicts with family life in employees (Ruotsalainen et al., 2014). Finally, information systems and bureaucratic workload in healthcare organizations are also important: Inefficient or user-unfriendly technologies such as electronic health records, unnecessary bureaucracy and paperwork create additional stressors that “do not contribute to workload” in healthcare professionals (Maheshwari et al., 2023; National Academies of Sciences, Engineering, and Medicine, 2019). In summary, structural and managerial problems at the organizational level – such as lack of support, excessive demands, and lack of control – are critical factors that reinforce the stress experienced by healthcare professionals.
1.4. Pandemic and crisis periods
Pandemics and similar crisis periods are special situations that increase the stress of healthcare professionals to an extraordinary level. The COVID-19 pandemic, which began in 2020 in particular, has created an unprecedented struggle and source of stress for healthcare professionals. Studies conducted on physicians and nurses working on the front lines of the pandemic show that symptoms of depression, anxiety, acute stress, and trauma are significantly elevated compared to the general population (Pappa et al., 2020; Tong et al., 2023). For example, a meta-analysis found that approximately one-quarter of healthcare professionals showed clinical symptoms of depression or anxiety in the first year of the COVID-19 outbreak (Pappa et al., 2020). A study conducted in New York at the beginning of the pandemic reported that 57% of healthcare professionals had symptoms of acute stress (Shechter et al., 2020). There are many unique factors that contribute to stress during the pandemic: The risk of infection and the fear of endangering their own health or the health of their families created a constant state of anxiety in professionals (Hossain & Clatty, 2021). Especially during periods of shortage of personal protective equipment (PPE), healthcare professionals felt unprotected and experienced intense stress (Hossain & Clatty, 2021). Another characteristic of the pandemic is the influx of patients and the explosion of workload; the necessity to care for a large number of seriously ill patients in a short time has led to both physical and mental exhaustion (Bahadurzada et al., 2024; Gündoğmuş et al., 2022). In addition, healthcare professionals have frequently encountered ethical dilemmas and “moral distress” during the pandemic: Making decisions such as distributing limited ventilators in intensive care units, coping with the distress experienced by relatives of patients due to visiting restrictions, or witnessing colleagues falling ill have increased the psychological burden on professionals (Hossain & Clatty, 2021). Similarly, stress reactions intensify in crisis scenarios such as disasters, wars, or major earthquakes, as the pressure and expectations on healthcare personnel increase exponentially. In short, pandemics and other large-scale crisis periods present extraordinary stressors in healthcare professionals, significantly increasing the risk of burnout, post-traumatic stress disorder, and other mental health problems (Pappa et al., 2020).
2. Psychological effects of stress on healthcare professionals
The intense and constant stress that healthcare professionals are exposed to not only causes momentary discomfort; it can also seriously negatively affect their psychological well-being in the long term and lead to many mental problems.
The burnout syndrome, which is the most important of these, is a condition characterized by emotional exhaustion, a sense of personal failure, and desensitization to work as a result of long-term stress (World Health Organization, 2019). The World Health Organization has defined burnout as “a syndrome resulting from chronic stress that is poorly managed in the workplace” and has recognized it as an occupational phenomenon in the international disease classification (World Health Organization, 2019). Burnout is quite common in the healthcare field: For example, in a comprehensive review conducted among physicians, it was stated that the prevalence of burnout varied widely, ranging from 0% to 80%, depending on the study and the measurement method, but most studies indicated that at least one third of physicians experienced burnout (Rotenstein et al., 2018). A more recent meta-analysis conducted during the pandemic period revealed that the burnout rate may be around 52% among all healthcare professionals, while it may be as high as 66% among doctors and nurses (Bahadurzada et al., 2024). Work stress can lead to anxiety and depressive symptoms as well as burnout. Studies on healthcare professionals show that those who experience high work-related stress have a significantly increased risk of developing anxiety disorders and depression (Pappa et al., 2020). For example, during the COVID-19 pandemic, approximately one-quarter of healthcare professionals working on the front lines were diagnosed with clinical-level anxiety or depression symptoms (Pappa et al., 2020). A strong relationship was found between high stress levels and anxiety/depression symptoms; insomnia, restlessness, difficulty concentrating, and feelings of hopelessness were reported to be common among stressed professionals (Pappa et al., 2020). It has also been reported that health care professionals exposed to traumatic work experiences may develop symptoms of post-traumatic stress disorder (PTSD) (Hossain & Clatty, 2021). In summary, intense and unmanageable stress in health care professionals is an important risk factor for the emergence of burnout syndrome, as well as anxiety disorders, depressive disorders and other psychological problems. This situation both reduces the quality of life of employees and negatively affects workforce productivity and quality of care.
