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New Code punishes failure to speak out

The NMC’s new code of conduct places a strong emphasis on the duty of nurses and midwives to speak up about poor patient care and make raising concerns a part of everyday practice. Registrants in management roles are required to protect any staff member who raises concerns. Forward thinking NHS organisations explain how they are helping staff to speak openly, but more support from regulators is needed.

As of March 31 this year, nurse managers who do not support those who raise concerns or protect them from victimisation could be placing their registration at risk.

The Nursing and Midwifery Council’s (NMC) new code of conduct emphasises nurses’ duty to raise concerns and makes it clear that they must not prevent their colleagues or members of the public from doing so.

The Code states that nurses must protect anyone for whom they have management responsibility ‘from any harm, detriment, victimisation or unwarranted treatment after a concern is raised’.

Nurses and midwives will need to demonstrate how they are meeting the requirements of the Code when the new model of revalidation – the process they will have to undergo to maintain their place on the register – is launched in October.

NMC director of continued practice Katerina Kolyva emphasises that managers who fail to support staff who raise concerns ‘will be in breach of the Code’.

‘In future, nurses and midwives will revalidate against the Code, which means raising concerns will be an important part of maintaining their registration,’ says Ms Kolyva.

The focus on accountability for nurse managers is a product of the 2013 Francis report on failures of care at Mid Staffordshire NHS Foundation Trust. This exposed the hierarchical culture within the organisation where staff were intimidated or bullied for raising concerns.

Picture credit: iStockphoto

Unison head of nursing Gail Adams welcomes the addition to the Code, and says that nursing directors will need to be ‘vigorous’ in ensuring organisational changes do not adversely affect patient care. They will also need the strength to raise concerns on behalf of staff and not allow the traditional trust board’s focus on finances to ‘trump patient safety or the quality of care’. She adds: ‘If staff feel their concerns are not being acted on, they won’t be comfortable speaking up.’

Last month, changes to the Public Interest Disclosure Act gave nursing and midwifery students the same level of legal protection as registered staff if they are mistreated or dismissed as a result of raising concerns.

Grant Byrne, a University of Glasgow third-year nursing student and RCN student committee member, welcomes this change. He points out that students worry that speaking up about something they have witnessed on a placement will have repercussions for their course grades. ‘They also fear they may have to work with the people they have raised concerns about again.’

London South Bank University principal lecturer Joady Mitchell, a registered adult and children’s nurse, says the Code coupled with the new legal protection could prompt more nursing students to raise concerns.

Duty of candour

Qualified staff have a tendency to view a student who raises concerns as a ‘troublemaker’, she claims. ‘There is a sense among staff that they need to be cautious of the student, instead of thinking that this is a person who speaks up on behalf of others.’

The NMC has updated its guidance on raising concerns (see box, p20) to reflect the Code, and is working with the General Medical Council to produce joint guidance on the duty of candour, due out in the summer.

Raising concerns

The NMC suggests four stages for raising concerns:

Raise your concern with your line manager, but if you cannot do this for whatever reason, go to stage 2.

Raise your concern with a designated person, for example someone who has been given special responsibility and training in dealing with employees’ concerns. If the concern cannot be dealt with properly, go to stage 3.

Take your concern further to a higher level, for example the nursing director or chief executive. But if this fails, go to stage 4 after seeking advice. You can get independent, confidential advice from your professional body, trade union or Public Concern at Work. Nursing students can speak to their university tutor or mentor.

Take your concern further to a healthcare regulatory organisation or a helpline.

Both the old and updated guidance state that raising concerns should be an ‘everyday part of your role’, but the new version reinforces the message that speaking out against poor practice should be the norm.

Cathy James, chief executive of the whistleblowing charity Public Concern at Work, welcomes this shift in emphasis.

She says that organisations’ whistleblowing policies need to give nurses the means to speak up when their concerns relate to their line managers, and warns that nurses who are the victims of a poor organisational culture could lose their registration for failing to raise concerns.

‘We have to look carefully at why the person did not feel able to speak up,’ says Ms James. ‘Where there is a toxic culture or bullying atmosphere, people will not speak up.’

