Implementation of 'Freedom to Speak Up Guardians' in NHS acute and mental health trusts in England: the FTSUG mixed-methods study

Article history

The research reported in this issue of the journal was funded by the HSDR programme or one of its preceding programmes as project number 16/116/25. The contractual start date was in May 2018. The final report began editorial review in March 2021 and was accepted for publication in July 2021. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HSDR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Disclaimer

This report contains transcripts of interviews conducted in the course of the research and contains language that may offend some readers.

Copyright statement

Copyright © 2022 Jones et al. This work was produced by Jones et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaption in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2022 Jones et al.

Introduction

The overall aim of this study is to better understand the introduction of a new role in NHS England that is designed to support workers to speak up about ‘anything that gets in the way of providing good care’ (© National Guardian’s Office. Contains public sector information licensed under the Open Government Licence v3.0). 1 These roles are called Freedom to Speak Up Guardians (FTSUGs). We were interested to find out how FTSUG roles are being implemented in acute trusts and mental health trusts and whether or not FTSUGs are helping workers to ‘speak up’ about their concerns.

Background to ‘speaking up’ in the NHS

Employees who ‘speak up’ or ‘raise concerns’ about problems with health-care services have traditionally been referred to as ‘whistleblowers’. The terms whistleblowing/whistleblower, raising concerns and ‘speaking up’ are commonly and interchangeably used in the health-care literature, policy and the media. This report refers to speaking up and raising concerns, referring to whistleblowing and its derivatives only where others use those terms.

Although speaking up makes an important contribution to delivering safe care, NHS workers who raise concerns have not always been listened to or treated well. 2 The public inquiry into appalling patient care failings at Mid Staffordshire NHS Foundation Trust, eponymously referred to as the ‘Francis Report’,3 found that workers’ concerns were often ignored, and that those speaking up were mistreated by colleagues. The report also concluded that the unnecessary and avoidable suffering of patients was primarily caused by serious failure on the part of the trust board, who ‘did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention’ (© The Stationery Office. Contains public sector information licensed under the Open Government Licence v3.0). 3

The issues identified in the Francis Report, however, were not unique to Mid Staffordshire or isolated to the early 2000s. Since the 1960s, several reports and inquiries4 have described the difficulties experienced by health-care workers attempting to speak up and how the many and varied concerns raised were missed, misunderstood or ignored by those responsible for assuring safety and quality across the NHS. 5,6 The failure to listen to and protect workers speaking up has been described by the House of Commons Health Select Committee as a stain on the reputation of the NHS. 7 Nonetheless, these issues are not exclusively found in the NHS because health-care employees globally report mistreatment and indifference as a result of raising concerns. 8–10

The introduction of Freedom to Speak Up Guardians

The events at Mid Staffordshire had a profound impact on health-care policy in England. 11 One of the many government responses to the Francis Report was the commissioning of a review of culture and practice around raising concerns in the NHS, the Freedom To Speak Up (FTSU) review, also referred to as the ‘Francis Review’. 12 The review refers to speaking up as a patient safety issue and confirmed many of the worries previously identified, finding widespread reluctance to speak up among some workers, rooted in a sense of futility. It also refers consistently to the detriment experienced by some who raise concerns and outlines that concerns raised about workplace incivility should be viewed as patient safety issues:

. . . wherever there is a reference to ‘raising concerns’, ‘speaking up’ or ‘whistleblowing’ it should be considered to refer to the raising of a concern relevant to safety or the integrity of the system. I include in this concerns about oppressive behaviour or bullying and dysfunctional working relationships, which I consider to be safety issues.

Francis12 © Francis R, 2015. Contains public sector information licensed under the Open Government Licence v2.0

In addressing these significant challenges, the FTSU review set out 20 principles to guide the development of ‘a consistent approach to raising concerns . . . whilst leaving scope for flexibility for organisations to adapt them to their own circumstances’ (© Francis R, 2015. Contains public sector information licensed under the Open Government Licence v2.0). 12 A single ‘overarching Principle’ states that every NHS organisation should ‘foster a culture of safety and learning in which all staff feel safe to raise concerns’ (© Francis R, 2015. Contains public sector information licensed under the Open Government Licence v2.0). 12

Principle 11 (‘Support’) proposed the introduction of the flagship FTSUG role in all NHS England trusts and foundation trusts, supported by the National Guardian for Freedom to Speak Up and the National Guardian’s Office (NGO) (see The role of the National Guardian’s Office). The FTSUG role was founded on three interlinked objectives to ensure that:

• NHS employees are not victimised for raising concerns

• speaking up is part of the normal routine business of any well-led NHS organisation

• NHS organisations, both individually and collectively, learn from employees who speak up.

The FTSU review12 further proposed that the responsibility for driving, maintaining and monitoring progress in effecting culture change rested with the board. Responsibilities were outlined for a designated non-executive director (NED) and executive lead for FTSU, which ensured that support was available to all workers speaking up, and facilitated open discussions, reflective practice and shared ownership of problems and solutions.

Implementing the review’s proposals, the government mandated that each organisation providing health care in England should appoint one or more Guardian13 to act as a point of contact for anyone with ‘a concern about risk, malpractice or wrongdoing (they) think is harming the service’ (© NHS Improvement, 2016. Contains public sector information licensed under the Open Government Licence v3.0). 14 FTSUG roles had to be funded from organisations’ own resources, with the NGO funded via a centrally allocated budget of £950,000 per annum. At commencement of data collection for this project (October 2018), over 500 FTSUGs had been appointed.

The FTSU review12 clearly states a preference for flexibility in the role’s implementation and local adaptations to fit with each organisation’s perceived needs. A universal job description, which was produced by the NGO for the FTSUG role,15 provided numerous and broad guidance, expectations, principles and outcomes for the role. The job description is discussed and analysed in detail in Chapters 4–6.

In broad terms, the role of the FTSUG is intended to be an independent, impartial and objective role, serving as a highly visible contact for any worker with a concern, while also ensuring that concerns are responded to appropriately. The independence of FTSUGs is a recurring theme in many of the NGO’s documents and guidance; however, this refers to cultivating independence of thought, and from the hierarchy within the NHS trusts, rather than in procedural terms. For example, the guidance stresses that FTSUGs should function within existing procedures and processes, serving as an additional route only where concerns raised through the organisation’s existing channels do not gain traction. 14 However, FTSUGs are also entrusted to open a line of communication between workers, senior managers and the board, offering a route to speaking up outside the direct line management and formal human resources (HR) options. Having to navigate these discipline-specific, professional and procedural boundaries places the FTSUG in a potentially precarious position. FTSUGs are also potentially vulnerable as employees of organisations that they must hold to account when practices are contrary to the Francis vision12 of open and transparent culture in which speaking up is a consistent and normalised feature of everyday practice.

The role of the National Guardian’s Office

The NGO was established in April 2016 as an independent non-statutory body that was tasked with normalising speaking up and leading effective cultural change, but was not concerned with historical cases and the instigation of speak-up investigations. The NGO is jointly sponsored by the Care Quality Commission (CQC), NHS England and NHS Improvement, and its Accountability and Liaison Board includes senior representatives from the sponsoring bodies. Three years after its establishment, additional funding was allocated to the NGO to support its work to integrate FTSU in primary care, including the appointment of regional leads to spearhead this work.

The NGO provides resources for Guardians and the organisations in which they are situated; for example, guidance on recording cases and reporting data for Guardians,16 and FTSU guidance for boards. 17 Training materials and events for Guardians are also disseminated, in addition to national guidelines on FTSU training for organisations. The NGO also arranges an annual FTSU conference and co-ordinates regional FTSUG networks. Data, annual reports, survey reports, responses to consultations and other publications are archived on the NGO’s website. The NGO also obtains feedback from FTSUGs on its own performance. Respondents to the 2019 Guardian’s survey18 were asked to rate how supportive they perceived the NGO to be, on a scale ranging from zero (‘not at all’) to 10 (‘fully’). The average score was 6.5, indicating that perceptions of support had dropped from the previous year’s score of 7.1.

In June 2017, a 12-month pilot scheme for case reviews was undertaken by the NGO, during which the NGO considered referrals for case reviews by current and former workers in NHS trusts and foundation trusts who were unsatisfied with speaking-up procedures and response to concerns. Following a review, the trusts involved were expected to implement the recommended improvements, which would then be monitored by the regulators. Publication of the findings encouraged learning to be shared across the FTSUG network, which many Guardians interviewed in work package (WP) 2 described as useful. Following an evaluation of the pilot scheme, the case review process seems set to continue.

Measuring and monitoring speaking up in the NHS

As is discussed at length in Chapter 4, FTSUGs submit non-identifiable data to the NGO about speaking up in their organisation. Data are collated every 3 months and are published in the NGO’s annual report. The 2019/20 report19 indicated that 16,199 FTSU cases were raised with Guardians, an increase from 12,244 cases in the previous year. Many concerns (23%) included an element of patient safety/quality, while 36% included an element of bullying/harassment.

In addition, the NGO, working with NHS England, devised a ‘FTSU Index’, which was described as a ‘key metric’20 by which organisations can monitor their FTSU culture, comparisons can be made between trusts and good practice can be shared. The FTSU Index is a compound measure that is calculated as the mean of responses to four questions from the previous year’s NHS staff survey, rounded to one decimal place. The index has risen nationally from 75.5% in 2015 to 78.7% in 2019, leading the NGO to declare that the NHS has much to celebrate. 20 The index is utilised by the NGO as an indicator of potential areas of good practice and concern on matters of FTSU culture in organisations. Information is shared with stakeholders, including CQC, NHS England and NHS Improvement, to inform various aspects of their work to normalise speaking up. FTSU is also inspected within the CQC ‘Well Led’ domain; those trusts exhibiting higher scores on the index are more likely to be rated ‘good’ or ‘outstanding’ by the CQC.