3. The concept of psychological safety
Psychological safety is a concept defined as the situation in which individuals do not feel fear of punishment or humiliation when expressing themselves or taking risks in work environments (Kahn, 1990; Edmondson, 1999). This concept was first put forward by Kahn (1990) while explaining the involvement and self-disclosure of employees in work; it was later popularized by Edmondson (1999) at the team level. According to Edmondson (1999), psychological safety is the shared belief among team members that taking interpersonal risks is safe. In other words, employees in a psychologically safe work environment can voice their opinions, ask questions, or admit their mistakes without worrying about appearing “stupid,” being ostracized, or being punished (Edmondson, 1999). Psychological safety is theoretically based on organizational behavior and learning organization literature. This concept is considered as a climate element that increases learning, innovation, and performance at the individual and team level (Newman et al., 2017). In teams with high psychological safety, members give more feedback, openly discuss problems, and focus on solutions together. While examining the historical development of psychological safety, Edmondson and Lei (2014) emphasized that this concept is especially key to the ability to learn from mistakes and adapt. Since individuals in environments with high psychological safety adopt an attitude that is open to learning rather than a defensive attitude, organizations can better adapt to changing conditions (Edmondson & Lei, 2014). In summary, the concept of psychological safety refers to a workplace climate where employees feel emotionally safe and therefore can engage in innovation and learning behaviors. This concept describes an environment where employees can contribute without worry, and different dimensions of psychological safety are examined to establish this environment in the workplace (Clark, 2020).
3.1 Psychological safety in the healthcare sector
The concept of psychological safety is of particular critical importance in the healthcare sector, which is a high-risk and complex work environment. Effective teamwork and open communication in healthcare are essential for patient safety. In a psychologically safe clinical environment, nurses and physicians can easily express an error or “potential error” when they see it; thus, precautions can be taken before problems escalate (Okuyama et al., 2014; Fukami, 2023). For example, in operating rooms or intensive care units, the ability of team members to speak without fear of hierarchy plays a key role in preventing medical errors (Derickson et al., 2015). A classic study conducted by Edmondson (1999) on hospital teams showed that nursing teams with high psychological safety reported errors more frequently (not because they actually made more errors, but because they did not feel the need to hide existing errors). This finding reveals that employees in units with high psychological safety prefer to “speak up rather than remain silent,” and this fosters a culture of learning and recovery (Edmondson, 1999). Psychological safety in the healthcare field is also associated with the quality of patient care. When nurses' perception of psychological safety is high, they can resolve their concerns about patient care by sharing them with their colleagues or superiors, which increases the effectiveness of care (Ito et al., 2022; Pfeifer et al., 2023). For example, in a study conducted in primary healthcare teams, it was found that employees who perceived psychological safety as high participated more actively in quality improvement initiatives and adopted innovations in patient care more easily (O'Donovan & McAuliffe, 2020; Nembhard & Edmondson, 2006). Psychological safety is considered an important component of patient safety culture. Although a healthcare service free of errors is not possible, an environment where errors are turned into learning opportunities and their recurrence is possible; This is achieved through a climate dominated by a supportive rather than punitive approach (Institute of Medicine, 2000; Kumar, 2023; O’Donovan et al., 2021). Indeed, the principles of “just culture” in healthcare organizations are based on employees feeling safe when reporting errors and revealing system-level problems (Edmondson & Lei, 2014; Wawersik & Palaganas, 2022). In summary, psychological safety strengthens intra-team communication in the healthcare field, contributing to the reduction of medical errors and the promotion of innovative practices and mutual learning. This creates a win-win situation in terms of both the well-being of employees and the safety of patients. For this reason, increasing psychological safety in healthcare institutions has become an important goal of quality improvement programs and leadership development initiatives today (Brimhallet et al., 2023; Ito et al., 2022).
