In The Code, the Nursing and Midwifery Council (2018) states that nurses must ‘act without delay if you believe that there is a risk to patient safety or public protection’, therefore nurse leaders and managers have a responsibility to support the reporting of concerns, in addition to acting on those concerns reported to them from their team members. Media reports continue to identify a plethora of situations and activities that are viewed as concerning for the public, NHS and the profession. Against this backdrop, it is essential that nurse leaders promote a timely and transparent approach in raising concerns, reporting errors, and encouraging a duty of candour to foster a learning culture for improvement (Royal College of Nursing (RCN), 2023).
How these concerns are communicated can affect how they are understood, shared or escalated to appropriate others, and ultimately what action is taken to address them. Despite senior NHS executive teams continuing to transform cultures away from blame to those of facilitating psychological safety to report and learn from concerns, a YouGov survey in 2020 identified that 33% of healthcare workers would be uncomfortable to some extent reporting dangerous practice, while 30% did not feel confident that issues raised would be properly handled or resolved (Ibbotsen, 2020). This article provides an overview of the influencing factors affecting support and communication strategies to raise concerns. It also provides suggestions for managers and leaders to consider when shaping organisational and team culture to promote voicing of concerns.
Organisational influences
Raising concerns can feel daunting, no matter what level of responsibility a leader has within an organisation. It has been well documented within previous high-profile organisational reviews that the reporting of concerns has been a matter of scrutiny – whether this is colleagues not feeling their concerns would be listened to or supported, or when concerns are raised and no actions are taken for improvement. This can be further influenced by the perceived assigned power of the person raising the concern and those to whom the concern is raised. Despite the various regulatory and organisational requirements, guidance, and processes, nurse leaders are often in unique positions to provide the conditions and support to encourage teams to discuss their concerns, while also influencing decision making for solutions and improvement, and determining when to escalate further.
As alluded to above, organisational culture has been found to be a key contributing factor in high-profile NHS care failings. Organisational culture can be defined as the collective values and beliefs of people who work in the organisation, however, Simpson et al (2019:3) suggested a more collective definition where:
‘Culture is co-created through the interaction, communications, influences and collaborations among members of an organisation … when culture is defined as co-created it makes staff individually and collectively accountable for the system, and thus the culture that they belong to/create.’
Organisational culture can also be influenced by individuals’ values, customs, and social behaviour norms. Within the healthcare team, the nurse leader can help to instil the values of the organisation to encourage an open and effective communication culture, drawing on values of the NHS constitution (Department of Health and Social Care, 2023). Identifying and demonstrating these values has been reported to affect patient safety and quality, the working environment, and an individual's sense of belonging (The King's Fund, 2025)
An additional concern affecting effective teamwork and a subsequent potential risk to patient safety is incivility. Shoorideh et al's (2021) systematic review and meta-analysis reported the presence of incivility toward nurses to be 55%, drawing on 30801 individuals and 60 studies. This review reported that poor communication, insufficient time, and delays in sharing information impacted on increased incivility, with role modelling behaviours of managers and supervisors also seen to impact on whether incivility was accepted and mirrored by other team members or seen as unacceptable to the team culture. This concurs with previous literature relating to how newly registered nurses are professionally socialised into a culture to ‘fit in’ (Smythe and Carter, 2022). All members of the team need to feel valued, and confident that their contributions will be heard, to avoid feeling powerless to challenge unsafe practice and raise concerns (Mansour and Mattukoyya, 2019).
Nurse leaders can draw on systems, processes and relevant personnel to help decision making when a member of staff or colleague raises a concern. These can include the relevant organisation's ‘raising concerns’ policy, Freedom to Speak Up Guardian, safeguarding lead, clinical governance department, and HR department. Navigating these processes may not always be easy, particularly when the initial step promotes solving the issue at an informal level where possible. The policy may not include a timeframe for investigation, but accurate recording of the concern and subsequent communications is imperative. Colleagues should be aware of the organisational policy, although often this is only mandated at induction. Nurse leaders should never be pressured into the non-reporting of a concern, by their colleagues or senior NHS personnel.
