Project posts & other items of interest

Updates on the FTSUG project and other items of interest

Project update March 2021

We completed data collection in January 2020, just as Covid-19 was reaching the UK. The last 12 months have been dedicated to writing the draft final report, which was submitted for review at the end of February 2021.

The final breakdown of the data collected across the whole project is:

  • Semi-structured interviews completed = 202 interviews undertaken – including interviews with Freedom to Speak Up Guardians (FTSUGs), organisational stakeholders closely involved in the implementation of the FTSUG role (such as managers, directors, board members, trade unions), workers who raised concerns to FTSUGs, workers who didn’t use FTSUGs and national stakeholders.
  • Approximately 240 hours of non-participant observations of various meetings and interactions involving the Guardians were recorded in fieldnotes. These were collated to explore the interplay of context, meaning and individual/collective engagement related to implementing the Guardian role.
  • Organisational documents (such as Board reports, minutes, agendas, newsletters) including recent CQC inspection reports, NGO guidance and data provided useful historical and contemporary insights into speaking-up within the case sites and local and national implementation decision-making.

Local implementation decisions were mapped rated and compared against role expectations in the Guardians job description document, written and published by the National Guardian’s Office. Several areas of established research and theory into speaking-up and organisational culture informed the later cycle of analysis.

The draft report is now under review and we expect the report to be published in the autumn.

In the meantime we have published a couple of early papers from the project, news of which will follow later.

New paper – modelling “internal whistleblowing” in healthcare

A new study in BMJ Open (follow this link for full version of the paper) has been published by Paul Rauwolf, Bangor University and Aled Jones – who, below, reflects on the paper.


The paper makes a distinctive contribution to the debate about speaking-up (or ‘internal whistleblowing’ as referred to in the paper). It was an interesting challenge to work on a different approach to generating and analysing data. Agent based modelling is a computational modelling approach, which simulates the actions and interactions of both individual or collective entities (such as organizations or groups) and assessing their effects on the system as a whole.

The work focuses on how different speaking-up rates compare with each other in a variety of environments. These models also demonstrate how much institutional nuances can alter the effectiveness of a given speaking-up rate.

Internationally, healthcare staff are being encouraged and supported to raise and respond to concerns in the workplace (see here for an example from a previous post). Given this, the paper aims to answer questions such as:

  • Are resources within the system able to cope with potentially hundreds or thousands of complaints per month?
  • What are the effects, if any, of any delays in responding to concerns on patient care and on employees’ propensity to raise concerns in the future?
  • Will patient care improve as a result of speaking-up?

The paper calls into question the a priori belief that speaking-up always improves patient care. Given resource constraints, whistleblowing /speaking-up policies should seek to understand the complex relationship between accuracy of information, efficiency in responding to concerns, formal and informal speaking-up channels and the utility of speaking up.

The results show that an optimal model for speaking-up include:

  • Organisations where employees’ practices are fully transparent to others and employees within an organisation have a propensity to raise concerns;
  • When introducing roles such as Freedom to Speak Up Guardians, organisational resources and efficient processes are required to ensure concerns are responded to in a timely way. Inefficient processes and response delays suppress speaking-up;
  • It is almost always beneficial to encourage and permit informal channels for speaking up. A combination of informal and formal speaking-up processes perform better than formal speaking-up in isolation. Cheap, timely and informal but less transparent and possibly accurate channels for speaking-up, mixed with more accurate, formal but costly channels leads to excellent patient care.


10 lessons for speaking-up: learning from Virginia Mason’s PSA system.


Virginia Mason (VM) Medical Center based in and around Seattle consists of one 350 bed hospital facility and 9 satellite units. They employ 5000 staff, 500 of which are physicians.

The Patient Safety Alert (PSA) system was introduced in 2002 following a staff survey. This showed that staff were fearful of speaking-up about concerns. Also, staff doubted that information generated from concerns would improve the safety of care. At the time of the survey VM staff wishing to raise concerns had to complete a quality incident report (QIR). Typically, QIRs would sit on a shelf collecting dust for months, then filed away and forgotten. As we know from countless reports and commentaries into safety failures in healthcare and other industries, perceptions of fear and futility around speaking-up are inimical to creating a positive speak-up or open culture.

Patient Safety Alerts (PSAs).

The philosophy of PSAs is based on Toyota’s “Stop the line” policy, which  empowers any employee to stop the multi-million pound production line to prevent a defect occurring. Specifically, the philosophy being replicated at VM is that instead of criticizing or silencing employees who raise concerns, they offer support and resources to fix the problem. PSAs have a broad remit and are intended to capture all events involving the safety and well-being of a patient.