However, drawing meaningful comparisons and definitive conclusions from FTSU data is fraught with difficulties. Despite NGO guidance, the collection of FTSU data is beset with problems of accuracy and consistency, as discussed in Chapter 4. There is also a fundamental question, possibly unanswerable, of what a rise or fall in the number of speak-up cases realistically signifies. Caution is also advisable regarding the contribution of FTSUG roles to upwards or downwards trends in data when we consider that this novel role was implemented locally without specific requirements over delimitation of remit, responsibilities and accountability structures. A further degree of localness is added because speaking up is highly situational and context dependent, and the work of FTSUGs is superimposed on to existing organisational procedures and protocols. These inherent issues could be positive in the sense that FTSU’s adaptation to the local environment, interwoven practices and operational contingencies could allow the Guardian role to evolve alongside the necessary changes in organisational culture. However, as an unprecedented intervention in the context of the NHS, or health-care internationally, and having no requirement for uniformity, the implementation of the Guardian role was always likely to vary across England.

Report structure

In Chapter 2, the aims and objectives are presented alongside the methods used to address these. Chapter 3 presents a literature review of speak-up interventions in health care. The results of telephone interviews undertaken with FTSUGs regarding the implementation of the role are presented in Chapter 4, which subsequently contributed to the design of data collection in case sites. In-depth exploration of the implementation and work of FTSUGs and the impact of FTSU more generally are presented in the findings from six case site reports in Chapter 5, and cross-case findings in Chapter 6, both drawing on non-participant observations, analysis of documents and interviews with FTSUGs and FTSU stakeholders. Finally, we summarise and discuss our findings and present our conclusions in Chapter 7.

Overview of theoretical approaches and work packages

This section opens with a discussion of the theoretical frameworks that informed the study’s design, followed by a detailed overview of the relevant WPs. For the purposes of this investigation, we conceptualise the FTSUG role as a complex intervention. 21 Complex interventions are conventionally defined as difficult to implement because they consist of several interacting and interlocking components spanning a number of organisational levels, from the macro level (national policy organisations and regulators) to the meso level (individual trusts) and the micro level (individual employees, teams and wards/units). 22 These organisational levels have also been described as ‘nested’, simultaneously sitting above and below (and interacting with) other systems of different scale. 23

Given the complex nature of the FTSUG role and the contexts within which the role was implemented, as outlined in Chapter 1, Normalisation Process Theory (NPT) offered an appropriate framework to guide the study. 24,25 NPT assists researchers to identify factors that promote or inhibit the routine incorporation of complex interventions, such as FTSUGs, into everyday practice. NPT consists of four main components, or generative mechanisms, that help to identify the social processes underpinning the implementation of complex interventions (Table 1). 25

In simple terms, NPT proposes that practices are embedded in social contexts as the result of people working, individually and collectively, to implement them. For example, if those involved in the implementation of FTSUGs can identify coherent arguments for adopting the role, are engaged in the process of implementation, are able to adapt their work processes to utilise FTSUGs (or FTSUGs adapt to fit in with existing practices) and judge FTSUGs to be valuable once they are in use, then FTSUGs are more likely to become embedded in routine practice. The introduction of FTSUGs cannot, therefore, be considered a discrete intervention that works in the same way regardless of the organisational context. Instead, FTSUG roles are likely to be designed and used in different ways depending on prevailing institutional arrangements.

A limitation of NPT is that it does not (and cannot) cover all phenomena of interest. 25 Accordingly, we also draw on insights from other relevant theories, such as the Consolidated Framework for Implementation Research (CFIR). 26 The CFIR provides terms and definitions for constructs that allow researchers to clearly and consistently articulate factors that potentially affect implementation outcomes. Particularly useful are CFIR insights into the influence of factors from the outer setting (e.g. policy or regulatory recommendations) and how they are often mediated through changes in the inner setting of organisations, such as changes in personnel or resources that affect, positively or negatively, the implementation of the FTSUG role implementation.

Work package 2: telephone interviews with Freedom to Speak Up Guardians working in acute hospital and mental health trusts

Work package 2 addressed the research aims, objectives and questions by providing an in-depth understanding and national picture of how FTSUGs are selected/recruited, deployed and organised within their organisations. To this end, we conducted semistructured telephone interviews (n = 87) with FTSUGs working in acute hospital trusts and mental health trusts. Participants were asked the same set of questions about their variable characteristics, such as their age, sex and nature of employment (e.g. hours allocated), as well as the work systems within which they were embedded. FTSUGs were also asked how they monitored FTSU within their organisation, such as the staff group and the demographics of those speaking up, and whether or not workers experience detriment following speaking up. The questions were informed by the findings of the literature review and existing concepts that had influenced some of our previous work on this subject (see standalone document 1 WP2 interview schedule; see https://fundingawards.nihr.ac.uk/award/16/116/25/#/documentation). 2,4,27–29 For example, interview questions regarding the coherence and clarity of new work processes and boundaries, the monitoring of change, and the availability of resources to support the implementation were informed by the literature review.

Freedom to Speak Up Guardians were identified and purposively sampled from the NGO register of FTSUGs. Initial contact with FTSUGs was made by e-mail and a telephone interview was arranged with those volunteering to participate. FTSUGs were recruited from each of the 10 (at the time) NHS England regions (see standalone document 2; see https://fundingawards.nihr.ac.uk/award/16/116/25/#/documentation) and worked in the following type and size of trusts:

• 23 out of 54 mental health trusts in existence at the time

• 64 out of 135 acute trusts in existence at the time

• 42 from small organisations (< 5000 staff)

• 35 from medium organisations (5000–10,000 staff)

• 10 from large organisations (> 10,000 staff).

We also interviewed FTSUGs from organisations with different CQC overall ratings, as shown in Table 2, which also shows the numbers of FTSUGs contacted, a 34% overall response rate and that a large percentage of FTSUGs responding were interviewed.

Interviews were audio-recorded, which allowed subsequent review to clarify any confusion or inaccuracy. Data analysis, which was aided by NVivo 12 software (QSR International, Warrington, UK), took place concurrently with data collection. Initially, descriptive statistics and bar charts were produced to help to visualise the ‘shape’ of the data, for example summarising categorical variables, such as sex and professional background. These steps helped to identify interesting or anomalous features and proved useful in generating cross-tabulations of the relationships between these characteristics and other variables.

Thematic qualitative analysis, which followed a recognised six-step process,30 proceeded with in-depth familiarisation of the interview transcripts followed by inductive coding and thematic analysis, which identified the range of respondents’ views about their experiences of organisational commitment to the role, including barriers to and enablers of role normalisation. FTSUGs’ accounts of their work were also situated within the NPT generative mechanisms (see Table 1), generating insights that were revisited during case studies.

Once data were grouped into qualitative themes, we revisited the quantitative findings to establish whether a theme (or its dimensions) applied to only a particular group or whether it was a more general theme. Implications for fieldwork in WP3, such as the emergence of issues or problems that were not initially anticipated, were discussed and our field methods were modified accordingly. For example, we became increasingly aware that many FTSUGs were employed in substantive roles that they undertook alongside the FTSUG role. Fieldwork was, therefore, arranged to minimise researchers’ exposure to sensitive or confidential information unrelated to the project.

Methodological rigour was ensured through standard procedures of reflexivity, transparency and auditability. 31 Initial coding and emergent themes were developed within and then across the two teams based in Cardiff and London. Research associates at each site (JB and CB) individually undertook the initial analysis, overseen by the chief investigator (AJ) and Mary Adams and Jill Maben, who reviewed a further proportion of all transcripts to ensure inter-rater consistency/reliability. Emergent and final themes were regularly discussed and agreed with all members of the research team during three-weekly team meetings (face to face initially and online following COVID-19 workplace and travel restrictions). Additional insights into emergent findings were provided by public involvement members and the project advisory group (PAG), thus ensuring rigour was maximised at each step of analysis and across the data set.

Work package 3: six organisational case studies

We purposefully sampled four acute trusts and two mental health trusts, initially identifying potential case study sites from our analysis of WP2 data. However, although we contacted several trusts from each CQC band and different ‘types’ of FTSUGs (full time, part time and undertaking another role or not), ultimately we could recruit only trusts that volunteered to take part. Eight trusts agreed to take part. An additional seven trusts expressed an interest but did not participate, citing organisational pressures, or following further discussion with senior colleagues. Following consultation with the PAG, the final six sites were selected because they provided a range of CQC ratings, sizes and types of FTSUGs deployed (e.g. part or full-time), which best addressed the research aims and objectives.

Three months were spent at each case site shadowing FTSUGs, followed by 1 month undertaking preliminary within-case and tentative cross-case consolidation. Case sites were divided equally between Carys Banks and Joanne Blake, who undertook the large majority of data collection and were supported and supervised by Mary Adams, Aled Jones and Jill Maben, who also undertook visits to case sites and undertook short periods of observations. Three-weekly online whole-team meetings provided Carys Banks and Joanne Blake with the opportunity to present updated progress reports to other team members and to compare and contrast case site activities and the overall management of data collection. Case studies focused on exploring whether or not and how the role had been normalised alongside other local roles and initiatives overlapping with FTSU, in addition to understanding how FTSUGs were working in relation to their social and physical settings. CQC inspection reports and the NGO ‘Speak-Up Index’ provided useful historical and contemporary insights into speaking-up cultures within organisations. Planning for the case studies also drew on the findings of the literature review (see Chapter 3), especially the key finding that the implementation of speaking-up interventions is best understood within the wider context that they occur.