‘Healthful’ leadership
The independent review of health and social care published in 2022, chaired by Sir Gordon Messenger, found that leaders were experiencing pressures that were resulting in their staff feeling unable to speak out about patient care, and where high levels of discrimination, bullying and blame were becoming the norm (Messenger, 2022). A workplace culture of mutual support, where staff feel that their voice is valued and respected, has been defined by McCormack and McCance (2016) as a ‘healthful culture’.
The leadership required to support a healthful culture was further investigated by Dickson et al (2022) using a systematic review approach following the COVID-19 pandemic. The evidence reported suggested that those leaders who can authentically demonstrate compassion, empathy and courage tend to forge more positive and supportive relationships between themselves and their staff. Having an informed leader who can act as a ‘conduit of information’, and who is able to use and signpost the organisational support services, can reduce psychological harm and contribute to the feeling of psychological safety for staff who wish to raise concerns (RCN, 2023). Figure 1 summarises the attributes of a leader who promotes a healthful workplace culture.
Communication strategies
Promoting psychological safety is seen to be paramount in facilitating colleague's confidence to raise concerns. A climate of fear leads to silence and disengagement which is ultimately a barrier for organisational improvement (Yalçın et al, 2022). In addition, care environments involving strict hierarchies are more likely to create a climate of silence where concerns are not raised (Erkutlu and Chafra, 2019).
The NMC (2024)Standards of Proficiency for Registered Nurses state that nurses should ‘demonstrate the ability to challenge and provide constructive feedback about care delivered by others in the team and support them to identify and agree individual learning needs’ therefore it is important that all members of the team feel a sense of support and security (Blenkinsopp et al, 2019). Consideration should be given to those members of the nursing team who may have more to lose if they raise concerns, for example, those in insecure positions such as agency nurses, new members of the team, or students who feel the need to fit in due to assessment requirements.
Constructive challenge involves voicing concerns or offering alternative perspectives in a respectful and professional manner with the aim of improving processes, practices, or outcomes. Unlike whistleblowing, which typically involves reporting serious misconduct, constructive challenge focuses on everyday practices and decisions within the healthcare setting. Having the courage to raise concerns should not be underestimated so it is imperative mechanisms are in place to support and guide this process. As highlighted in a study by Tarrant et al (2017), teams who share understanding of safe practice and how this is socially created, can subsequently become pro-active in agreeing what is acceptable and unacceptable behaviours.
As a guide, nurse leaders can consider the civility aspects of NHS England's (2022)‘Safety culture: learning from best practice’ insight report. Section 5 gives the following examples of effective communication practice to facilitate a positive culture, where all colleagues feel safe and supported to raise concerns:
Civility
Appreciation
Whistleblowing
Whistleblowing and constructive challenge play vital roles in ensuring transparency, accountability, and continuous improvement within healthcare organisations. The nurse leader can play a pivotal role in creating an environment in which other health professionals feel empowered to speak up about issues that may compromise patient safety or quality of care. Whistleblowing refers to an individual's deliberate act of reporting misconduct, illegal or unethical practices, and wrongdoings to persons who can affect action (Yilmaz and Gamze Özbek, 2024), and it has been responsible for bringing to light some notable healthcare scandals as noted above (Department of Health, 2013;Francis, 2013). Whistleblowing in healthcare settings can be complex and challenging, and due to hierarchical structures, there can be fear of retaliation, and concerns about reputation. Nurse leaders must recognise the importance of creating a culture that values transparency and encourages open communication without fear of retribution. Although whistleblowers typically act in the public interest, and attempt to serve the interests of the organisation, by exposing ‘behaviours’, they may risk personal retribution, ostracism or being labelled as troublemakers, ultimately deterring health professionals from reporting wrongdoings and negatively impacting on patient care and safety, as highlighted by Francis (2013).
Wiisak et al(2022) proposed that rather than a single process, the act of whistleblowing is three-phrased, and involves:
In considering this three-phase approach, nurse leaders play a part in facilitating early communication and action when poor patient care is observed or suspected, pre-empting full whistleblowing. Although whistleblowing has its place in raising concerns, it is usually perceived as the ‘last resort’ and is actioned when the potential for harm is heightened or has already occurred. It must be recognised that other avenues can be taken by health professionals to speak up or speak out about the quality and safety of patient care at a more immediate level. Lee et al (2022) highlighted that nurses are often the first to recognise the potential for adverse patient events and a timely response can have an immediate impact.
