This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Freedom to Speak Up Guardians (Guardians for short) help healthcare workers to raise concerns about patient safety and other work-related issues. But research found that many lack adequate resources. The study called for trusts to ensure that Guardians have the time, budget and psychological support they need to work effectively.
Researchers investigated the role of Guardians at acute and mental health trusts in England. They asked 87 Guardians about their experiences, and observed and interviewed a further 106 people (Guardians and their colleagues), for 3 months in 6 case sites.
They found variation in how Guardians worked (full-time versus part-time) and the resources they received (the time, budget and workspace allocated, for example). The role was often emotionally draining, but Guardians received little support.
The findings fed into the National Guardian’s Office guidelines; they also informed related guidance in Wales. A recent report from the Department of Health and Social Care stresses the importance of Guardians, and provides details about the support available for staff who raise concerns.
For more information about Freedom to Speak Up Guardians, visit the NHS website.
The issue: what do Freedom to Speak Up Guardians do?
Healthcare workers who speak up about problems in services are sometimes called whistle-blowers. They help ensure patient safety and healthcare quality. But they are not always well-treated or listened to. Serious and avoidable harm to patients and staff can occur when opportunities to learn from workers’ concerns are missed.
In 2015, the Freedom to Speak Up Review made raising and addressing concerns an everyday part of working in the NHS. From October 2016, all NHS trusts in England introduced Guardians to support workers to speak up. The review gave broad guidance about how to implement the Guardian role, but left trusts to decide on the details. This has led to differences in the role across England.
This study aimed to better understand the Guardian role, in acute trusts and mental health trusts in England. Researchers observed and interviewed Guardians and their colleagues about how the role had been introduced, and how well it was working.
What’s new?
Researchers carried out telephone interviews with 87 Guardians working in acute and mental health trusts. They then spent 3 months in 6 trusts (4 acute and 2 mental health trusts) observing and interviewing a further 106 Guardians and people who worked with them (including the trust’s chief executive, chair and board members).
Some Guardians were full-time; others performed the role alongside another job. The experiences of Guardians, and how they helped workers to raise concerns varied. For instance, one Guardian said: ‘Some individuals feel I am too senior to approach with a concern. It’s tricky… more junior Guardians struggle with getting a response from managers [but] it isn’t an issue for me.’
Many reported that the lack of resources, especially time, reduced their ability to respond to concerns, and to analyse and learn from data. A Guardian said: ‘Implementing the role was a bit of a kneejerk reaction. Not enough thought went into although full of good intentions. Lots more work than expected and not enough time to do it.’
More generally, Guardians struggled to develop their role, and create a more positive culture in which staff feel free to voice concerns: ‘I’m just being reactive and unable to triangulate data and promote the role as there’s just no time to think.’
Bullying and harassment were frequent concerns: ‘I do get patient safety concerns but not as much as I should or as often as you would think.’ Some Guardians had supportive managers and directors, while others did not. Guardians found their role stressful and received little psychological support. As a result, many were concerned that they would be unable to continue in this role long. One said: ‘I often feel overwhelmed, it’s difficult to keep up with managing and tracking concerns and strategy work.’
The study concluded that neither local decisions nor national guidance had learned from past events or key reports.
The researchers said that, as a minimum, Guardians need:
- allocated time and resources including full-time employment, budget, and workspace
- access to a standardised system for reporting concerns
- dedicated mental health support to protect their wellbeing.
Guardians could be more effective if they had:
- agreement from senior staff that their role contributes to a positive workplace culture
- clear policies on who should respond to concerns and within what time period
- frequent evaluation of the introduction of Guardians in trusts.
Why is this important?
The researchers believe this is the first study to investigate the role of Guardians within NHS workplaces. It provides insights into how Guardians work in the NHS.
The researchers worked closely with the National Guardian’s Office, which has changed its guidance because of the findings. They call for trusts to allocate more resources to Guardians. This would increase Guardians’ capacity to impact on workplace culture and normalise speaking up, alongside their core tasks.
The study informed the National Guardian’s Office guidelines, the NHS Wales Speak Up Safely initiative and the United Nations ODC Guidance on Whistleblowing. It has informed discussions about whistleblowing in NHS Scotland.
A reflection for trusts…
How can we better support our Freedom to Speak Up Guardians?
What’s next?
Further research is needed to explore the experiences of people from minority communities and workforce groups that are often overlooked, such as estates and facilities staff, and recently recruited international staff. The National Guardian’s Office discourages Guardians from collecting data about the ethnicity of whistle-blowers, but some Guardians believe that such data could improve the voice of minority workforce groups.
Studies could also explore how to implement the role of Guardians outside of hospitals, for instance in ambulance services and primary care settings.
You may be interested to read
This Alert is based on: Jones, A and others. Implementation of ‘Freedom to Speak Up Guardians’ in NHS acute and mental health trusts in England: the FTSUG mixed-methods study. Health and Social Care Delivery Research 2022;10.
The National Guardian’s Office provides information about Freedom to Speak Up Guardians.
Francis, R. Freedom to speak up. 2015.
Conflict of interest: No relevant conflicts were declared. Full disclosures are available on the original paper.
Funding: This research was funded by the NIHR Health and Social Care Delivery Research programme.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
