In November 2020 the Royal College of Nursing (RCN) published a new policy document for nurses, nursing associates, students and healthcare support workers entitled Raising and Escalating Concerns (RCN, 2020). The document emphasised that all care staff should feel safe and supported when raising any concerns about patient care. The guidance is timely, given the stress on NHS staff caused by the ongoing pandemic.
Background
Following the events at the Mid Staffordshire NHS Foundation Trust and the subsequent public inquiry (Francis, 2013), new strategies to promote patient safety were introduced across the NHS (Health Foundation, 2021).
Despite the introduction of these new patient safety procedures, December 2020 saw the publication of an interim report into the deaths of mothers and babies at the Shrewsbury and Telford NHS Trust (Ockenden, 2020). The review, led by senior midwife Donna Ockenden, reported on the largest number of individual clinical reviews ever conducted as part of an inquiry relating to a single clinical service in the history of the NHS.
Health and social care regulator the Care Quality Commission (CQC) responded to the findings of the Mid Staffordshire public inquiry by strengthening its hospital inspection processes. Most readers will have subsequently participated in the CQC's more robust inspection processes. The CQC monitors, inspects and regulates services to ensure that they meet fundamental standards of quality and safety. During a typical hospital inspection, for example, the inspectors and their specialist advisers triangulate data from both quantitative and qualitative sources to determine if a service is safe, effective, caring, responsive and well led. These five domains of inspection have been designed to illuminate the success of an institution in meeting the nationally prescribed standards of quality and safety. Each domain is objectively rated as outstanding, good, requiring improvement or inadequate.
The assessment of the safe domain is pivotal to any hospital inspection. In order to capture a three-dimensional view of those processes that are implemented in any core service such as medical care (which currently includes older people's services), the CQC has designed a range of key lines of inquiry for inspectors to follow. These help inspectors illuminate those elements of patient safety that are crucial for protecting patients from any harms that may occur during care delivery. There are six key CQC safe domain lines of inquiry, each with numerous subsections that offer additional scrutiny prompts to inspectors (CQC, 2018):
Other royal colleges have also produced policies and procedures to address and improve patient safety. The Royal College of Paediatrics and Child Health (RCPCH) has published a SAFE resource pack. SAFE is an acronym for Situation Awareness for Everyone. This resource is designed to offer clinical staff who care for sick children a method of enhancing their ability to protect patients from potential harms, especially from unrecognised clinical deterioration (RCPCH, 2019).
Similarly, the adoption of early warning tools such as the National Early Warning Score (NEWS) 2 designed by the Royal College of Physicians (RCP), has enabled a national system to be introduced that standardises the assessment of and response to acute illness by care staff to help them detect and treat the deteriorating sick patient (RCP, 2017).
Many core services within acute care hospitals have introduced the concept of ‘safety huddles’. Such multidisciplinary team huddles usually involve hospital ward staff coming together at the beginning of a shift and quickly discussing any patient concerns or safety issues (Di Vincenzo, 2017).
In July 2019 NHS Improvement launched a strategy to help the NHS to continuously improve patient safety. It sets out the steps that the NHS must take to achieve its vision of continuously improving patient safety through adopting a safer culture, and implementing safer systems (NHS Improvement, 2019).
Since the Francis inquiry, the NHS has striven to foster a culture of transparency and patient safety. Much of this has been modelled on those processes introduced by the Virginia Mason Medical Center (2021) in Seattle, USA.
Although there have been great strides in patient safety over the past decade, NHS Improvement has highlighted that up to 11 000 lives a year are lost in the NHS due to safety concerns, with older patients the most affected. The additional financial burden of treating patients following safety incidents has been estimated to cost about £1 billion per year (NHS Improvement, 2019). A patient safety incident is any unintended or unexpected incident that could or did lead to harm for any patient undergoing or receiving NHS care.
The RCN guidance
Raising and Escalating Concerns (RCN, 2020) is designed to enhance some of the previous guidance documents and underscore the importance of timely identification of a patient safety issue, which should be raised by bringing it to the attention of a colleague or manager. The RCN defines escalating concerns as further addressing a specific concern by submitting evidence and entering into formal organisational processes. Such processes should already be firmly embedded within all NHS Trusts and the CQC will expect to see evidence of these when conducting an inspection. The latest coronavirus insight report produced by the CQC and based on data from patient surveys shows that, on the whole, people's experience of receiving hospital treatment during the pandemic is positive, despite the huge pressure that COVID-19 has put on the service (CQC, 2020).
A key message of the RCN's guidance is that all healthcare staff should be confident that their specific teams and organisations will focus on system learning, not individual blame, and that care workers should feel safe when raising concerns. The RCN recognises that the prospect of raising a concern can be daunting for individuals to contemplate. Raising and escalating of concerns is a subject covered by a significant clause in the Nursing and Midwifery Council (NMC) Code (NMC, 2018:13-17).
The RCN document lists examples of concerns that should be raised and that if left unaddressed might result in harm to a patient. Staff are advised that if they are in any doubt, they should always err on the side of caution and raise their concerns by following their employer's policy or, in the case of a student or trainee nursing associate, their higher education institution's policy. The type of incidents that might concern individual staff include:
The RCN document emphasises that being asked to cover up any risk, inappropriate behaviour or action is wrong. If staff members are asked not to raise or pursue any concern, even by a person in authority such as a manager, they should not agree and should continue to escalate their concerns.
If any concern poses an immediate risk to the health or safety of either patients or staff, this should be reported verbally immediately to the person in charge of the shift or duty manager. The RCN recommends that this verbal report should be followed up with a written summary using a formal risk management reporting method. Subsequently, if the issue cannot be resolved locally and continues to pose a risk, then this should be escalated immediately to the next level within the organisational, managerial or professional structure.
All organisations should have effective procedures in place to allow all staff to raise any concerns they may have. Despite this, a recently published YouGov health professionals' survey revealed that only one in five health professionals are completely confident their workplace could resolve issues of malpractice, and less than a quarter (22%) said they would be ‘very comfortable’ reporting malpractice to a senior colleague (YouGov, 2020).
The RCN policy recommends that when a staff member has identified the right person to approach to raise a concern, they should:
The RCN policy stresses that staff raising concerns should expect to be treated fairly, have their concerns taken seriously and have access to reporting mechanisms such as Datix. Additionally, staff should receive timely and constructive feedback. Staff who believe that their concerns have not been adequately addressed at front-line level should escalate their concern to the designated named individual within the Trust. The RCN (2020) publication also provides specific advice to senior nurses who manage other groups of nursing staff.