Purposive sampling was again used within the case sites to identify key informants, documents and stakeholders who were involved in the oversight and delivery of the FTSUG role, and any related speak-up initiatives. Prior to data collection, an initial visit to each site was arranged with the FTSUG to discuss plans for data collection, including how the FTSUG’s activities could be shadowed without the researcher’s presence being intrusive. With this in mind, an activity planning document (see Appendix 1) was completed in conjunction with the FTSUG, including information on FTSU-relevant events/meetings and key individuals who may subsequently be recruited for interview.

An initial 2-week introductory and orientation period helped to establish rapport with FTSUGs and other staff, and enabled an early sense of the Guardian’s work and FTSU in each organisation. Thereafter, data were concurrently generated at two sites using the following methods:

• Overt non-participant observations of:

  • the FTSUG role in practice, for example delivering ‘speaking-up’ training and advice to workers, participating in walk-rounds and attending meetings within the trust (e.g. board meetings and operational meetings)

  • face-to-face meetings and/or telephone or e-mail activities with workers wanting to speak-up or with workers who had already spoken up to the FTSUG

  • meetings to review concerns with colleagues, such as line managers and NED/executive leads for FTSU.

• Descriptive free-text fieldnotes were recorded during and/or following each observation event, either while in the field or soon after being in the field. These were written up in Microsoft Word^® (Microsoft Corporation, Redmond, WA, USA) and collated at the completion of data collection at each site alongside relevant documentation, and summarised prior to analysis to identify the most relevant content in relation to FTSU.

• Relevant organisational policies, internal communications and reports carried out by FTSUGs were recorded.

• Trust board reports on concerns raised by workers were also collected.

• Semistructured interviews were conducted with the following individuals:

  • FTSUGs – two interviews: one when fieldwork commenced and one towards the end of the data collection period

  • employees who had raised concerns via the FTSU service

  • key stakeholders closely involved in the implementation and ongoing deployment of the FTSUG role, including board members, executives, NEDs, directors or assistant directors of HR, organisational development (OD) and staff-side chairpersons

  • employees who had not spoken-up to the FTSUG.

Up to 20 interviews at each site were tentatively predicted, with the final number (Table 3) being slightly short of this. The final number of interviewees (n = 109) tallies with our purposive sampling strategy, which meant that the data saturation point was reached when key participants (listed above) at each case site were interviewed. We were very encouraged by the range of staff at all sites who dedicated time for the interviews, often despite very busy schedules. The data generated proved to be rich and contributed greatly to our understanding of the implementation of the role.

Central to our conduct throughout the study was sensitivity to the demands of the FTSUG role and the potential for the researchers’ presence to influence speaking up by workers. During observation periods, the researcher removed themselves if it appeared that the FTSUG was being approached by someone with a concern or if the FTSUG or employee requested that the researcher withdraw (see Research ethics). The main objective during observations was for the researcher’s presence to be unobtrusive and to alter practices as little as possible.

Although the data collection phase is presented here separately from data analysis, in practice the two phases were intertwined. A software package (NVivo 12) assisted with the storage of transcribed interviews and other documents, as well as the thematic analysis of data in a process underpinned by the same approach to methodological rigour outlined in Work package 2: telephone interviews with Freedom to Speak Up Guardians working in acute hospital and mental health trusts. An inductive ‘data condensation’28 process, foreshadowed by research aims/objectives/questions, was used to select, focus, simplify and abstract data from the range of field data and interview transcripts. Each case study was individually analysed prior to cross-case analysis. To integrate and aggregate findings across cases, a series of NPT thematic charts were developed for each case study. Further exploration of the charted themes was then undertaken to map and understand the range of views and experiences across each site. Established theory and research into speaking up and organisational culture, in addition to our own expertise and the perspectives from the PAG/patient and public involvement (PPI) team members, all contributed to the interpretation of the qualitative findings.

Telephone interviews with national stakeholders (n = 7)

Semistructured telephone interviews were undertaken by Daniel Kelly and Aled Jones with national stakeholders. These individuals were purposively sampled from roles and organisations involved on a national level in establishing, liaising with or oversight of the FTSUG initiative, or had worked in organisations that had a direct interest in FTSU (e.g. trade unions or patient safety campaign groups). Individuals were initially identified from organisational webpages or from previous contact with or awareness of the research team and PAG members. If agreeing to participate, interviewees were recruited and interviewed and the data analysed in the same manner as described in WP2.

Research ethics

All study work packages were approved by the School of Healthcare Studies, Cardiff University, Research Ethics Committee reference HCARE/14082018.

Patient and public involvement in the research

From the outset, PPI was integral to the development, design and overall conduct of this project, shaped by the awareness that PPI involvement should be both meaningful and relevant. A group of four PPI members initially participated during the study design phase. Two of the PPI group continued to contribute directly to all WPs throughout the study via the PAG and other activities, such as the following:

• contributing to preparation for data collection and data analysis activities, such as reviewing emerging findings and development of later findings

• informing the preparation and accessibility of dissemination materials

• participating in future workshops and other dissemination events and activities, such as authoring and providing a PPI perspective to training materials for NHS employees

• playing a significant role in setting future research priorities and, overall, helping us to not lose sight of why the research is important and how the research might positively influence practices from a PPI perspective.

Details of the PPI and PAG members can be found in the Acknowledgements.

Summary

This chapter has set out the research design and the approaches taken towards data generation and analysis, which were underpinned by NPT. The empirical elements of the study were set across two phases: WP2 comprised telephone interviews with FTSUGs working in acute trusts and mental health trusts in England, and WP3 comprised six in-depth case studies of the implementation of FTSUGs at four acute trusts and two mental health trusts. Input from relevant external stakeholders was interwoven throughout in the form of contributions by PPI members and a dedicated PAG.

Introduction

A systematic narrative review of the literature was conducted for two purposes:

1. to identify and examine international research reporting on strategies or interventions promoting ‘speaking up’ practices in the workplace

2. to critically appraise and map key concepts and tensions to inform the development of research tools and to inform interpretation of primary research findings.

A version of the review was published in January 2021. 32

Review question and methodology

The review question was ‘What workplace strategies and/or interventions have been implemented to promote speaking up by health-care employees?’. Consistent with the study’s theoretical orientations (see Chapter 2), the review was underpinned by recent writing on complex adaptive systems in health care. 33,34 A previous scoping review35 identified that this topic area embraces diverse theories and methods across numerous contexts and is, therefore, unsuitable for systematic review approaches involving the formal weighting of independent bodies of evidence. Instead, an acknowledged and widely used systematic narrative review approach was used to ‘tell the story’ from within the literature36 and to deepen the understanding of the review question by interpretation and critique. 37

Searching and screening

Searches were undertaken to include findings on studies of international speak-up interventions designed for workers in all areas of health-care practice and all health-care settings, including education. Grey literature, statutory interventions and regulatory interventions were not reviewed because they were unlikely to contain empirical research reporting the outcomes of speak-up interventions in the workplace (Box 1 gives further information on search terms and inclusion/exclusion criteria).

The searches identified 1300 citations, with a further 36 records identified via searches of reference lists or search updates. After eliminating 478 duplicates, the titles and abstracts of 858 records were screened for relevance by Aled Jones and Joanne Blake. Of these, 729 were excluded because they did not meet the inclusion criteria (e.g. editorials or viewpoint articles rather than empirical research), leaving 129 articles for full-text review. Following full-text review, a total of 34 papers were included in the final review, as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (Figure 1). Joanne Blake and Aled Jones undertook data extraction, which enabled data analysis and synthesis (see the following section).

FIGURE 1.

The PRISMA flow chart of the paper screening process.

Data analysis

The team’s prior experiences of researching the topic area and undertaking narrative reviews38,39 indicated that an inclusive review of the research would help to identify a range of evidence that best represented the complexities and ambiguities associated with the topic. Although the emphasis was mostly on including rather than excluding papers, the relevant Critical Appraisal Skills Programme frameworks guided the appraisal of papers and resulted in the exclusion of some studies owing to a lack of key information, such as research ethics approvals or data analysis approaches. The review findings were subsequently themed and synthesised by Joanne Blake and Aled Jones, with particular reference to authors’ accounts of the effectiveness of interventions and contextual factors, such as implementation barriers or facilitators. Other members of the team critically reviewed and contributed to the iterative process of identifying themes and synthesising the literature.

The remainder of this chapter describes the types of study design and interventions reported. This is followed by interpretation and synthesis of the findings, taking into account contextual factors40 identified within the studies that influence (for better or for worse) the implementation of employee speaking-up initiatives.

Results

The final 34 publications originated from Europe, Asia and North America, comprising studies using quantitative (n = 23), qualitative (n = 5) and mixed-method (n = 6) methodologies. Three types of intervention feature in the included papers: educational initiatives (n = 5), workplace/workforce training initiatives (n = 17) and workplace initiatives (not involving formal or overt training, or educational input) (n = 12). Interventions were designed as either ‘stand-alone’, focusing on only improving the act of speaking up,41–59 or ‘bundled’ initiatives,60–72 in which speaking up was targeted within a multifaceted intervention aimed at improving teamworking62 or clinical protocols65 (Table 4).