Professional responsibility
As a nurse leader, the NMC (2018)Code, section 16.6, makes it clear that there is a professional responsibility to support and protect members of the team for whom they have responsibility, after a concern is raised. Part of this professional responsibility may require the nurse leader to be an advocate for staff wishing to raise a concern as well as being knowledgeable regarding their employer's policy for raising concerns, speaking up or whistleblowing and the support networks available both internally and externally.
Creating a culture within the workplace where staff feel empowered and able to openly raise concerns or question decisions about patient care and safety in a constructive way, will help to maintain professional responsibility and credibility amongst the team (RCN, 2023: 8). This also relates to the NMC's (2019) ‘Raising Concerns: Guidance for nurses, midwives and nursing associates’, which discusses how generating a safe culture within the workplace where staff are encouraged and empowered to question, seek guidance and suggest improved ways of working is protective for both patients and staff alike. To encourage this process, the nurse leader may act as an advocate for those raising concerns.
As defined by the National Institute for Health and Care Excellence (2021), an advocate represents the person's interests, which they can do by supporting them to speak, or by speaking on their behalf. As a registered nurse, section 3.4 of the NMC (2018)Code states that one must ‘act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care’. Within the RCN's (2023)Raising Concerns document there is clear evidence of the need for nurse leaders to be a staff member's advocate. Where the level of concern or risk is outside of the nurse leader's level of responsibility or authority, this then needs to be escalated on behalf of the staff member whilst recognising protection and care of the individual/s raising such a concern. Accurate record keeping and preparing well for this advocacy role will ensure the nurse leader is able to articulate clearly and concisely in this forum. Reporting back to the staff member(s) who initially raised the issue, and keeping them informed throughout the process, will ensure that the process is as transparent as possible for all concerned and that staff will see that their concerns are being taken seriously.
The RCN (2023) indicates the following steps to take when discussing a concern with staff. It is important to identify the type of concern being raised and the policy that applies. When staff raise a concern, the nurse leader should always (RCN, 2023):
Local support networks and mechanisms
Each employer within the NHS is required to have a current ‘raising concerns policy’, which should be made available to staff, and therefore nurse leaders should be knowledgeable about the systems and processes that are in place to support staff who wish to raise concerns. Support can be offered from within the organisation, however, knowing what and how to access confidential support services external to the organisation may be required. As part of the requirements for employer organisations, the NMC (2018)Code states that support for staff to uphold the standards required for patient care and safety should be provided by the employer organisations. This may include the National Guardian's Office where the local Freedom to Speak up Guardian will be listed. The NHS Employers website offers a range of guidance and resources for leaders who are supporting staff to raise concerns (https://tinyurl.com/2v9s55st), including helping leaders to encourage their colleagues to speak up, and in turn, improve learning and patient safety/care.
The Point of Care Foundation (2024)Impact Report 2023 outlined the improved patient experience when staff receive the practical and emotional support that they require, within a safe and compassionate space. In particular, the organisation promotes the practice of Schwartz Rounds, ‘a multidisciplinary forum designed for staff to come together once a month to discuss and reflect on the non-clinical aspects of caring for patients, including the emotional and social challenges associated with their jobs’ (Point of Care Foundation, 2016). Where nurse leaders have implemented the Schwartz Round forum, the impact report highlighted improved satisfaction within staff teams, reduced stress and ultimately more compassionate safe care for patients. The challenges being felt by staff in providing care can be explored in this safe forum, which helps staff to feel less isolated and more supported with a resulting reduction in concerns being raised regarding unsafe patient care.
As a nurse leader it may be appropriate to signpost staff to external support, for example, the confidential support offered by nursing and healthcare unions or organisational confidential support networks. The RCN, for instance, offers free, confidential help and advice for its members which address a range of issues as well as telephone coaching, counselling and peer support (https://www.rcn.org.uk/Get-Help/Member-support-services). The NMC's advice on raising concerns also includes links to various organisations who can offer help and advice (https://tinyurl.com/eyc8c7kp).
Conclusion
It is acknowledged that raising concerns should be supported by all colleagues to ensure a positive patient safety culture. Nurse leaders can be instrumental in shaping how this is embedded within their teams, encouraging civility, and drawing on professional responsibilities to support staff to feel empowered in voicing concerns without fear of reprisal.