In the extraordinary months since covid-19 started, NHS healthcare professionals have found themselves in a surreal situation, straddling two distinct realities. On the one hand, there is such enormous gratitude for their exceptional work from the public and politicians, that they have become the heroes in the frontline of our national fight against the virus. On the other hand, some have reported cases of workplace bullying, retaliation, or threats of disciplinary action when raising legitimate concerns over access to crucial and reliable personal resources, like personal protective equipment (PPE), for their own and their patients’ safety.

NHS workers’ unflinching commitment to the care of patients and colleagues during the pandemic surely needs recognition, as does their development of new ways of working at speed and scale. However, the depiction of their work as “heroic” diminishes the acceptability of healthcare workers’ petitions to employers for suitable working conditions, environments, and adequate equipment. [1] Heroes do not tend to remind their enraptured followers of the human and necessary limits to their endeavours. Heroes do not often point out that their work was done on the basis of equitable returns or entitlements. Heroes overcome fear and vulnerability.

However, recent public expressions of appreciation of healthcare professionals also rests on the identification of actual people with distinct and memorable life stories and regional or ethnic identities. The public’s desire to know more about the personal histories and experiences of healthcare workers offers a window of opportunity for frontline staff to revise the foundations of a longer conversation within the NHS over if, when, and by who their workplace concerns can be heard and acted on.  

These new possibilities are open because collective social trust, now called for to manage public fear and uncertainty, is directed towards an NHS that is seen to be made up of various groups and organisations. Public trust may lean towards the competence and integrity of the NHS—with its various organisational fractions and responsibilities—but there seems to be a reinvigorated confidence in the integrity and courage of people working at the “sharp-end” of provider organisations. Perhaps there is a new possibility for trust in both.

While some healthcare employees are silent about workplace concerns, institutional silencing of, or “deafness” towards, healthcare staff who raise concerns over concerns with their own and patients’ safety, has been a feature of NHS workplaces for decades. [2,3]

In the UK, there is legislation that directs healthcare professionals to speak up and promises to protect them from detriment. Research shows that raising concerns depends more on informal workplace norms and influences rather than on formal policies and procedures. [4] As the covid-19 situation unfolds, the importance of staff in raising safety concerns, and of organisations to listen, has been noted by NHS inspectors. [5] However, in some NHS Trusts and services, commitment to the local Freedom to Speak Up Guardian’s (FTSUG) work, and the value of hearing staff concerns seems perfunctory. There is no time for the local FTSUG to do more than respond to individual cases of bullying or harassment and no capacity for them to leverage organisational or public concerns about staff and patient safety issues. [6]

The regular reporting via the media and social media of staff raising concerns to their employers over the inadequacy of safety equipment or environments of care, and of being threatened or punished for this, show that some healthcare professionals have become confident in finding a public voice when their NHS employer ignores them. Securing a hearing through media outlets may be quicker and less risky to job situations and relationships than finding a FTSUG or a senior manager to deal with a concern. To raise concerns with FTSUGs or managers, you have to have trust in the people you speak to and confidence in the systems they work in. Staff and patient safety managers also need courage to act on concerns that can unsettle their colleagues because they redirect of resources and organisational priorities. [7]

In all, the covid-19 crisis has laid bare the question for healthcare professionals over how—and to what effect—they can raise concerns for themselves and their patients. They might appeal to an attentive public through various media outlets and commentaries or they might still seek out those organisational managers or FTSUGs who will act on their petitions. The pandemic has also shown us that public trust in organisations cannot be assumed, it has to be earned. [8] If public confidence in the management of NHS organisations is to be earned, NHS managers and the still relatively new FTSUGs have a critical role to play in working together to demonstrate that the workplace concerns of staff are being acted on, and that a longer conversation about raising staff and patient safety concerns becomes possible.

Mary Adams is Senior Research Fellow in the Department of Women and Children’s Health, Faculty of Life Sciences and Medicine, King’s College London.

Daniel Kelly is Royal College of Nursing Chair of Nursing Research Sciences, School of Healthcare Sciences, University of Cardiff

Jill Maben is Professor of Health Services Research and Nursing and leads the Workforce Organisation and Wellbeing (WOW) theme in the School of Health Sciences at the University of Surrey

Russell Mannion is Professor of Health Systems at the University of Birmingham

Carys Banks is Research Fellow, School of Health Sciences, University of Surrey.

Aled Jones is Professor of Patient Safety and Healthcare Quality, School of Healthcare Sciences, University of Cardiff and Lead Investigator of the ongoing NIHR Evaluation of the implementation of Freedom to Speak Up Guardians in NHS England.

Twitter: @FTSUGproject @AledJonze @maryluadams @profdkelly @nursingpolicy  

Competing Interests: None declared by all of the authors.

References:

1. Cox CL. 2020 ‘Healthcare Heroes’: problems with media focus on heroism from healthcare workers during the COVID-19 pandemic. Journal of Medical Ethics. Jun 16.
2. https://blogs.bmj.com/bmj/2020/06/23/covid-19-and-the-problem-of-employee-silence-in-healthcare/
3. Jones A, Kelly D Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong BMJ Quality & Safety 2014;23:709-713
4. Mannion, R. and Davies, H., 2019. Raising and responding to frontline concerns in healthcare. Bmj, 366, p.l4944.
5. https://www.cqc.org.uk/news/stories/safety-speaking-during-covid-19-emergency
6. Jones A, Blake J, Banks C, Adams M, Kelly D, Mannion R and Maben J (in press) Speaking up about bullying and harassment in healthcare: reflections and analysis of worker well-being and patient safety following the introduction of an innovative new role in NHS England. In Montgomery A et al. Connecting Health care worker well-being, patient safety and organisational change: The Triple Challenge. Springer Publishing
7. Mannion, R., Davies, H., Millar, R. and Freeman, T., 2018. Board governance for better, safer healthcare. In Global Patient Safety (pp. 43-57). Routledge.
8. Calnan M., S.J. Williams & J. Gabe 2020 Uncertain Times: trust matters during the pandemic. Social Discovery June 2020.