Quantitative approaches were as follows:

• randomised controlled trials of speak-up interventions, for example simulations41,42 and training programmes60

• quasi-experiments of speak-up educational interventions for registered nurses and health-care students43,61

• post-course surveys following safety communication training62 and a speaking-up action exercise44

• pre- and post-implementation surveys of interventions, including executive walk rounds (EWRs);45–50 various team-based communication tools for use by trauma resuscitation teams, by interventional ultrasound teams, by theatre/anaesthesia teams and during infection prevention practices,51–54,63–67 and an educational intervention and an educational course for nursing students. 68

Qualitative approaches were as follows:

• interdisciplinary team development using focus group interviews and auto-ethnography55

• communication and decision-making using observation, audio-recorded meetings and individual interviews69

• infection prevention using individual interviews70

• EWRs using semistructured interviews. 56,57

Mixed-methods approaches were as follows:

• speak-up teaching and learning activities using a survey, a focus group and individual interviews58

• a patient safety course for medical students using a survey and written vignettes71

• an intervention to prevent faculty mistreatment of medical students in learning environments using surveys and focus groups72

• workplace patient safety initiatives using qualitative interviews, observations and surveys,59,73 including routine hospital data. 74

The following sections discuss indicative conclusions about the effectiveness (or otherwise) of the interventions. Given the large array of interacting and emergent factors that influence whether or not interventions in complex systems are successfully implemented, it is unsurprising that the studies reviewed could not be apportioned into a neat binary of effective or ineffective interventions. 33,34 Instead, the effectiveness of most of the interventions reviewed was indeterminate, that is, some aspects of an intervention resulted in the desired changes but other aspects did not. As a number of others have recently noted,75–77 the success or failure of interventions within complex adaptive systems is rarely ‘all or nothing’; more typically, interventions are partially fulfilled. Based on these insights and informed by narrative reviewing guidance,36 we divide the results into an overview of interventions that were effective, ineffective or indeterminate, followed by a section that synthesises the results to draw new insights and conclusions based on the body of evidence.

Discussion

This review demonstrates that health-care researchers internationally are attempting to address difficulties that are associated with speaking up in health care. A disparate range of research designs, academic and professional disciplines, and perspectives informed the studies, including medicine, nursing, social work, human factors, sociology and psychology. Some significant limitations were identified across the papers reviewed. For example, there was very little evidence of researchers critically reviewing and building on extant studies when preparing and designing new projects, with many of the flaws of previous study designs being overlooked. Similarly, researchers rarely placed their findings within broader local, national or transnational policies and contexts. The body of knowledge is, therefore, piecemeal and limited in impact.

The small-scale nature of most studies may be explained by the fact that research funding was seldom declared. Relatively poorly funded research can also result in implementation studies that often fall short of truly understanding how complex socioprofessional systems work. 33 This is evident in many of the papers reviewed, which reflect implicit mechanistic or cognitive-rationalist assumptions about the nature of speaking up. Researchers consistently overlooked how otherwise well-conceived individual components of training interventions (e.g. improved communication skills) are often usurped in practice by complex inter-relationships with pre-existing contextual issues, such as sociocultural relationships, workplace hierarchies and perceptions of speaking up.

Figure 2, informed by complex systems thinking perspectives and implementation models such as the CFIR,26 presents a nuanced and intersectional model of the forces described that speak-up interventions had to contend with. The model takes into account pre-existing and entrenched inner forces (workplace barriers) and outer sociocultural forces, many of which are present in the NHS and relevant to the implementation of FTSUGs. An intersectional approach refers to the complex ways in which multiple issues (e.g. race, sex and cultural norms) routinely interact to influence everyday experiences of people receiving and working within health care. 83

FIGURE 2.

Iterative model of intersectionality of pre-existing workplace and societal barriers to and their effects on speak-up interventions. This model takes account of the intersectionality of pre-existing societal and workplace culture, which forms a formidable barrier (blue arrows) to the implementation of speak-up interventions in practice. Some interventions successfully bridge the gap (green arrow), others bridge but the effect is variable or weak (amber arrow) and others fail to bridge the gap (red arrow).

There are few certainties within the complex realities of modern health-care practices;84 however, a significant theme in the literature is the global pervasiveness and dominance of workplace cultures that were inimical to speaking-up interventions. Implementing speak-up interventions was reported as immensely challenging work in the USA, Republic of Korea, Islamic Republic of Iran, Canada and England. Regardless of their location, health-care researchers and policy-makers who are interested in improving employee’s freedom to speak up will have to overcome pre-existing complex societal and workplace norms, which are often long standing in nature.

To the best of our knowledge, this narrative review is the first to locate the evidence within broader health systems and a policy context, and to adopt a complex systems perspective that is currently lacking within systematic review literature. 40 Doing so results in a better understanding of ‘speaking up’ as an action that has emergent and dynamic properties within a ‘messy’ system, rather than as fixed entities and stable properties. We problematise certain aspects of psychological safety that have been left unexplored in other reviews;85 in particular, we discuss the concept of mutual respect and how the closely related issue of deference can be a significant barrier to speaking up. Furthermore, we have shown how the complex interplay between societal/cultural values and societal/cultural norms affect speak-up intervention, although this was largely unexplored within the evidence reviewed.

Summary and conclusions

While noting the limitations of the review (Box 2), the review presents a critical overview of factors that could assist policy-makers and researchers when developing interventions to support speaking up in the health-care workforce. We recommend that future developments are based on a meaningful collaboration between a range of stakeholders from diverse cultural backgrounds and workplaces, including researchers, policy-makers, service users and practitioners. One enabler of meaningful collaborative working is adequate research and development funding to properly resource various stakeholders, meetings and equipment. We also recommend, therefore, that speaking-up research (and related engagement and research impact activities) be prioritised in the allocation of research funding.

Recommendations for future research include the need to consolidate and build on existing knowledge and to better situate studies within complex local and national contexts and culturally diverse workforces. In addition, more studies of speaking up in health care within low- and middle-income countries would address a significant gap in the literature and provide better understanding and solutions to meet the demands therein. Our review findings can facilitate the implementation of new policies as it surfaces conditions that may counter efforts to create more open speak-up cultures in health care. However, there is unlikely to be a one-size-fits-all approach to creating such a culture.

Freedom to Speak Up Guardian: one title, many roles

The age, ethnicity and sex of the Guardians who were interviewed closely mirror the NGO annual survey results,18 with Guardians mostly consisting of white women (n = 75) aged 45–64 years (n = 58) (see Appendix 2). Although the FTSUGs who were interviewed ranged from entry-grade professionals (band 5: £25,000–30,000) on the NHS ‘Agenda for Change’ pay scale to very senior managers (earning > £100,000 with board-level responsibilities), most Guardians (n = 44) interviewed were working at middle-ranking management bands 7 and 8a.

Surprisingly, given the extensive and challenging remit of the FTSUG role, as outlined in Chapter 1, the majority of Guardians (n = 55) who were interviewed were allocated ≤ 2 days to undertake the role, with most allocated ≤ 1 day (n = 44); only 11 out of 87 worked as full-time Guardians (see Appendix 3). Furthermore, most Guardians (n = 59) undertook the FTSUG role alongside a range of clinical (e.g. nurse specialist, radiographer and physiotherapist) or non-clinical (e.g. HR or OD practitioner) roles, whom we refer to as ‘adjunct’ FTSUGs. The remaining 28 Guardians who were interviewed occupied no other role within the trust and were appointed as part-time or full-time FTSUGs; we refer to them as ‘stand-alone’ Guardians.

From the outset, it is clear that there is much variation in terms of both those undertaking the role (their seniority, disciplines and skills) and the implementation decisions related to the role. At one extreme of implementation variation are the full-time ‘stand-alone’ FTSUGs, who are supported (as will be demonstrated later in the chapter) by administrative staff, external supervision and an independent budget. At the other extreme is the ‘adjunct FTSUGs’, who are allocated no time, or any supporting resource, while undertaking the role alongside a substantive full-time role.

The effects of such implementation variation on the practical fulfilment of the role are considerable, and an attempt to unpick this is the focus of much of this report. Nevertheless, a fundamental point to consider at this stage of the report is that the role title ‘Guardian/FTSUG’ has rather inexact and ‘fuzzy boundaries’,87 which makes precise ‘like-for-like’ comparisons across trusts difficult. The origins of such variation are embedded within the FTSU report,12 which offers little implementation guidance for trusts other than ‘Boards should decide what is appropriate for their organisation’ (© Francis R, 2015. Contains public sector information licensed under the Open Government Licence v2.0). 12 The assumption that trust boards know what is ‘appropriate for their organisations’ requires further scrutiny given the evidence that points to significant contrast between NHS senior managers’ perceptions of raising concerns and the problematic realities encountered by workers. 88

The following extracts from the telephone interviews demonstrate that pre-implementation decisions within some trusts were often poorly thought-out or were based on assumptions that proved unsustainable once the FTSUG role was implemented:

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.

r64

When I started I was told by senior management to expect only one or two concerns a year. In reality the number is very different.

r08

Although the NGO produced guidance for the FTSUG role,15–17 which is discussed at length in Chapter 6, the prevailing approach adopted during the role’s implementation was for boards to decide what was appropriate. Throughout this chapter, and elsewhere in the report, we return to the various NGO guidance as we track the implementation of the FTSUG role through different local organisational structures, systems and processes.