Results of implementing PSAs.

Result 1: From March 2002 to January 2014 staff raised concerns a total of 43,615 times. This has grown from around 10 or so reports a year in the period 2002-2004, to 850 reports a month in January 2014.

Result 2: Between 2004 and 2014 there has been a 74% reduction in insurance liability premiums paid by staff, which is an indicator of a major shift in “risk perception” by insurers. This shift in risk perception is probably based on insurers having paid out less in liability payments related to claims against VM staff – think “no claims bonus” with car insurance! Complaints and claims management go down as PSAs go up.

Result 3: PSA reporting has provided intelligence to drive improvements to quality. An improvement system where priorities are often identified and owned by sharp-end employees, who are supported by senior leaders and executives in the organization. Bottom up meets top-down.

Lessons from Virginia Mason…..

The rate change in PSAs reported in 2004-05 and
2009-10 seem to be linked to specific events which the
executive team subsequently used to publicise the
PSA’s philosophy to all employees. These events
seemed may have built employee trust in the system. Examples of events included what was termed “You call in a
PSA, we’ve got your back” which publicized how the PSA system supported a nurse speaking-up about a physician’s lack of compliance with safety procedures. Similarly, another event publicized how a senior physician used the PSA to report his own drug error. The “showcasing” of these series of events enabled the executive team to establish a new narrative supplanting traditional norms of skepticism and silence about reporting concerns with a “new” narrative of trust , openness and improvement stemming from raising concerns.

10 lessons for speaking-up in the NHS

1. VM didn’t get the PSA system right first time. It took almost a decade of learning.
2. They still haven’t got it right all the time, but reporting of concerns and responses to concerns are significantly better.
3. The PSA system has undergone continuous improvement.
4. Executive leadership is a prerequisite to building a culture of speaking-up.
5. Extensive staff education around listening and responding to employee concerns needed.
6. Publicizing positive case studies can dictate a safety narrative and create a new norm around
7. Mechanisms for speaking-up should be easily accessible, with multiple options available.
8. Rapid feedback to staff in the first instance. Keep staff updated with progress thereafter.
9. “Significance” is in the eye of the beholder: Open the floodgates to all concerns.
10. Be prepared to change as the organization learns from speaking-up.


Kenney C. A Leadership Journey in Health Care: Virginia Mason’s Story. New York: CRC Press; 2015.

Furman C, Caplan R. Applying the Toyota Production System: Using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007; 33(7): 376-86.

Embedding a System to Protect Patient Safety


Literature review update

Having previously blogged about registering the literature review see here the team have subsequently spent the last few weeks diligently searching numerous literature databases. We have also reviewed several hundred titles, abstracts and full text of papers.Time, therefore for an update on progress.

A reminder that the scope of the narrative review is to search and critique research studies of workplace initiatives designed to promote speaking-up, and responding to speaking-up. Initiatives within healthcare and other industries/sectors are of interest. Some of the headlines from the review include:

  • Overall, the quality of the research is poor.
  • We have broadly divided studies into reports of
    • Educational initiatives – speak-up learning interventions undertaken within universities with undergraduate students.
    • Workplace initiatives: speak-up interventions undertaken within workplaces not involving formal training or educational input.
    • Workplace/workforce training initiatives: mostly voluntary, occasionally mandatory enrolment of employees onto formal training courses, often involving simulated practices and/or team-working interventions.
  • There were no published, peer review studies of initiatives resembling the Freedom to Speak Up Guardian (FTSUG) role.

However, as we have learnt from our interviews (more of which in the next blog post) FTSUGs design and implement speak-up training initiatives and undertake a variety of workplace initiatives to promote speaking-up. Therefore, the review of literature will be useful in terms of helping us understand some of these activities. We are preparing a paper for submission in the new year to an internationally acclaimed peer reviewed journal.

Grey literature

We are also undertaking a review of grey literature. Grey literature publications are usually not from peer reviewed academic journals. This can include policy documents and reports/evaluations of speaking-up initiatives by organisations, charities and commercial companies. The team have identified speak-up initiatives from various sectors such as humanitarian aid, telecommunications and law enforcements. We are always on the lookout for more, so please get in touch if you know of any interesting grey literature in this area.

More questions than answers? Whistleblowing report 2018

Last week’s joint report from healthcare regulators on whistleblowing was interesting for many reasons. The report appears as a result of all “Prescribed bodies” having a new legal duty to publish   whistleblowing disclosures made to them by workers.

