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'It's one thing to raise concerns, but another to act on them'


Creating a safety culture requires acting on safety concerns rather than just counting past harms, says Elaine Maxwell

We’ve come a long way since Graham Pink raised concerns about safety at Stockport in 1990, but have we come far enough? Pink wasn’t the first or the last nurse to do so and the importance of identifying poor practice has been raised recently by Sir Robert Francis QC in his two reports on Mid Staffordshire and in his most recent review, Freedom to Speak Up.

The 2014 NHS Staff Survey includes a new question on this issue. Nationally, 68% of staff said that they felt secure raising concerns about unsafe clinical practice, leaving one-third who presumably do not. Despite this, 94% said that the last time they witnessed an error, near miss or incident, they or a colleague reported it. So why do we still have safety failures?

Some of the answers can be found in the NHS Staff Survey. Unlike in 1990, clear processes are now in place and 93% of staff reported they know how to raise concerns. However, only 57% felt confident that their organisation would address concerns and only 29% reported that senior managers acted on feedback from employees. The major problem seems not to be raising concerns but acting on them.

Is this because managers do not want to hear employees’ concerns? While there are clear examples of some staff being intimidated or even bullied by managers, 74% of staff said they were able to make suggestions on how they could improve the work of their team. I think this shows that it is important not to conflate failure to listen with failure to act on concerns. Staff at all levels want the best for patients, but change is complex and making well-intentioned changes in one part of the system often creates unintended consequences elsewhere. The best example of this is the four-hour wait target in accident and emergency departments. Introduced to improve the patient experience, this had the unintended consequence of an increase in moves between wards and an increase in unplanned patient discharges.

The staff survey suggests that a lack of understanding of how to manage unsafe practice is our major challenge rather than poor reporting processes. Escalating reporting and creating Freedom to Speak Up guardian posts in each organisation is unlikely to deliver the improvements that all whistleblowers ultimately desire.

Skilled managers and boards who are confident and competent to respond to concerns will focus on creating safety, encouraging staff who raise concerns and welcoming their input. For the small number of cases where concerns are not taken seriously or staff raising them are victimised, trusts will already have been lost. It will be too late to carry out internal processes so an independent, external body should investigate and mediate.

Creating a safety culture requires protected time for improvement activities, with both managers and direct care staff who are skilled in creating active safety rather than counting past harms. In such a culture, peer pressure rather than bureaucracy will ensure concerns are celebrated rather than tolerated.

Elaine Maxwell is principal lecturer in leadership, London South Bank University.

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Readers' comments (3)

  • Hi Nursing Times, I would like to highlight a concern about employment practices in the NHS which I feel has been overlooked. There has been recent press coverage about the high levels of Agency staff in the NhS with it being identified there should be more fully employed staff. What seems to have been missed is the fact that Agency staff are very vulnerable and not covered by employment law to the extent of fully employed staff.
    I feel that unscrupulous NHS trusts and managers are trying to turn the clock back 100 years by hiring staff not covered by modern employment laws. I am an Agency Mental Health nurse and was subjected to degrading and inappropriate treatment from a manager at the Manchester Mental Health and Social care Trust. I had tried to leave my post and given 7 days notice as my contract allowed. The manager then contrived to summarily dismiss me which has harmed my future employment prospects. He would not have been able to do this if I was a fully employed staff member. I made a official complaint and the manager whom investigated was dismissive of me and upheld the previous managers behaviour, conveniently ignoring the issue I complained about and conducting a investigation which suited her purposes. I was represented by the RCN and the rep was hostile to me, treating the meeting as a job interview for her joining the H.R. Dept of the trust. My agency would not make any waves as keeping a lucrative contract rather than protecting their staff is their priority. The Manchester Mental health Trust also took sanctions against me for raising the concern by barring me from working for the trust again.
    I use this illustration to highlight the vulnerability of Agency staff in the NHS and the potential for them to be subjected to appalling treatment with impunity by the NHS. I feel this has been completely overlooked by the media, unions and organisations such as yours.
    Benefits for the NHS include hiring and firing as they please, no sick pay, no pension etc, complete impunity of unethical treatment of staff.
    Regards Paul

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  • Graham Pink was not the first. In March 1778 Thomas Baillie a Royal Navy officer published a work of 116 pages in quarto, a RN publication regarding abuse. How far have we come.
    He reported the watering down down of beer (the safe drink at the time) serving smelling meat to the patients, giving short rations, fraud, knocking down wards to make apartments for senior wardens.
    False allegations were made against him, he was even taken to court and found guilty, dismissed the service. The charges eventually overturned and he was reinstated but he was demoted.
    He got through because his family knew a Peer of the realm.
    How much has changed? Only the charges, the false allegations remain, the demotions remain, the sackings remain.
    Those of us who have suffered know that others pay lip service to it

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  • Well done Paul Richardson | 17-Mar-2015 11:06 am for speaking up. Of course managers will blacken your name professionally and personally.
    The RCN are rubbish and really should be charged with fraud for taking money for a service they dot provide.
    The NMC are useless as they want 'proof' for any allegations you make.
    I wet to a care home and on application form said I left after a disagreement with management but at interview I said I had been victimised and sacked for whistleblowing.
    Wish you and all other victimised WBs all the best. You are bigger than bullying management. Go for a new job no matter how low you feel

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