Tag: <span>speaking-up</span>

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.


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.

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.

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 …