4. The relationship between psychological safety and stress
Psychological safety is seen as an important factor that can shape the effects of stress experienced by healthcare professionals. There is increasing evidence that individuals working in a psychologically safe environment can better cope with stress, find support, and are protected from burnout (Frazier et al., 2017; Bahadurzada et al., 2024). In this section, the protective role of psychological safety on stress, team dynamics and leadership dimensions, and the importance of safe communication environments will be discussed.
It has been emphasized in the literature that employees with a high perception of psychological safety in the work environment can be more resistant to the negative consequences of stress. Psychological safety, in a sense, serves as a social support network for employees and creates a buffer effect against stress factors (Frazier et al., 2017). In their study with healthcare professionals, Bahadurzada et al. (2024) revealed that employees with high team psychological safety at the beginning had a slower increase in burnout levels in the following years and lower intentions to leave their jobs. In the same study, it was determined that even in hospitals that faced serious resource shortages during the COVID-19 crisis, the increase in burnout was significantly limited in employees of units that had a psychologically safe climate before (Bahadurzada et al., 2024). These findings suggest that psychological safety can be a resilience-enhancing factor. Thanks to psychological safety, employees can talk openly about the stress they experience, ask for help when necessary, and do not have to hide their mistakes or troubles, thus reducing the destructive effects of stress (Fattori et al., 2022; O’Donovan et al., 2021). For example, if a nurse feels safe, she can tell her team that she is very busy and needs support; in this way, the problem can be shared and resolved. Otherwise, the same nurse working in an environment without psychological safety will not say that she is struggling in order not to appear weak, but will struggle alone and will probably experience more stress. Therefore, safe climates reduce individual stress burden by encouraging cooperation and empathy (Frazier et al., 2017). In addition, psychological safety has been found to be associated with increased motivation and commitment to work; this can help employees make their stress sources more meaningful and overcome them (Newman et al., 2017; Wang et al., 2024). As a result, psychological safety can act as a “protective shield” in the work environment, alleviating the destructive effects of stress on healthcare professionals. Therefore, building psychological safety at the team and organizational level, rather than relying on employees’ individual coping strategies alone, will be an effective strategy in preventing burnout and mental health problems in the long term (Bahadurzada et al., 2024).
5. Conclusion and recommendations
The findings presented in this study indicate that work-related stress in healthcare professionals is a widespread and multidimensional problem, but can be managed and reduced with appropriate interventions. Factors such as excessive workload, time pressure, emotional strain, and organizational problems can negatively affect both the psychological and physical health of healthcare professionals, leading to burnout, anxiety, depression, sleep disorders, and various psychosomatic disorders (Fu & Chen, 2011; Güdük, Vural, and Güdük, 2022; Starc, 2018; Okoli et al., 2019; Pappa et al., 2020; Turunç and Öğen, 2022). Moreover, high stress among employees increases the risk of medical errors, reduces the quality of patient care, and weakens the overall performance of the healthcare system (Rink et al., 2023; Melnyk et al., 2018; Tawfik et al., 2019). Therefore, it is clear that there is a close relationship between the well-being of healthcare professionals and patient safety and care outcomes. In this context, establishing a psychological safety culture in the workplace is a promising approach to reduce the harmful effects of stress. Environments with high psychological safety are environments where employees feel supported, can work without excessive fear of making mistakes, and can ask for help when necessary (Edmondson, 1999; Kahn, 1990). Such an environment acts as a buffer for employees, allowing them to tolerate stressors more easily and develop collective resilience (Frazier et al., 2017). For example, if problems can be openly discussed within the team, the burden carried by an individual employee can be shared by the team, and no one has to struggle with problems alone. Therefore, developing a psychological safety climate in healthcare organizations offers a two-way gain that will increase both employee well-being and the quality of patient care (Derickson et al., 2015; Ito et al., 2022).