Over 60 prescribed bodies exist in the UK. These are organisations and individuals that a worker may approach outside their workplace to report suspected or known wrongdoing. For example, the joint report details cases from the: General Dental Council (GDC), General Medical Council (GMC), Nursing & Midwifery Council (NMC), General Chiropractic Council (GCC), General Optical Council, General Osteopathic Council, General Pharmaceutical Council, and Health & Care Professions Council. Of interest in the context of our study is that the National Guardian’s Office is a prescribed person.

The joint report shows that between in 2017/18, the GDC who regulate 111,00 workers received 61 whistleblowing disclosures. By contrast, the NMC who regulate more than 690,000 professionals, reported 60 such cases. The GMC, which has a register of around 298,000 professionals, received 23 whistleblowing disclosures. The GCC received no disclosures.

A few points of interest…

What do the numbers tell us?

When the total numbers regulated by each body is considered it is obvious that the GDC received proportionally far more disclosures than the NMC and GMC (however see below for more on the NMC). Why this occurs is an interesting question. Could it be because most dentistry is provided in primary care settings, where there are fewer robust clinical governance frameworks compared to other forms of healthcare? Alternatives to whistleblowing or disclosing concerns, such as Freedom to Speak Up Guardians, are less present or absent in dentistry. A larger proportion of concerns may, therefore, become whistleblowing disclosures to be dealt with by the regulator

Coordinated learning effort?

The new joint report highlights the regulators’ coordinated effort to work together in handling serious issues. Regulators also express their wish to improve collaboration across the healthcare sector. This is laudable but there is no little or no information about the nature and outcomes of the coordinated effort. For example it would be very useful to know

  • whether the GDC disclosure rate been considered by the GMC or the NMC in relation to their regulated primary care workforce?
  • what leaning has occurred across the regulators – how might things be done differently for the 2018/19 reporting period?

Whistleblowing rates about nursing and midwifery & the NMC’s response to whistleblowing disclosure

In total, 371 pieces of information were assessed by the NMC against the whistleblowing criteria. Of these, 60 (16%) were recognised by the NMC to be ‘qualifying disclosures’ as they met all of the whistleblowing criteria. This is, by some distance, the highest rate of non-qualifying disclosures. For example, all of the 61 disclosures received by the GDC were considered ‘qualifying disclosures’. It is therefore important that the total numbers of concerns raised/disclosures are looked at. Looking only at the numbers that are deemed qualifying disclosures may provide an incomplete picture. In response to this disparity the NMC state that “we are considering clarifying our whistleblowing guidance on our website”. Watch this space.









Important new research report published

Mannion et al (2018) Further details and full report available here

A quick post related to the publication of an important new study led by Professor Russell Mannion (co-applicant on the FTSUG project) focusing on whistleblowing and speaking-up in health care. The report contains a narrative review of the research and formal inquiries, an analysis of legal initiatives and interviews with key stakeholders about the development of whistleblowing policies.  This is an important contribution to the UK literature which also provides broader learning and conclusions of relevance to health systems internationally.

See abstract below and a link to the full report and other resources is included above.


There is compelling evidence to suggest that some (or even many) NHS staff feel unable to speak up, and that even when they do, their organisation may respond inappropriately.


The specific project objectives were (1) to explore the academic and grey literature on whistleblowing and related concepts, identifying the key theoretical frameworks that can inform an understanding of whistleblowing; (2) to synthesise the empirical evidence about the processes that facilitate or impede employees raising concerns; (3) to examine the legal framework(s) underpinning whistleblowing; (4) to distil the lessons for whistleblowing policies from the findings of Inquiries into failings of NHS care; (5) to ascertain the views of stakeholders about the development of whistleblowing policies; and (6) to develop practical guidance for future policy-making in this area.


The study comprised four distinct but interlocking strands: (1) a series of narrative literature reviews, (2) an analysis of the legal issues related to whistleblowing, (3) a review of formal Inquiries related to previous failings of NHS care and (4) interviews with key informants.


Policy prescriptions often conceive the issue of raising concerns as a simple choice between deciding to ‘blow the whistle’ and remaining silent. Yet research suggests that health-care professionals may raise concerns internally within the organisation in more informal ways before utilising whistleblowing processes. Potential areas for development here include the oversight of whistleblowing from an independent agency; early-stage protection for whistleblowers; an examination of the role of incentives in encouraging whistleblowing; and improvements to criminal law to protect whistleblowers. Perhaps surprisingly, there is little discussion of, or recommendations concerning, whistleblowing across the previous NHS Inquiry reports.


Although every effort was made to capture all relevant papers and documents in the various reviews using comprehensive search strategies, some may have been missed as indexing in this area is challenging. We interviewed only a small number of people in the key informant interviews, and our findings may have been different if we had included a larger sample or informants with different roles and responsibilities.


