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Speak out on the “small things”


To act as our patient advocates, we must recognise when care has fallen short

Sometimes, knowing when to speak out isn’t easy. Yet, if we see care we would not want for our relatives or ourselves and do not raise concerns, we implicitly accept these poor standards.

The momentum gathered by Nursing Times’ Speak Out Safely campaign has been impressive: over 60 hospitals, community trusts and other bodies have signed up. It is innovative in supporting all staff to speak up on poor care.

Standards of care can fall short in small ways: nurses ignoring relatives as they approach a nurses’ station; a buzzer left unanswered for too long; colleagues talking about their weekend exploits, oblivious to the presence of their patient.

These “small things” give strong verbal and non-verbal messages to patients and relatives they are not important. In the maelstrom of day-to-day work, it can be all too easy to forget that we have the privilege of being part of others’ lives at times of great stress and vulnerability.

There are times when I have participated in or not addressed the small things. On one shift handover, I remember to my lasting shame complaining about a broken nail to a colleague in front of a dying patient and their relatives. How could I have thought my trivial cosmetic problem was relevant? I once escorted a patient to a ward and a staff nurse glowered and said: “Who said you could bring her here now?” in an aggressive tone. “She” was conscious, alert and heard every word. I capitulated and said nothing to the nurse.

Preparing for difficult conversations

● Be clear about the reason and purpose for the conversation
● Beware of assumptions you make about the other person’s intentions
● Draw the person in by describing how an observer would see the scenario
● Consider how you have contributed to the issue (Ringer, 2006)
● Make sure your trust has signed up to Speak Out Safely. Go to

We may remember similar episodes. It is not easy to challenge a peer but we have a duty to do so. These conversations can be difficult but many websites, articles and books give tips on doing it.

Difficult conversations often do not go to plan but, with even small amounts of preparation, they can achieve the desired outcome.

It’s important to start in the right way. Draw the person in by describing how an observer would see the scenario: “I need your help with what just happened. Can we talk about it?” (Ringer, 2006).

As nurses, we spend more time with patients than any other health professional so are privileged and empowered by seeing the whole spectrum of care. We have a duty and a responsibility to be their advocates.

Next time we participate in or witness a “small thing”, it is worth bearing in mind the question: “Is the standard we walk past the standard we accept?” (Morrison, 2013).

Erica Reid is a senior nurse at NHS Scotland, has a wide experience of frontline nursing and is a Health Foundation quality improvement fellow at the Institute for Healthcare Improvement


Ringer J (2006) We Have to Talk: a Step-By-Step Checklist for Difficult Conversations.

Morrison D (2013) Chief of Army Message Regarding Unacceptable Behaviour.



Readers' comments (5)

  • Do you realise that it is still not safe to speak out?

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  • Safe for whom? If we don't speak patients get worse care - how is that ultimately safe for anyone?

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  • This below might give you some hints about how unsafe it is to speak out:

    The post about whistle blowing...

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  • tinkerbell

    formerrmn | 3-Feb-2014 11:43 am

    Thanks for your blog. Did we work at some of the same shoddy shambolic institutions back in the day. Perhaps RMN's get to see more abuses than RN's, don't know cos only ever worked as an RMN and boy have I seen some abuses in the 80's & 90's and yes have spoken out to my cost and would do the same again, but maybe one has to bear in mind that if you do speak it it could cost you your job, sad but still probably true, very much hope all this can change. Very much hope, fingers crossed, toes crossed and anything else that crossable.

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  • Nurses will be far less likely to speak out once revalidation is railroaded through as for the first time, your ability to remain on the nursing register will be inextricably linked to your employer.

    Every time a nurse witnesses abuses by her employer eg patients being put at risk due to short staffing she will have to balance raising concerns with the possibility of her employer not revalidating her or making it very difficult.

    Those who are for revalidation should be very careful in what they wish for!

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