Why do people find it so hard to speak out in the interests of patients?

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Health care staff are usually motivated to enter their professions by a desire to make a difference for patients and service users. Why then, do they find it so hard to speak up for patients when they see care that does not meet satisfactory standards? And when they do, why do they find it so hard to be heard?

The Francis Inquiry report highlighted three key characteristics of health care culture: openness, transparency and candour; these are desirable, but can be hard to achieve. There are a number of reasons for staff in all professions and at all levels to stay silent when they see practice that falls short of acceptable standards. The structures and processes within an organisation can be hierarchical and defensive, which mitigates against speaking up or exposes those who do to risk; there can also be social reasons – challenging friends and colleagues can often be difficult. Sometimes staff keep quiet because they wonder: if I am saying this about my colleague’s practice, what does it mean for my own?

Our Patient and Family-centred Care programme supports frontline clinical staff, and leaders in NHS organisations, to deliver patient-centred care. We run a ‘Beyond Silence’ workshop, which explores the reasons that speaking up is so difficult, and what can be done to make it easier to speak, to hear, and be heard.

Participants in the workshop explore what causes silence and the implications of silence, using examples from other industries: who can forget the Challenger disaster, where the space shuttle exploded only seconds after taking off from Cape Canaveral? The subsequent investigation revealed that people had had concerns but were afraid to speak up and felt under tremendous pressure because of it. In health care too, numerous inquiries stretching back decades (and most recently in Mid Staffordshire) have documented examples of poor care, where some staff did not speak up and others were not listened to when they expressed their concerns.

In any workplace there are issues that are not discussed. In health care, these can have an adverse effect on patients. Research, for example that by Maxfield D et al on the seven crucial conversations for health care, shows that a high proportion of health care professionals say they have worked with people who take shortcuts or show disrespect in the way they go about their work. There is also evidence that people are particularly likely to take shortcuts when they are tired and under pressure. So how can these issues be dealt with?

Organisations must support and celebrate those who are willing to speak up and develop structures and processes to support this, and their leaders must model this behaviour themselves.

They must provide opportunities for staff to remain connected to patients’ experiences so that their perceptions are not dulled by routine exposure. And they must equip staff with the skills to enable them to speak up: teaching them how to challenge in a constructive and non-blaming way; helping them to work in teams to establish a common cause and shared responsibility for standards; being clear that the intent behind any challenge is to improve care; and approaching colleagues with an attitude of curiosity rather than blame. To create a culture in which people acknowledge that there is a risk of things going wrong, teams need to establish routines for understanding their own performance, and need time to reflect on what it means for their work.

The NHS has a history of ‘deficit inquiry’, rather than appreciative inquiry – quick to judge and blame when things go wrong, slow to learn when things go right. Many staff take on guilt and blame when care is not ideal, even though the reasons may often lie within the design of the system rather than individual failings.

There cannot be an inspector at the end of every bed – self-improving organisations will be sustainable only when every member of staff feels able to express their care and concern for patients and colleagues and confident that they will be listened to and heard.


Barbara Bradbury

Halland Solutions
Comment date
15 July 2013
Agreed, David. People are not open and honest with each other because the culture is generally one that shoots the messenger and people are fearful of retribution. It is the organisational culture that needs to be addressed. We help people with communication and assertiveness skills and individuals can become better able to challenge, listen and support their colleagues. However, until the organisational culture is one that values challenge, seeks honesty and openness, wants to know where practices are sub-optimal and supports staff to speak up in order to improve care, it is lone voices speaking rather than groups and teams who wish to bring about change. It is lonely being the sole challenger, takes a lot of energy and huge strength of character. However, if you are a professional health care provider - clinician or manager - and are passionate about providing excellent care to patients, don't compromise your values. Speak out and don't collude with poor practice - then you will have nothing to feel guilty about.

David Oliver

consultant geriatrician/kings fund fellow/professor of medicine for older people,
Royal Berks/Kings Fund/City Uni
Comment date
11 July 2013
In the journal of the royal society of medicine a couple of months ago, Aidan Halligan wrote a piece (regarding professionals and the Francis Report) "what we permit, we also promote" 'nuff said. But if frontline staff have a duty to raise concerns then line managers (often not practicing clinically) have a reciprocal duty to listen. If we really have a culture of openness in the NHS, how come most posters on the HSJ message board choose to remain anonymous

Hesham Abdalla

Walsall Healthcare NHS Trust
Comment date
11 July 2013
Agreed, Bev. At its heart though is a reticence to sacrifice personal interest for professional goals. Toxic organisational cultures may make this harder to do, but each decision not to blow the whistle is an act of selfishness and professionalism is often a proxy for maintenance of the status quo.
I have found that the PFCC programme helps redress this jaundiced perspective by reconnecting with core values of beneficence and taking pride in a job well done.

Kerry Bareham

Community Specialist Practitioner,
Lincolnshire Community Health Services
Comment date
10 July 2013
Excellent! Mirrors exactly what I said to my own line manager last week, when I was challenged with regard to safety in my own area of practice. Highlighting concern is not about blame but provides an alert to trigger reflection and make changes to improve the situation!
I will certainly be sharing this with my own team!
Thank you

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