Current policy prescriptions that seek to develop better whistleblowing policies and nurture open reporting cultures are in need of more evidence. Although we set out a wide range of issues, it is beyond our remit to convert these concerns into specific recommendations: that is a process that needs to be led from elsewhere, and in partnership with the service. There is also still much to learn regarding this important area of health policy, and we have highlighted a number of important gaps in knowledge that are in need of more sustained research.


A key area for future research is to explore whistleblowing as an unfolding, situated and interactional process and not just a one-off act by an identifiable whistleblower. In particular, we need more evidence and insights into the tendency for senior managers not to hear, accept or act on concerns about care raised by employees.

Managers influence speaking-up at the sharp end.



Managers have an important role in influencing speaking-up. A recent paper discusses how managerial approaches may directly influence speaking-up by nurses.


Alingh et al (2018) have published an interesting paper in BMJ Quality & Safety (available here). They focus on the influence of managerial safety approaches on speaking-up. Survey data collected from nurses and nurse managers in the Netherlands. Findings compare well to similar studies undertaken elsewhere and with different professional groups. Also notable is the sample size of 302 nurse managers (response rate 42%) and 2627 ward nurses (response rate 22%) who completed the survey.

The study looked at difference between

  • Control-based safety management approaches – where managers stress the importance of following safety rules, monitor compliance and provide employees with feedback and
  • Commitment-based safety management approaches, where managers clearly prioritise patient safety by exhibiting role modelling behaviour; they show determination to ensure safe care delivery, encourage employees to participate in safety improvement initiatives and create awareness on safety issues.


The findings, in a nutshell, suggest the following:

  • Both control-based and commitment-based management approaches seem to be relevant for managing patient safety.
  • Control-based safety management is positively related to a climate for safety, although no association was found with speaking up.
  • When it comes to encouraging individual’s speaking up attitudes, a commitment-based safety management approach seems to be most valuable.
  • Communications are important. There is a divergence between nurses’ and managers’ perceptions. Nurse managers say they do more on safety management than what is actually perceived by nurses.  Nurses are possibly not always aware of everything their manager does with regard to patient safety management.

So what could this mean for speaking-up?

Displaying a preference for monitoring compliance, rule-bound safety thinking and feedback seems to inhibit speaking-up. Role-modelling and encouraging employees towards safe care is more valuable. This resonates somewhat with Martin et al’s recent paper on soft and hard intelligence and challenges to voicing safety concerns (see here). This found that formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. I see parallels here between control-based management (prioritizing hard intelligence) and commitment based management (prioritizing softer intelligence). To paraphrase Martin and colleagues – rule-bound and compliance driven (control-based) management which equates to finding  the ‘facts of the matter’ through proceduralised processes—turning the soft intelligence into hard intelligence —might actually result in information losses rather than gains.

Review of evidence registered

Undertaking a review of the literature and research evidence is often the first-step in the research process. The FTSUG project is no exception to this. Our activities in work package 1 includes:

“A review of literature that investigates different approaches used to encourage staff to speak up in healthcare and other sectors. This will help us develop our survey questions for WP 2”.

Good progress on the review is being made. We have registered the review with PROSPERO (the international register for prospective systematic reviews). Further details about the review, such as search terms used, can be found on the PROSPERO site here. Details will be updated as further progress is made.

Although we are undertaking a systematic search of the literature, we are not undertaking a “Cochrane” style review. The approach being taken is a narrative synthesis review, following the excellent guidance provided by Popay and colleagues available here.

A notable early milestone….research ethics approval

An early milestones outlined in our project plan (which can be found on this page here) was to gain research ethics approval. This was achieved last week for all phases of the project. The approval of the Research Ethics Committee (REC) comes with the usual proviso that updates are provided. For example, we will need to develop a lone worker policy/risk assessment for each specific project location when they are identified. The process of gaining research ethics approvals is often regarded with dread by researchers. However, in this instance, the thoughtful and constructive feedback from REC reviewers definitely helped the research team’s thinking. With their help we now have the practical steps in place to ensuring ethical conduct throughout the life of the study.

Project update March 2021

We completed data collection in January 2020, just as Covid-19 was reaching the UK. The last 12 months have been dedicated …

New paper – modelling “internal whistleblowing” in healthcare

A new study in BMJ Open (follow this link for full version of the paper) has been published by Paul Rauwolf, Bangor University …

10 lessons for speaking-up: learning from Virginia Mason’s PSA system.

Background.  Virginia Mason (VM) Medical Center based in and around Seattle consists of one 350 bed hospital facility and …