Abstract

Purpose: Psychological safety (PS) is necessary for effective simulation-based education (SBE) and students' learning. However, few research examines how undergraduate students conceptualize and actively shape it. This study explored student and teacher perspectives on PS using a co-creation approach designed to minimize hierarchy and enable equitable dialogue. Methods: Guided by critical realism, this qualitative study employed a four-phase co-creation process: preparation, sensitization using autonomous reflection, structured workshop pairing students and teachers with no prior academic ties, and content analysis with collaborative synthesis. Six guiding questions on PS structured the inquiry. Participants were. Results: Analysis of 308 meaning units, that reflect input from six participants (three faculty, three students), yielded five interrelated categories influencing PS in undergraduate SBE: (1) Student Capacities (e.g. emotional regulation, self-confidence, adaptability); (2) Teacher Influence (e.g. credibility, communication tone, feedback style); (3) Peer and Social Dynamics (e.g. trust, respectful collaboration); (4) Structural and Physical Environment (e.g. pre-briefing, scenario clarity); and (5) Institutional and Cultural Framework (e.g. confidentiality, safety norms). A timeline-based model illustrated distinct contributions of students and teachers to PS before, during, and after simulation. Conclusion: Co-creation revealed that PS is not only a facilitator-driven condition but a shared, culturally situated process shaped by students, teachers, and institutional rituals. Engaging students as co-creators offers practical, context-sensitive strategies to strengthen inclusion, relational trust, and resilience in SBE.