Raising concerns is an essential part of improving practice, as the Francis Freedom to Speak Up review indicated last week. Escal8 sets out steps to deal with these issues
Sir Robert Francis QC’s Freedom to Speak Up review reported that there is still a “serious issue” around the treatment of whistleblowers. This article explores why raising and escalating concerns are integral to healthcare governance systems and processes, and presents Escal8 - a new model that outlines the steps in doing this. It also examines the importance of learning and sharing from escalation, and the impact on quality and safety.
Citation: McSherry R, McSherry W (2015) A model to support staff in raising concerns. Nursing Times; 111: 8, 15-17.
Authors: Robert McSherry is professor of nursing and practice development at the School of Health and Social Care, University of Teesside, Middlesbrough; Wilfred McSherry is professor in dignity of care for older people at School of Nursing and Midwifery, Staffordshire University and Shrewsbury and Telford Hospital Trust, Stafford, and part-time professor at Haraldsplass Deaconess University College, Bergen, Norway.
- This article has been double-blind peer reviewed
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The prospect of raising or escalating concerns about care can be daunting for health professionals to contemplate. It has the potential to damage their own general health and wellbeing, and affect those about whom they are raising concerns and the service users/patients involved. High-profile stories of whistleblowers who lose their livelihoods or have their mental health or personal integrity publicly questioned while the people about whom they raised concerns appear unaffected have exacerbated the problem.
For the purposes of this article, raising concerns is defined as identifying an issue and bringing it to the attention of a colleague or manager. Escalating concerns is defined as taking a concern further by submitting evidence and going through the formal organisation processes.
The Public Interest Disclosure Act 1998 says those considering whether to raise or escalate issues or concerns about care need to feel confident they will be given respect, dignity and, if necessary, anonymity and confidentiality by their team and organisation. This is imperative to protect the individual, the patient and the public.
The important message for all health professionals is that raising a concern is the right thing to do. It is about safeguarding and protecting, as well as learning and sharing from a situation.
In recent years, serious concerns and questions have been raised about the poor quality and standards of nursing practice in some areas, which led to a barrage of accusations and allegations in the media that nurses in general do not care.
However, there is significant evidence to demonstrate the opposite. Nurses’ commitment is evident from the National Inpatient Survey 2013 (Care Quality Commission, 2014). More than three-quarters (77%) of patients who responded said they “always” had confidence and trust in the nurses treating them; 20% said “sometimes”, and 3% “no”. In addition, 81% of respondents said that, overall, they were “always” treated with respect and dignity while in hospital.
However, a range of factors influence nurses’ ability to safeguard high-quality care, including:
- Increasing workloads;
- Complex organisational systems and processes;
- Reduced staffing and capacity;
- Rising sickness/absence;
- Advances in technologies;
- Efficiency and effectiveness targets.
To minimise the influence of the above factors, healthcare providers must make it a priority to create organisational environments and cultures, in which nurses, other health professionals and healthcare students can deliver safe, high-quality care - and raise concerns when care is unsafe, unsuitable or potentially harmful.
Health professionals must feel confident that if an incident, accident or significant event occurs in their area of practice or placement, they will be supported if they speak out or raise a concern - particularly since this is now a duty they are expected to fulfil.
Raising and escalating concerns is a central clause in the revised Nursing and Midwifery Council code, which says nurses must “act without delay if you believe that there is a risk to patient safety or public protection” (NMC, 2015).
The requirement to report concerns is often included in employment contracts, and within the roles and responsibilities set out in job descriptions. These usually state that staff members must notify relevant managers, leaders, educators or regulating organisations or authorities (NMC, 2013).
Building and maintaining honest, open and transparent therapeutic relationships with patients, carers and staff is imperative to ensure the safety and quality of care.
However, in the past, concerns were often dealt with by NHS organisations and other health and social care providers using corrective, reactive reviews and investigation. We need to move to a proactive and human interactive approach. That is to say the identity, apprehensions, insecurities and vulnerability of the person raising concerns must be safeguarded and protected at all times.