To summarise, there was little in the way of shared understanding and coherence across trusts about how to implement the role. Variations in time and banding allocated to the role could be the result of some boards carefully and optimally tailoring the role to fit the conditions ‘deemed appropriate for their organisation’. However, there is also evidence of knee-jerk implementation of the role and unrealistic expectations, with marked differences in implementation across organisations of similar size, function and CQC rating. Nonetheless, the majority of trusts believed that it was feasible and appropriate to appoint one person, allocated little or no extra time alongside a substantive role, to address the challenging prospect of supporting cases of speaking up, while simultaneously building a trust-wide culture of openness. The following comment neatly summarises the views of many FTSUGs:

Speaking-up is couched as an issue and solution which concerns organisational culture but it’s certainly not possible for one individual to change culture of one organisation that is part of a complex system.

r06

Selection and appointment of Guardians

Ensuring the careful selection and appointment of FTSUGs would appear to be particularly important, given the contested nature and long-standing problems of speaking up in the NHS and the ambitious culture change remit associated with the new role. The only reference made to selecting and appointing FTSUGs in the FTSU review, however, states that the person should be appointed by the organisation’s chief executive officer (CEO) to act in a genuinely independent capacity.

Trusts chose very different approaches to appointing Guardians, varying from open and democratic approaches to closed and obscure selection processes that favoured those already known to decision-makers. Most Guardians (n = 54, 62%) were appointed following a formal and competitive recruitment process, culminating in a selection interview:

I applied following an external advert. It was the most stringent process and toughest interview I’ve ever been through. Very senior people interviewing.

r36

Some trusts deployed a democratic/participative recruitment process that involved employees in initial recruitment decisions, such as the following process in which employees’ views also informed implementation decision-making:

Staff were asked did they want an internal candidate, did they want it bolted-on to an existing role or to be a substantive role. The board agreed to go with whatever decision was made, which was an externally appointed person in a full-time role.

r33

Interestingly, whenever the broader workforce was consulted, their decision was for a full-time FTSUG role to be externally advertised and appointed following a formal interview process. On each of these occasions, an external applicant was appointed.

By contrast, other trusts (n = 33, 38%) opted to appoint Guardians via closed, informal and opaque recruitment processes, often following a personal approach from a senior manager or a board member:

The trust secretary suggested I submit an expression of interest. I then met with them and the board chair and they offered me the role.

r85

I created the job following a discussion with the CEO. I wrote the job description and was seconded to set up the role and remained when it became a substantive post.

r45

Several respondents reported being ‘tapped on the shoulder’ (r32) as a direct result of their current or previous roles within the organisation. Those working in ‘patient complaints’ or ‘staff liaison’ roles were often approached because they were regarded as offering ‘a good fit, they said I was already talking confidentially to staff and raising concerns with senior managers’ (r74).

Others described how they were informed when interviewed for a substantive role or soon after appointment that the remit of their new role included being the Guardian. A newly appointed director of nursing explained that she was unexpectedly ‘advised that I was the Guardian on my second day’ (r35). Importantly, none of these unexpected and retrospective appointments was allocated any time to undertake the role.

There were no discernible patterns based on type of trust (acute or mental health) or on differences in trust size or CQC ratings. For example, a trust rated as inadequate and another rated as outstanding both appointed FTSUGs through closed processes. It is questionable whether or not the ‘good fit’ argument is sufficient justification for trusts to embark on restrictive recruitment processes that deny others the opportunity to apply for the role. Given that FTSUGs generally and those interviewed primarily identify as being of white ethnicity, it is also important to note that ethnic minority groups are likely to be disadvantaged in any organisation that relies on informal recruitment methods. 89 Furthermore, according to recent analysis,90 only 8% of NHS chief executives and chairpersons (who are often involved in FTSUG recruitment) are from ethnic minority communities, who make up 19% of the workforce. The potential significance of this can be seen in research findings that suggest that executives and managers commonly identify and sponsor the cases of demographically similar individuals, thereby facilitating their career progression and conserving rather than disrupting existing workplace culture. 89

Effects of implementation decisions on the Freedom to Speak Up Guardian role

Building on the above findings, the following sections discuss how FTSUGs undertake the role in the light of trust’s resource implementation decisions, especially time allocation. Realising that most FTSUGs were allocated little time to undertake such a potentially complex role, we asked Guardians whether or not they felt able to fulfil the requirements of the role. Most felt that they fully (n = 25) or mostly (n = 28) met the role’s requirements in the time allocated (Table 6).

Given that completely unbiased self-assessments are unattainable,91 Table 6 is illustrative of the perceptions of FTSUGs rather than a definitive analysis of role fulfilment. We also recognise that some Guardians may have been reluctant to say that they were unable to fulfil the role’s requirements. Most described being fully, or mostly, able to undertake the role in the time allocated, including 54% of Guardians who were allocated ≤ 1 day. We now discuss how some Guardians managed the seemingly impossible task of fully undertaking the role by deploying workaround behaviours that temporarily compensated for a range of workplace issues and implementation decisions, such as insufficient time and poor work design. 92 Some of the following extracts include the time allocated to the role, type of trust and type of Guardian role, where relevant and possible without compromising participants’ anonymity.

Counting and recording speaking-up data

The NGO’s guidance on recording cases and reporting data16 states that FTSUGs ‘are required to record all cases of speaking-up that are raised to them . . . in a consistent and systematic way’ (original emphasis) (© National Guardian’s Office, 2021. Contains public sector information licensed under the Open Government Licence v3.0). 16 Numerous FTSUGs followed the guidance closely, which they found to be ‘clear, coherent and very helpful’ (r7):

I count everything whether it comes to me by e-mail, text, phone call or bumping into someone in the corridor. They are all counted and reported every quarter to the NGO including signposting to others.

r36

However, Guardians’ practices often diverged from national guidance. By contrast to the extract above, ‘signposting’ concerns to other processes (such as diverting concerns to a grievance process within Human Resources) was not counted by some Guardians, while others counted only those cases that they considered to be ‘proper’ concerns:

I do not record signposting, a phone call or a chat in the corridor. I will record cases when people properly offload, when something takes time to address. If I recorded everything I would run out of time so it’s only when I’ve got a loop to close that I record it as a proper concern.

r73

The only concerns I recognise as a proper case is what I end up working on. If I counted everything this would skew the figures. Anything that is signposted to others I bat away and don’t count them.

r47

The FTSUGs were, thus, making various individual judgements about what ‘counts’ as a concern. Not all concerns were considered as having equal weighting, with many Guardians keen to ensure the primacy of patient safety concerns:

The NGO are too prescriptive about categorising concerns. I know some will count everything but minor issues like car parking is not something the NGO should know about. I deal with it but it doesn’t get counted. If I recorded those things as a concern then it would have the same weighting as a patient safety issue, which isn’t right.

r51

I know some Guardians would count every concern even if it was a light not working properly. That is where I think the NGO is wrong and not reflecting the true patient safety essence of what we should be doing.

r05

Despite considerable unease that counting all concerns could misrepresent what FTSUGs considered to be the essential (patient safety) meaning of their work, care was needed when deciding what constituted a ‘minor issue’:

I never push anyone away and always thank them for coming. They’re more likely to trust you if something bigger comes up in the future. If the culture is right staff will speak up. Even if someone takes the time to help someone with a mundane concern, that creates a better culture, it’s all interlinked. A concern was raised about air con where I felt the person may have been testing me with a minor issue and indeed they came back later with something serious. Another was when a shredder was reported to me as broken and when I explored I found a bigger issue as confidential information was left lying around the room. You can’t be too quick to dismiss things.

r46

There were also difficulties when applying the NGO’s counting guidance that ‘each individual speaking-up through the Guardian route should be counted as a separate case even if they are speaking-up about the same issue, together or separately’ (© National Guardian’s Office, 2021. Contains public sector information licensed under the Open Government Licence v3.0). 16 Most of the FTSUGs who were interviewed did not comply with the guidance because they (again) thought that it risked ‘over-inflating the numbers of concerns’ (r77):

The NGO wants every single concern to be reported as a separate case. This doesn’t make sense. I had 10–12 different people raising concerns about the same thing which I counted as a single concern.

r02

Despite the NGO’s attempts to establish consistency through codifying the process of counting and recording concerns, FTSUGs described deeply held reservations about a process that was too open to interpretation and difficult to generate meaningful comparisons across trusts:

My greatest criticism so far of the NGO is that they need to develop a national reporting system as the categories and what to report is currently too subjective. Practically it means we are not always comparing like with like.

r01

Similar issues of subjectivity and robustness of data produced and published are further discussed in the following section.

Monitoring and learning from speaking up

Concerns raised to a Guardian have the potential to facilitate organisational learning and to generate a culture in which workers feel free to speak up. The NGO acknowledges that Guardians alone cannot be responsible for tapping into this learning potential. Their guidance document for NHS boards17 suggests that boards should ensure that FTSUGs have access to data that ‘enable Guardians to triangulate speaking-up issues and proactively identify patterns, trends and potential areas of concerns’ (© NHS Improvement, 2019. Contains public sector information licensed under the Open Government Licence v3.0). 17 Furthermore, the NGO’s education and training guide for FTSUGs103 stipulates that FTSUGs should be competent in ‘analysis and identification of trends. . .and interpreting data’ (© National Guardian Freedom to Speak Up, 2018. Contains public sector information licensed under the Open Government Licence v3.0). 103 The following sections explore the practical ways in which Guardians collect and analyse data for patterns and trends, which generates learning from FTSU data.

