Where to Help: Appreciative Inquiry Workshops Improve Resident Communication and Psychological Safety Perceptions

Setting and Problem

Burnout and emotional exhaustion during residency are often linked to a lack of autonomy and a perceived sense of powerlessness. In response, the Accreditation Council for Graduate Medical Education (ACGME) has prioritized learner wellness and psychological safety in its annual Resident/Fellow Surveys.¹ Yet, empowering residents to express concerns meaningfully remains challenging. One critical dimension of psychological safety is the ability to raise concerns without fear of retaliation.

Appreciative inquiry, a strengths-based framework, promotes autonomy by encouraging individuals to identify what works well and envision shared areas for improvement.² Our internal medicine residency program adapted this method into recurring workshops called “Where to Help” (WTH), designed to enhance communication between residents and program leadership. This initiative aligns with ACGME goals by empowering residents to collaboratively shape the learning environment.

Intervention

WTH workshops, which started in May 2024, are monthly 1-hour sessions held during protected didactic time. These program leadership–facilitated sessions empower residents to explore program processes using the 4 phases of appreciative inquiry: Discover (what works), Dream (what could be), Design (what should be), and Deliver (what will be).² A key element of these workshops is resident participation in enhancing their experience by reflecting on successes, identifying key areas for improvement, collaborating with leadership to develop solutions, and planning change management strategies to effectively implement those solutions.

To evaluate the impact, we administered a post-intervention attitudinal survey after 3 WTH workshops, using 5-point scales and an open-ended question to assess participants’ perceptions of communication. Responses were analyzed using independent samples t tests with Cohen’s d effect sizes. In addition, we compared institutional ACGME survey outcomes from 2024 to 2025 using a chi-square test to assess changes in psychological safety, specifically the item “Able to raise concerns without fear of intimidation or retaliation.”

Outcomes to Date

Following 3 WTH workshops, 61 of 77 residents (79%) completed an attitudinal survey. Five of 6 communication metrics showed improvement among residents who attended WTH vs those who did not. Satisfaction with communication improved markedly (d=1.587, mean [SD] 3.88 [±0.60] vs 2.34 [±1.08], P<.001), as did effort invested (d=0.801, mean [SD] 3.67 [±0.75] vs 2.93 [±0.82], P<.001), interest in communicating concerns (d=0.674, mean [SD] 4.18 [±0.81] vs 3.50 [±1.07], P=.022), frequency of communication (d=0.979, mean [SD] 3.41 [±1.18] vs 2.32 [±1.10], P=.001), and confidence that concerns are communicated (d=1.301, mean [SD] 3.71 [±1.16] vs 2.32 [±1.03], P<.001). The only item that showed no change was the perceived importance of communication, which remained consistently high across all groups. Many of the 16 residents who responded to the open-ended question described improvements in communication, such as “the WTH session helped establish a specific framework for what exactly would be changed and how,” and “it has increased the ability for all residents to be heard,” which support the observed gains in satisfaction.

After 12 WTH workshops, institutional ACGME survey data supported these findings. In 2024, 71 of 77 residents responded (92%), and in 2025, 75 of 80 residents responded (94%). Favorable responses to the item “Able to raise concerns without fear of intimidation or retaliation” improved from 52% in 2024 to 77% in 2025 (χ² [1]=10.21, P=.001). Calculations produced an odds ratio of 3.13, highlighting a large improvement in perceptions of psychological safety after WTH. The intervention was feasible to implement during scheduled didactic time without requiring additional resources.

WTH workshops provide a scalable and replicable intervention to enhance communication and foster psychological safety in graduate medical education. Outcomes demonstrate the intervention’s feasibility, improved resident engagement, and significant improvements in both attitudinal survey results and institutional ACGME metrics. Because the approach is adaptable, it can be implemented across various specialties and institutions as a novel, strengths-based appreciative inquiry strategy for enhancing learner well-being and empowering resident voices.

Author Notes

The views expressed are those of the authors and do not necessarily represent official policy or position of the United States Air Force, Defense Health Agency, Department of War, or U.S. Government.