In addition to organisational and disciplinary functions, people management should involve recognising and rewarding staff using simple human interactions, behaviours and gestures (Verweire and Van den Berghe, 2005). This can be as simple as saying thank you to a person or team for their hard work during a busy shift.
This type of behaviour or gesture recognises and respects the contribution of an individual or team, and is an effective way of improving motivation, commitment and confidence in the workforce. It also validates and preserves the dignity of each individual in the healthcare team (McSherry, 2010). Celebrating success and acknowledging staff when things go well should, therefore, be as much a management priority for healthcare managers as ensuring staff feel safe to raise concerns.
Expressing appreciation can have a profound effect on the morale, sense of self-worth and dignity of individual staff members and teams. It may lead to the development of more open and positive cultures in which everyone feels able to raise questions and complain without fear of incrimination or retribution (Department of Health, 2006).
Such positive cultures may also support implementation of the recommendations from the report into the care failings at Mid Staffordshire Foundation Trust (Francis, 2013) associated with a “duty of candour”. The report’s executive summary notes that organisations should “ensure openness, transparency and candour throughout the system about matters of concern”.
Healthcare governance systems
Clinical governance is “a protective mechanism for both the public and healthcare professionals” (McSherry and Haddock, 1999). It is designed to safeguard and protect both the public and staff through fostering a culture and working environment in which safe, high-quality care can flourish (McSherry and Pearce, 2010).
The mechanism was introduced in the NHS as a framework to support healthcare workers and organisations to provide safe, high-quality care (DH, 1997).
The aim was to draw together the key concepts of patient safety, risk management, information and communication, accountability and evidence-based practice, and to foster organisational cultures and working environments that:
- Systematically harmonise clinical and managerial/leadership roles and responsibilities associated with individuals’ accountability and practice;
- Improve team dynamics, function and working by fostering more integrated team working in both the public and the independent sectors;
- Strive for continuous improvement in all that the NHS does by monitoring, changing, evaluating and improving practice to safeguard standards;
- Nurture a culture of continuous sharing and learning by placing a duty of care to improve individual, team and organisational performance;
- Place a person-centred approach at the heart of clinical governance (McSherry and Pearce, 2010).
Despite the importance of clinical governance, many health professionals continue to feel uncomfortable, fearful and at times threatened if they raise or escalate a concern about an individual’s and/or team’s performance (Social Partnership Forum and Public Concern at Work, 2010 ).
Implications of raising and escalating concerns
Everyone working in healthcare must always remember that people have priority over systems and processes. The danger in raising concerns and escalation is that they focus on processes, systems, outcomes and procedures at the expense of ensuring that those involved (whether raising concerns or the subject of those concerns) are supported and treated justly and fairly.
Dealing with concerns should not be focused on judging and accusing - instead it should involve exploring an issue in an open, transparent manner to allow for timely evidence, solutions and recommendations.
Many nurses, midwives and students lack the confidence to raise and escalate concerns when faced with a situation in which patient safety is compromised. It is vital that they not only have the confidence to raise and escalate concerns but also that they understand how to do this.
For these reasons we have developed Escal8 - a simple model that outlines fundamental steps when raising and escalating concerns and celebrating good practice.
The Escal8 model (see attached) highlights eight steps to raising and escalating concerns, along with recognising good practice. It is designed to highlight the importance of building organisational cultures and working environments that require honesty, openness, transparency and trust.
These principles are important to empower staff to come forward to highlight when situations go well and when they have not gone so well. Raising concerns should be encouraged and regarded as an integral part of safety, quality and governance systems and processes, and therefore an integral part of individual employees’ accountability.
Raising concerns and escalation should be viewed as an immediate safeguarding quality mechanism that requires urgent actions and responses. This is essential to identify where interventions, procedures and interactions need improvement, along with individual attitudes, behaviour or performance. It is equally important to acknowledge openly and regularly when matters go well at an individual, team or organisational level, as rewarding and celebrating success and achievements help to create an open and honest culture.