Monitoring detriment

Numerous government inquiries, reports and research findings from the UK and elsewhere have described the costs borne by those speaking up in health care. The FTSU review12 gathered ‘harrowing’ testimony from workers who had experienced reprisals, resulting in deterioration of their emotional and physical well-being, detriment to their professional standing and career progression, and financial hardship. Given these serious and long-standing concerns, it is unsurprising that the NGO guidance on counting cases instructs Guardians to record the number of cases where ‘an individual feels they have suffered detriment as a result of speaking-up’16 and where a case reveals elements of detriment these should be recorded ‘even if the individual bringing the case does not identify detriment’ (© National Guardian’s Office, 2021. Contains public sector information licensed under the Open Government Licence v3.0). 16 The same document describes detriment as ‘any treatment which is disadvantageous and/or demeaning and may include being ostracised, given unfavourable shifts, being overlooked for promotion, moved from a team, etc. (© National Guardian’s Office, 2021. Contains public sector information licensed under the Open Government Licence v3.0). 16

The NGO’s 2019 annual report19 described detriment occurring in 5% of the 12,244 cases handled by FTSUGs; however, as discussed in the previous section, the Guardians whom we interviewed often did not receive feedback from those speaking up. Furthermore, according to recent data published by the NGO, only 45% of Guardians (n = 592) agree with the statement that ‘people in my organisation do not suffer detriment as a result of speaking-up’ (© National Guardian’s Office, 2020. Contains public sector information licensed under the Open Government Licence v3.0). 18 In response to our question ‘Do workers suffer detriment as a result of speaking up?’, 68% (n = 59) of Guardians stated yes, with 32% (n = 28) replying no.

There is a notable discrepancy, therefore, between the numbers of Guardians agreeing that detriment occurs within their organisation (68% in our interviews, 55% in the NGO survey) and the number of actual cases where detriment was identified via feedback (5% in the 2019 NGO annual report). The following sections offer further insights into how Guardians count and respond to incidents of detriment and provide a window into workers’ distressing experiences of dealing with colleagues’ reprisals within the workplace.

Chapter summary and conclusions

This chapter has provided detailed insights into the implementation, deployment and work of FTSUGs, which are discussed via the theoretical ‘lenses’ outlined in Chapter 2. In so doing, barriers to, facilitators of and unintended consequences relating to the implementation of FTSUGs have also been identified and analysed.

The 87 Guardians who were interviewed collectively portrayed wide variability in how the role had been implemented, resourced and deployed by organisations. The role title ‘Freedom to Speak Up Guardian’ is, therefore, best considered as an umbrella term, covering the multiple versions of the role that exist simultaneously across England and within the regions. Any comparisons of Guardians’ effectiveness and/or of the FTSU performance of a trust are likely to be possible or meaningful only when this variability is properly accounted for and factored alongside the numerous other variables that affect speaking up.

In NPT terms, a lack of shared coherence or sensemaking within trusts of the current demand for speaking up, and the aims, objectives and expected benefits of a FTSUG, explained many of the suboptimal implementation decisions made. The experiences of the FTSUGs who were interviewed suggest that most trusts underestimated both the resources required by FTSUGs and (relatedly) the unmet need for speaking up within their workforce. The roots of such misaligned coherence, in part, lie in the absence of detailed specification issued to trusts about the appointment, responsibilities and accountabilities of the role’s introduction to the NHS. However, it is also striking that, given the freedom to choose how to implement the FTSUG role, most trusts opted to invest minimal resources into an initiative that was described at its commencement as potentially making a ‘huge contribution’12 to the NHS. A potentially notable backdrop of significance, not directly addressed in this study, was the economic pressures within NHS England when the FTSUG role was first introduced.

Pre-implementation and early implementation decisions were consequential for the way that the FTSUG role was realised in practice. The lens of NPT brought into focus the problematic issues of operationalising routine and everyday aspects of the FTSUG role and how they often overlapped with early decisions about resource allocation. For example, delayed or limited responses by FTSUGs to cases, a lack of awareness-raising or culture-improving activities and/or Guardians’ being restricted to telephone or e-mail interactions were common where resources, especially time, were limited or non-existent. Such problems also negatively affected another area of implementation, identified within NPT as reflexive monitoring, or the appraisal work that is undertaken to understand how a new set of practices are embedded within an organisation and the effects of these practices on others. In this case, the lack of resources had an impact on data gathering and the limited analysis of data, and/or in generating meaningful organisational learning. The literature review in Chapter 3 found that workers became disillusioned when organisational leaders failed to deliver on their promises to listen and respond to concerns, while other studies demonstrated that delayed or ineffective responses to concerns deter workers from speaking up in the future. 112 In view of the underlying mistrust and scepticism experienced by some FTSUGs, these issues may result in damaging delays to or reversal of FTSU culture change and a situation in which insufficient allocation of resources is misinterpreted as a problematic culture of speaking up within the workforce. These points are further developed, especially from a NPT perspective, in Chapters 5 and 6. Improvements in the response rates and/or quality of feedback to FTSUGs from those speaking up is essential to enable a full understanding of the realities of speaking up within their organisations.

The FTSUGs were faced with limited resources, seemingly unexpected demand and a caseload consisting of a large number of concerns about bullying and harassment, which led them to resort to a variety of compensatory and discretionary strategies in an attempt to best manage their workload. For example, we identified a number of workarounds deployed by FTSUGs that proved temporarily beneficial in meeting the role’s demands in most cases, but were unsustainable in the longer term. Guardians also reported having to prioritise certain aspects of the role, describing a reactive mode of working (i.e. reacting to concerns as they are raised and deadlines for compiling data returns and reports) at the expense of proactive working (culture building and triangulating data were often aspects of the work that were left fully or partially undone). Unsurprisingly, the question of the role’s sustainability was raised by many FTSUGs, especially in the light of the role’s potential to impair the FTSUGs’ well-being.

The implementation process also shows signs of being ‘historically ignorant’. For example, implementation decisions made within trusts and guidance/recommendations for practice produced at a national level demonstrate little evidence of learning from past events, which clearly showed that speaking up in the NHS could result in personal and professional detriment, especially so for those from minority communities.

Research questions

How is the work of FTSUGs defined and negotiated in relation to the work of others who also deal with employee concerns and patient safety at local and national levels?

Research aims

The research aim was to generate evidence of the extent to which the FTSUG role has been ‘normalised’ in organisations.

Research objectives

To assess how the work of FTSUGs is organised and operationalised alongside other relevant local and national roles with responsibilities for managing concerns.

Case study sites and methods

The six case sites were four acute trusts and two mental health trusts (Table 9), which were purposefully sampled and the names anonymised and assigned pseudonyms (US state capitals). Further details of each case site are provided prior to the individual case site analysis.

A full account of our case study methods is provided in Chapter 2, but, to summarise, we collected non-participant observational data and organisational documents relevant to FTSU activities and meetings. In addition, 109 semistructured interviews were undertaken with a range of organisational stakeholders key to the implementation of the FTSUG role, including Guardians, executives and non-executives, directors and managers. We also interviewed workers who had or had not spoken up to the Guardian (see Appendix 4 for all case study interview schedules).

These rich data were subjected to within and cross-case thematic analysis, informed by Damschroder’s implementation framework26 and the NPT model24 (see Chapter 2), focusing on the influence of organisational characteristics and key stakeholders on the implementation of FTSU and the FTSUG role within trusts. The distinctive and dynamic nature of inter-relationships within each case site and their unique effects on implementation decision-making reinforce the findings discussed in Chapter 4, which concluded that the FTSUG role cannot be conceived of nationally as a single entity, creating challenges when considering like-for-like comparison.

The following section describes how the FTSUG role was shaped by historical events within each trust, also providing an introductory understanding of context and setting at the pre-implementation phase, before we present a fuller analysis of the role’s early and ongoing implementation at each case site.

Organisational legacies that shaped the pre-implementation phase

Developing an understanding of how prior events and circumstances shape current organisational contexts and events is important when evaluating the implementation of complex interventions. 33 The idea of the ‘critical juncture’ (and synonyms, such as ‘turning point’) and the underpinning logic of historical causation113,114 are particularly relevant here. Historical events were invoked as ‘touchstones’ during interviews, used to frame and determine the relative value of FTSU generally and the introduction of the Guardian role specifically. For example, the narratives of key organisational stakeholders (e.g. a FTSU executive and NED leads, a CEO and board members) in each of the case sites identified past moments of far-reaching significance that informed the course of FTSUG implementation. Seen through this lens, the implementation of the FTSUG role unfolds as contingent on a temporally bounded sequence of events and interactions. 115

It is important to note that, despite our reference to causation and contingency, our position is that prior events do not solely or fully shape the direction of FTSUG implementation. Nonetheless, historical events clearly informed the ongoing sensemaking25 work within trusts, often underpinning collective understanding and coherence about the purpose and potential value of the FTSUG role. For example, stakeholders at Albany and Olympia recounted challenging events, which took place approximately a decade beforehand, that shaped formal and informal organisational narratives and strategies within which FTSU was implemented.

In Albany, the significant historical event was an internal report into a serious patient safety failure. In turn, this led to a concerted and successful organisational strategy founded on principles of continuous improvement, which the Guardian was described by the CEO as being ‘immersed’ within. Olympia’s critical juncture, according to the trust’s CEO, was the time when the trust was ranked near the bottom of the NHS England staff engagement table. Since then, organisational leaders have invested significant resource in communicating with staff and identifying shared organisational values to inform staff engagement and trust strategies. A senior leader described the Guardian as ‘embodying’ the principles of this engagement approach. Both trusts, therefore, reinforced a narrative arc of ‘lessons learned’ following suboptimal performance, framing the implementation of FTSU as embedded within previous episodes of suboptimal performance to the extent of appointing FTSUGs who were clearly aligned with ongoing changes.