In general, the literature suggests that a multi-level approach will yield the most effective results in combating stress and burnout in healthcare professionals (Chaisurin & Yodchai, 2024; National Academies of Sciences, Engineering, and Medicine, 2019; West et al., 2016). Although teaching stress management techniques at the individual level is important, it is not sufficient on its own. At the same time, systematic improvements in the work environment (e.g., reduced workload, supportive leadership) and employee-friendly regulations should be implemented at the policy level (Adam et al., 2023). It is critical that institutions see the well-being of healthcare professionals as a prerequisite for institutional success and invest in this area (Habeger et al., 2022; Shanafelt & Noseworthy, 2017). Therefore, in the healthcare sector, where stress is inevitable, providing a supportive culture for employees and creating work environments with high psychological safety should be an indispensable goal for sustainable and quality healthcare services.
In line with the findings, the following general recommendations can be made to reduce the stress of healthcare professionals and increase psychological safety:
  • Workload and working hours management: Healthcare institutions should review their personnel planning and take measures to prevent excessive workload. Optimal nurse-patient ratios should be maintained, and physicians and nurses should be provided with effective use of rest and break times (National Academies of Sciences, Engineering, and Medicine, 2019; Ruotsalainen et al., 2014). Limiting shift and duty times in line with scientific recommendations (e.g., not working more than two nights in a row) will reduce the risk of burnout (Tamminga et al., 2023).
  • Psychological support and counseling services: Free and confidential psychological counseling and support programs for healthcare professionals should be expanded. Employee support units with psychologists or counselors can be established in hospitals. Support mechanisms that employees can turn to after traumatic events or high stress should be clearly defined and easy to access (Maheshwari et al., 2023; Shapiro & Galowitz, 2016). In addition, peer support programs (e.g., mentor nurse-employee pairings) should be encouraged.
  • Education and awareness-raising: All healthcare professionals should be provided with training on coping with stress, self-care, and psychological safety when they start work and at regular intervals. This training may include practical skills such as mindfulness, relaxation techniques, time management, and effective communication (Ng et al., 2024; Rinaldi et al., 2019). Special training programs should be organized for managers on recognizing and approaching the signs of burnout in employees (World Health Organization, 2022).
  • Supportive leadership and communication culture: Individuals in leadership positions such as institution managers, department heads, and head nurses should encourage open communication and psychological safety in their teams. A non-accusatory, solution-oriented attitude should be displayed towards employees who report errors or problems (De Giorgi, 2021; Edmondson & Lei, 2014). Regular team meetings should be held to ensure that employees can convey their opinions and suggestions, and managers should be sensitive to feedback. Employees should be able to reach management at any time with practices such as an “open door policy” (Shanafelt & Noseworthy, 2017).
  • A work environment that supports well-being: Institutions should create physical and social environments that take into account employees’ needs for rest and renewal. For example, hospitals can have calm and comfortable staff rest rooms and kitchens with healthy snacks. Offering facilities such as an in-house gym and yoga classes helps employees relieve stress. In addition, successes and good practices should be regularly celebrated and a culture of appreciation should be created (Brooks Carthon et al., 2021; White and Myers, 2024).
  • Policy-level improvements: National action plans should be implemented to prevent burnout in healthcare professionals. For example, “Healthcare Professional Well-Being” programs can be initiated by the Ministries of Health and the performance of hospitals in this area can be monitored (Giga et al., 2018; National Academy of Medicine, 2022). Legal sanctions should be strengthened against violent incidents that threaten employee safety. In addition, regulations should be made to ensure that healthcare professionals who receive mental health support are not discriminated against in professional licensing and promotion processes (World Health Organization, 2022). As a result, simultaneous steps should be taken at the individual, institutional and policy levels in order for healthcare professionals to cope with stress and burnout problems. Building a psychologically safe and supportive work culture should be at the center of these steps. Meeting this need means ensuring the “happy and healthy healthcare professional, happy and healthy patient” policy. The sustainability of the healthcare system and the increase in service quality will be possible with proactive investments in this area. Efforts to reduce stress and establish psychological safety should be prioritized for the benefit of both employees and the society they serve.

Veysel Kaplan

Harran University

Author for correspondence.
Email: vyslkpln@hotmail.com
ORCID iD: 0000-0001-9082-1379

Turkey, Sanliurfa, Turkey Associate Professor (Psychiatric Nursing), Nursing Department, Faculty of Health Sciences

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