The eight steps to Escal8 (see attached) depend on recognising and valuing the above. To achieve excellence in practice, organisations need to be able to share and learn from adverse incidents and to celebrate achievement and success. The process is about “safeguarding the health and wellbeing of those in your care” (NMC, 2013) along with safeguarding the health and wellbeing of staff and the public.
To raise and escalate concerns successfully we suggest focusing on the eight steps. Staff need to be aware of the mechanisms and frameworks within which to raise concerns, and have the knowledge, skills and understanding to do this. This is only possible if they can navigate the process using frameworks such as whistleblowing policies, in collaboration with stakeholders and partner organisations such as the Care Quality Commission and local safeguarding teams. This is essential to ensure any concerns raised are thoroughly and, where necessary, independently investigated.
Escal8 highlights the importance of ensuring that evidence of the learning and sharing gained when concerns are raised, and its potential impact on quality and safety, are relayed back to those involved in the process and the organisations involved. Evidence in this context is not just about empirical findings from research - it is about having the facts, figures, accounts and narrative to put together a true picture of the situation to highlight the issues, concerns or good practice.
Informing health and social care workers - including students - about raising and escalating concerns, along with recognising and celebrating success, must become an integral part of all nursing, health and social care curricula. These must be designed so practitioners understand that highlighting concerns about care is an invaluable way of learning and sharing. They must also make clear the mechanisms and frameworks to support escalation.
Nurses need to foster and create working environments where raising and escalating concerns becomes a natural and integral part of everyday learning and activity. Whistleblowing should not be viewed as a negative, destructive activity, and those who do raise questions should not be subjected to intimidation, victimisation or isolation by colleagues. Such attitudes and approaches are destructive and do not lead to the changes in behaviour, attitude, practice and culture that may be necessary.
All health and social care professionals have a duty and a professional responsibility to report, challenge and change poor, unsafe practice and to do this requires courage, confidence and support.
Raising and escalating concerns therefore requires the development of systems and processes that create environments and opportunities for staff to highlight concerns about care without fear of retribution or retaliation.
Ultimately, this is about dispelling myths and fears about raising concerns so individuals, teams and organisations can use such situations as opportunities for personal and professional learning. Escal8 is designed to demonstrate how this fundamental aspect of safe, high-quality care should become integrated with - and not be an adjunct to - care.
- Nurses have a duty to report and challenge poor and unsafe practice
- Concerns about care should be used as opportunities for learning
- Systems and processes must be in place so staff are in an environment where they can highlight concerns without fear of retribution or retaliation
- The Escal8 model gives eight steps to raising and escalating concerns, along with recognising good practice
- The model highlights the importance of an organisational culture of honesty, openness, trust and transparency
Care Quality Commission (2014) National Findings from the 2013 Inpatients Survey.
Department of Health (2006) Dignity Challenge: High Quality Care Services that Respect People’s Dignity. Department of Health: London.
Department of Health (1997) The New NHS: Modern. Dependable. London, HMSO.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.
McSherry W (2010) Dignity in care: meanings, myths and the reality of making it work in practice. Nursing Times; 106: 40, 20-23.
McSherry R, Haddock J (1999) Evidence-based healthcare: its place within clinical governance. British Journal of Nursing; 8: 2, 113-17.
McSherry R, Pearce P (2010) Clinical Governance: a Guide to Implementation for Healthcare Professionals. Blackwell Science: Oxford.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Nursing and Midwifery Council (2013) Raising Concerns: Guidance for Nurses and Midwives.
Social Partnership Forum and Public Concern at Work (2010) Speak up for a Healthy NHS. How to Implement and Review Whistleblowing Arrangements in your Organisation.
Verweire K, Van De Berghe L (2005) Integrated Performance Management: a Guide to Strategy Implementation. Sage Publications: London.