Concord’s critical juncture was also prompted by feedback that reported it was failing on several aspects of patient and staff outcomes. However, in this instance the feedback was a publicly reported judgement of the organisation’s failure in the form of a very critical CQC inspection rating. Concord’s recent organisational history was, consequently, best understood as occurring over two epochs, namely the time before and the time after the CQC inspection report. Prior to the report’s publication, rudimentary preparations to implement the FTSUG role were under way, although Concord was the least prepared of the six case sites, having achieved little by way of a collective or coherent vision for how the role fitted into the trust. The CQC report resulted in workers’ morale plummeting, acute escalation of a pre-existing ‘atmosphere of blame’ (as described by the FTSU NED) and wide-ranging structural and personnel changes. Most of the key stakeholders involved in early discussions about implementing FTSU soon left the trust, with only one being in post when we undertook the case study (although their departure was also imminent). As the case site analysis demonstrates, plans to develop and embed the FTSUG role into the trust’s working practices were disrupted, often despite the Guardian’s best attempts.

Montgomery and Columbus’s key historical frame of reference was their legacy of successful innovation and performance, including a recent history of winning regional and national awards for clinical improvements and leadership. Continuing this tradition of leading and improving through innovation was a significant contributory factor to decisions made during the pre-implementation and early implementation phases of FTSUG. For example, both trusts had drawn lessons from the 2013 Francis Report12 and launched ‘in-house’ speak-up initiatives prior to the 2015 FTSU Review3 recommendations and the subsequent obligation to appoint Guardians. The initiative in Columbus pre-dated the Francis Review by at least 2 years, whereas Montgomery’s was launched approximately 6 months prior to the full details of the FTSUG role being published. A board member at Columbus pointed out (twice) during interview that they were ‘probably one of the first’ organisations nationally to appoint a Guardian-like figure. The FTSUG roles in both trusts were merged into the pre-existing speak-up initiatives and their constituent structures and processes.

Key stakeholders in Providence explained how the trust’s understanding of speaking up had been shaped by learning from the Mid Staffordshire Inquiry. 3 A pattern emerged in which new speaking-up policies and practices were launched in the wake of the initial Francis Report and then subsequently adapted following the Francis Review. More recently, a modernisation of the trust’s structures, personnel and operational philosophy heralded a new era in which changes were driven from within, rather than in response to external prompts. For example, the rebranding and re-envisaging of HR as the ‘Directorate of People’ and the appointment of a director whose background was in OD, not in HR, led to significant changes to how the FTSUG role was understood and deployed.

The in-depth cross-case analysis and findings will be fully explored in the next chapter. However, on the whole, all trusts, apart from Concord, demonstrated a progressive trajectory of change, in which speaking-up strategy and interventions (including those pre-dating the FTSUG role) were developed collaboratively and agreed on by senior stakeholders, and subsequent effects measured and reviewed. Concord was initially on a similar pathway, with progression stalling and regressing following the CQC report. Key internal stakeholders at the pre-implementation and early implementation stages were similar across trusts, with directors of HR/people, FTSU NEDs and executives, staff-side representatives, chairpersons and chief executives all featuring prominently in decision-making. We also saw complex interaction between events originating in the outer setting (e.g. regulatory or policy imperatives) and decisions in the inner setting of trusts. 26 For example, in Albany’s case, an outstanding CQC inspection rating motivated leaders towards maintaining and furthering a culture of patient safety and improvement, efforts that the FTSUG implementation was aligned with. By contrast, Concord’s CQC inspection ratings led to immense internal disruption, fuelling a pre-existing culture of blame and resulting in FTSUG implementation paralysis as senior leaders and FTSUG stakeholders vacated the organisation and their replacements took time to orientate to troubled surroundings.

Case study: Albany (Box 3)

Albany had implemented formal mechanisms for speaking up prior to the introduction of the FTSUG role, including access to trade union officials, a trust-confidential ‘concerns mailbox’ and a ‘whistleblowing’ policy, although these were used infrequently by staff. A FTSUG was not immediately deployed when required; instead a decision was taken to observe how other organisations recruited and deployed FTSUGs before finalising the role’s implementation. The CEO considered the FTSUG role to be a ‘huge opportunity to provide as much intelligence as possible’, enabling senior leaders ‘to look for where there are issues or problems’ (CEO, Albany). Such a problem-sensing11 approach ensured that a trust that was rated ‘outstanding’ remained alert to failure; this was a rating that was described as a ‘burden’ by the CEO, who believed it could lead to organisational complacency and a loss of focus on key issues.

Kate (NED) was a key influencer during the pre-implementation phase, having attended an information day at the then newly created NGO and gained insights into early implementation elsewhere. Kate then wrote a board report suggesting ideas for the implementation of the FTSUG role, which she explained ‘the execs then made it happen’. Kate was subsequently appointed as the FTSU NED and remained a key strategic actor in FTSUG recruitment and deployment decisions. This included consulting with Albany’s workforce committee on how the role should work alongside trade unions and HR. Besides determining the role’s boundaries, pre-implementation decisions included providing protected time for the role and ensuring that the role holder had autonomy and confidence to ‘manage upwards . . . go to very senior people and say difficult things’ (CEO).

The Guardian (Delia), an existing employee at Albany with a clinical and project management background, was appointed via a recruitment process open to internal and external candidates. She was initially deployed as an adjunct FTSUG for 2.5 days per week, with an equal amount of time allocated to a project management role. Delia was described by the CEO as possessing the desired attributes and being ‘immersed in improvement methodology’. Appointing an individual who had previously demonstrated confidence and competence in the language and techniques of improvement seemed to be important in ensuring that FTSU was seamlessly embedded into Albany’s working practices and organisational norms.

To summarise, there were limited pre-Francis speak-up mechanisms and processes in Albany. The trust was relatively late in implementing the FTSUG role, but this delay was strategically shrewd rather than an indicator of resistance or apathy towards FTSU. Being a late adopter allowed Albany to review implementation progress in other trusts, which, alongside consultations with key individuals and committees, informed the pre-implementation decision-making process that was led by a NED and closely supported by the executive team.

The following sections focus on the role’s ongoing implementation in relation to existing roles, structures and processes. It becomes clear that shared sense-making about the role’s remit, value and purpose identified at pre-implementation and early implementation stages were continually subjected to scrutiny and reflection, which, in turn, fed into adaptations made to the Guardian role. This interweaving of reflexivity, sense-making and ongoing implementation decision-making is well captured by the FTSU executive lead, who stated that:

We are continually reviewing . . . so has this made a difference? If it hadn’t, is it because we haven’t implemented it in the right way? And if it has, great but then do we need more, the same or something different?

FTSU executive lead

Case study: Olympia (Box 4)

There appeared to be no formal mechanisms for speaking up within Olympia that pre-dated the FTSUG role, with a low trade union presence. The CEO articulated that pre-implementation decisions about FTSU and the Guardian role were only ‘one component of a whole range of people management strategies . . . to set the organisation on a path towards continuous improvement’. The path referred to by the CEO could be tracked back ‘to at least 2008 when we were about the third worst rated trust in the country for staff experience. Now we are in the top half a dozen’. Such was the progress being made that the FTSUG role was not initially welcomed:

Because it was imposed on by the outside there is a natural inclination just to sabotage it. We were already doing these things. We didn’t need an externally defined role.

CEO

Several interviewees positioned FTSU as contributing to a larger strategy of staff engagement and continuous improvement; for example, a prominent director in FTSUG implementation described the key function of FTSU as ‘identifying key improvement themes which come through people’s stories’.

Olympia was unique among the case sites in that the FTSUG (Rachel), who at that time was a senior manager, was closely involved in the pre-implementation. Rachel initially alerted trust leaders to the role after attending a workshop, describing how ‘I was ready for a change and thought the role might be of interest to me’. Rachel subsequently wrote the job specification and presented it to the trust executive committee, which triggered the recruitment process overseen by the deputy CEO and a director.

The decision to appoint Rachel, a senior leader who had worked closely with senior stakeholders and was key to establishing the FTSUG role, was not considered risky by the senior leaders interviewed. The view of many was that the process of appointment was openly contested (one other person interviewed for the role) and that Rachel’s outstanding personal characteristics and professional experiences legitimated her appointment:

She had a reputation with front-line staff for being approachable and quite credible . . . we also knew that she wasn’t really afraid of the hierarchy. We thought the best chance of success was her mixture of approachability and passion for helping staff, and also her seniority of experience.

Board member

Rachel’s involvement as a principal figure in pre-implementation decision-making about the FTSUG role is, however, impossible to separate from subsequent recruitment and deployment decisions. For example, the hours and banding allocated for the role accorded fully with Rachel’s previous banding and her time availability. The following sections untangle and track the unfolding implementation of the role in terms of how Rachel’s work was enacted and accomplished.

Case study: Montgomery (Box 5)

In 2015, after a concern was raised about a senior member of staff, the director of patient safety (David) identified potential barriers to and the lack of a meaningful mechanism for workers to speak up, with staff perceiving that when faced with concerns ‘organisational leaders would circle the wagons and look after their own’. David and Isabel (chief nurse and FTSU executive lead) subsequently appointed a senior medical clinician (Catherine) to develop and launch an ‘in-house’ initiative to support staff to speak up. Catherine was selected because she had previously led award-winning changes to clinical services at Montgomery, informed by QI approaches. Isabel explained that appointing Catherine to lead the in-house initiative was also a strategic move ‘to get medical staff engaged and to realise that the concerns of a porter or health-care assistant is as valid as yours. Catherine was outstanding and just flew with it’. The director of HR was also a key influencer at this stage, described by Catherine as a ‘fantastically helpful springboard for ideas’.

