Following the publication of the investigation into the failings of the Mid-Staffordshire Hospitals, which saw the government committing to further actions to clarify procedures for staff to raise concerns, Sir Robert Francis QC published an independent review on the creation of an open and honest reporting culture in the NHS (Francis, 2015). The report of the Freedom to Speak Up review revealed serious cases of bullying and discrimination towards staff who had tried to raise concerns over patient care, and suggested that this was fundamentally a patient safety issue.
The review took evidence from over 600 people and 19 000 online surveys and called for:
- A ‘freedom to speak up guardian’, to be appointed in every NHS trust to support staff
- A national independent officer to help guardians if cases were going wrong
- A new support scheme to help NHS staff who had found themselves out of a job as a result of raising concerns
- The establishment of processes at all trusts to make sure concerns were heard and investigated properly.
Yet, 8 years on, we continue to see media headlines discussing how serious patient harm has occurred, and one could also argue that the psychological safety of staff who have raised concerns has potentially suffered harm and detriment. These health and care investigations often reveal that there are incidents of avoidable harm following concerns were often raised and ignored by senior personnel.
I believe that significant progress has been made over the last decade in terms of dealing with patient safety incidents, supported by national guidance such as A Just Culture Guide (NHS England, 2023) and the NHS Resolution ‘Being Fair’ guidance, which aimed to support leaders in health and social care to understand how they can support staff when things don't go as planned by sharing thinking, and examples to enable a just and learning culture. There will however, inevitably be wider concerns other than patient safety incidents, such a behaviour that registrants will need to consider raising as something that affects patient safety.
The Nursing and Midwifery Council (NMC) Code includes candour as a golden thread, specifically we are told to:
‘Act without delay if you believe that there is a risk to patient safety or public protection.’
This section is clear that we need to raise – and if necessary, escalate – any concerns that we may have. Considering the need to continue to progress, the Welsh Government (2023) has recently published its Speaking up Safely framework for the NHS in Wales, which is an impressive practical toolkit. The launch statement from the Minister for Health and Social Services said that the framework was for staff:
‘To support their reflection on their quality and safety systems in light of recent events, which have served as a stark reminder of how vital it is that everyone working in the NHS feel safe and confident to speak up about anything that gets in the way of delivering safe, high-quality care.’
The framework considers a range of roles, systems, and processes for consideration, one of the areas that I think is particularly strong for us as senior nurses to consider the section on ‘what to do if someone has spoken up to you’, which considers three areas:
- Recognition and validation of the courage to speak up
- Non-judgmentally and actively listening to the concerns raised
- Action taken as a result of speaking up.
Another resource that I would recommend is the Civility Saves Lives website (https://www.civilitysaveslives.com), where there is a great repository of evidence that details the impact of incivility in the workplace and its link to patient safety. As the NMC lead Director for Wales,, I am more aware than I used to be of the work across all four devolved nations of the UK. As someone who has previously spoken up in relation to poor behaviours, and knowing just how difficult this is, I think that the Welsh Government framework will further enable the opportunity for positive safety culture change to support both patient and staff safety and should be shared widely.