The NMC advises that nurses who want confidential advice should contact their professional body or trade union, or Public Concern at Work; the latter is ‘an absolutely safe haven’, insists Ms James.

Four-step process

Tameside Hospital NHS Foundation Trust, one of 11 trusts put into special measures during Sir Bruce Keogh’s post-Francis review of underperforming organisations, has now launched a campaign to make raising concerns the norm.

The campaign, If in Doubt… Speak Out, promotes a four-step process to support staff:

See if the issue can be sorted out there and then.

If the issue cannot be sorted immediately, staff should raise it with their line managers.

If this does not work, staff should write to an executive director with their concerns.

The last option is to write to the chief executive, who will look into the issue personally.

Trust deputy director of nursing Lindsay Stewart says the chief nurse has introduced monthly ‘safe forums’ with ward managers to enable them to raise concerns in confidence, which she says represents a real shift from where the trust was two years ago.

The trust has a mantra it uses throughout the organisation to foster a positive working environment: ‘Happy staff make happy patients’.

‘Before, staff were too afraid to speak out because they felt it would have repercussions,’ says Ms Stewart. ‘Now it is unusual for the place to be silent because people are asking questions about anything and everything.’

But the NMC still needs to be more proactive to protect registrants who highlight poor care in organisations that have a bullying culture, insists Roger Kline, Middlesex University research fellow and director of Patients First, a network of health professionals who have raised concerns about care.

‘It is not uncommon for nurses who have raised concerns to then find themselves referred to the NMC,’ says Mr Kline. ‘Any time that anyone is referred to the NMC, the first thing the regulator should ask is: did this person raise a concern before being referred?’

He calls on the NMC and the other regulators to agree a clear protocol on how they respond when multiple concerns are raised about a particular hospital.

An NMC spokesperson says: ‘We would investigate such concerns and intervene at an appropriate level in our remit as the professional regulator of individual nurses and midwives. There are instances where it may be more appropriate and effective to make our concerns known to other organisations, such as system regulators.’

Where complaints are a ‘gift’ Picture credit: iStockphoto

In November last year, primary care organisation Salford Health Matters in Eccles, Manchester, was rated as ‘outstanding’ by the Care Quality Commission. The commission praised the way it listens to patients and views complaints as a ‘gift’.

Lead practice nurse Moira Ogunsakin explains: ‘Complaints are very important, as we see them as a learning exercise. We look at whether the aspect complained about could have been prevented.’

The organisation ensures all complaints are discussed every week across each of its four sites, and uses the information to help identify where staff require further training. On one Wednesday afternoon per month, all staff receive training relevant to their work. These continuing professional development hours are logged in nurses’ portfolios to help prepare for revalidation. ‘They are a good way of reflecting on what we are good at and what we are bad at,’ says Ms Ogunsakin. She adds that her organisation is a ‘lovely place to work’ where staff feel ‘motivated’, which she attributes to its non-hierarchical ethos. Staff members are able to take an issue straight to the clinical director if it cannot be resolved at a lower level. ‘It is engrained in us that we can talk about anything,’ says Ms Ogunsakin.

At Staffordshire and Stoke On Trent Partnership NHS Trust, around 30 staff in various roles are training to become cultural change champions. They will support others speaking out and ensure that raising concerns is made a priority at team meetings. Former Mid Staffs whistleblower Helené Donnelly is now the trust’s ambassador for cultural change, a role focused on enabling staff to feel safe and confident about speaking out.

What to do if you have a concern

Top tips from NMC guidance on raising concerns:

Take immediate action.

Protect client confidentiality.

Refer to your employer’s whistleblowing policy.

Keep an accurate record of your concerns and action taken.

Ms Donnelly says a handful of trusts are now appointing similar roles and she is hopeful that in the near future, every trust in England will have an ambassador. But she adds that guidelines are needed to standardise the implementation of the role. Every person in the role should have the same title to avoid confusion, and they should be assured autonomy and independence, clear reporting lines to the chief executive and confidentiality in all their communications.

‘This role can work,’ she says. ‘It just needs to be set up and implemented in the right way’.

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