These four senior stakeholders collectively agreed that the guiding principle of Montgomery’s in-house speak-up initiative was that all workers, regardless of status, should initially try to resolve their concern by speaking up directly to the person causing the concern. Where that proved ineffective, or not possible, workers were signposted to utilise existing internal mechanisms for raising concerns and reporting (e.g. incident reporting processes or contacting a line manager). If the concern remained unresolved, workers were then signposted to contact Catherine, who would intervene to seek a satisfactory outcome to the concern. This final step was referred to by many as a ‘safety net’, operating when all other avenues had been exhausted or were considered unsuitable. Triggering the safety net signalled, therefore, that one or more response mechanism was ineffective and acted as a cue for Catherine to deploy a QI approach that would ‘beef up process so they are fit for purpose’ (Catherine).

A communications strategy to raise awareness of speaking up was also deployed, including the use of posters, screensavers and an e-bulletin. The ‘in-house’ initiative was launched in early 2016 when the FTSUG role and the NGO were still being formed, although Catherine explained that they realised that the proposed FTSUG role was ‘going to be more or less the same type of thing we were doing’.

As further details about the FTSUG role emerged during 2016, these were progressively merged into the in-house speak-up initiative. The terms FTSU and FTSUG were adopted, and Catherine was appointed the first FTSUG (4 hours per week, a non-competitive appointment mandated by David). However, the logo, colour scheme and design for the in-house initiative were mostly retained on posters, for example, rather than adopting the national FTSU branding. The decision to implement the in-house initiative, rather than delaying in the light of the imminent introduction of the national FTSU initiative, was symbolic of the team’s confidence and indicative of an organisational culture that valued leadership, innovation and distinctiveness. The fact that the in-house branding was retained when FTSU/FTSUG was later mandated across the NHS was a further sign of self-confidence and the desire to retain Montgomery’s distinctiveness.

Montgomery then embarked on a period of substantial and rapid expansion, including taking over trusts in the region that were poorly performing. In January 2018, Catherine assumed additional and demanding responsibilities as a director overseeing FTSU for each of Montgomery’s trusts, prompting Helen’s appointment as the FTSUG for Montgomery. There were no other applicants for the role and Helen was recruited without interview. Prior to becoming the FTSUG, Helen had been assisting Catherine as a voluntary FTSU ‘Champion’, who had been deployed to help raise awareness of, and signpost relevant concerns to, the Guardian. Helen described how she was initially attracted to the Guardian role as it was ‘very much around supporting staff to raise concerns about patient safety’. However, as was commonplace for almost all Guardians, Helen reported that ‘the majority of concerns are bullying and harassment or toxic cultures’.

The role was an adjunct to Helen’s substantive role as a busy, full-time, band 7 clinician. Following a handover period, Helen continued to deliver Montgomery’s pre-existing vision of FTSU, largely based on the in-house signposting initiative. The appointment of a new Guardian was, therefore, mostly a case of ‘business as usual’ rather than an opportunity to review and reset priorities. One small change saw an increase in the time allocated from 4 to 6 hours per week, with the additional hours earmarked for increasing communications with workers via social media activity or publishing a FTSU newsletter and posters.

Box 6 exhibits an extract from an updated ‘How to’ poster displayed across the trust, illustrating a four-step approach that was core to Montgomery’s FTSU strategy, including reference later in step 4 to contacting the trust’s Guardian. The information was particularly orientated towards safety concerns and professional workers (i.e. those practising as a regulated workforce), with little specifically targeted information for other workers (non-regulated). There is also no acknowledgement of concerns about cultural or behavioural transgressions, despite these being the issues most frequently raised with the FTSUG.

To recap, the pre-implementation and early implementation stages saw the FTSUG role being absorbed within a pre-existing ‘home-grown’ initiative, which marginally predated the mandatory introduction of the FTSUG role. With only 6 hours per week allocated for the Guardian role, it was critically important to the workability of the FTSUG role that Montgomery’s workers followed a four-step approach to speaking up, with the FTSUG functioning as a ‘safety net’ to capture any concerns that were not addressed by the initial three steps. It was also critically important, in terms of managing the FTSUG workload, that one of the initial three steps resulted in a satisfactory response to the worker’s concerns and, where this was not the case, that identified shortcomings were rectified by a QI approach. The following sections present common themes from the data that explore the ongoing implementation of the role in the light of these early guiding principles.

Case study: Columbus (Box 7)

The Francis Report in 2013 was an external trigger for Columbus to undertake a series of ‘listening exercises’ with workers, led by the chief nurse (Sheryl), to better understand any barriers to or facilitators of speaking up. As a result of this activity, Columbus launched an employee speaking-up initiative in 2015, which comprised a confidential e-mail service, external speak-up telephone line and a large network of speak-up ‘Champions’ situated across the organisation. This early initiative was a clear signal of organisational commitment to learn the lessons of the Francis Reports and confidence to be at the forefront of change nationally.

With the emergence of the Guardian role, the pre-existing initiative was completely subsumed within FTSU. The transition process was again led by Sheryl, who established a formal working group consisting of the then director of HR, a NED (Suki) and the staff-side lead. Interviews and documents indicate that channels of communication between the working group and other organisational stakeholders were open from the start, including communication with the CEO and the board, who were regularly updated (and approved) of the working group’s progress. During this transitional period, considerable effort was invested into generating a shared coherence of the FTSUG role’s position and remit. The transition group’s preparation also included a number of calls with the NGO to further clarify national FTSU guidance, described as ‘very haphazard’ by a working group member. These calls signified the group’s commitment to establishing external and internal coherence about the role, and further reflected the trust’s sense of assured self-confidence in liaising directly with national bodies.

Sheryl explained that the working group agreed that the role required someone with ‘authority and gravitas’, who felt ‘confident to talk to whoever in the organisation’. The culmination of several weeks’ interaction resulted in the working group agreeing clear boundaries and the remit for the FTSUG role:

. . . number one is signposting, number two we deployed it as speaking up for patient safety. Everyone understood their role and the Guardian understood that anything HR and employment based like bullying or pay is outside their remit.

FTSU working group member

Suki was initially appointed the FTSUG, working 1 day per week, and was supported by a deputy Guardian (Charlie) who had worked in Columbus in a clinical role for a number of years, with Sheryl appointed the FTSU executive lead. However, following the publication of NHS guidance117 detailing expectations regarding resources and positioning of the FTSUG role, alongside internal insights that the role required the allocation of more time to function effectively, Charlie was appointed (following interview) as a full-time FTSUG, with Suki appointed the FTSU NED. The trust’s strong financial position, which was referred to in a number of interviews with senior stakeholders, was intrinsic to the successful re-evaluation of the role, ensuring that sufficient resources were mobilised to support a full-time role at band 8a (uplifted from the original band 7 allocated), in addition to Charlie having her own budget and access to office space on the executive floor.

These changes were framed as delivering on the working group’s pre-implementation vision of an independent FTSUG who had access to senior leaders. To this end, the physical positioning of the role alongside senior management was considered symbolically important by Suki, while Sheryl described Charlie as ‘approachable to all in the organisation’. Data collected during fieldwork suggest that this pre-implementation conception of the role was translated into practice. Charlie’s clinical credibility and approachability was foregrounded on FTSU promotional material (wearing a uniform), somewhat distancing the role from too close an association with corporate or managerial functions. FTSU service users (SU1, SU3) described how promotional material had been helpful in alerting them to the existence of the FTSUG and how they viewed Charlie as approachable and having influence with but functioning independently of management. The CEO also stated that Charlie has raised issues directly to him, facilitated by their physical proximity.

To summarise, several resources were deployed to support speaking up that predated the Francis Review and its requirements by some months. These existing resources were subsequently and fully rebranded to ensure consistency with the mandatory introduction of the FTSUG role. A transitional working group agreed and demarcated the remit and boundaries within which FTSUG operated and undertook deliberations with key internal and external stakeholders. Considerations concerning the interface of the FTSUG with trade unions and HR were at the fore, and the role’s signposting remit was agreed. It was made abundantly clear to the Guardian that any involvement in employment issues would be regarded as an unwelcome breach of existing boundaries and encroachment into territory occupied by trade unions and HR. The following sections consider these pre-implementation and early implementation assumptions as the FTSUG role became further established.

Case study: Providence (Box 8)

Since 2013, whistleblowing and speaking-up processes in Providence had been consistently reviewed and adapted. As Table 14 outlines, a pattern of external policy factors prompted internal appraisal and sense-making activities between 2013 and 2016. Senior leaders from HR, the staff-side chairperson and a NED collaborated throughout these review activities, which were requested by and reported to the board, who also approved the subsequent modifications. The appraisals analysed various ‘soft’ and ‘hard’ data sources, such as e-mail and telephone support-line usage, the numbers of concerns raised by workers and their experiences of doing so.

Three different versions of the FTSUG role were implemented between 2015 and 2018. Initially, in response to the FTSU review, the role was undertaken by four FTSUGs, who worked in different divisions within Providence, with the aim of offering workers a choice of Guardians. Members of the executive team approached individuals directly to undertake the FTSUG role. However, the FTSUGs were allocated no time for the role and were largely tasked with undertaking awareness-raising and promotional events, with few concerns being raised.

Version 2 was implemented in 2016 following the NGO’s publication of the FTSUG job description, which recommended ‘ring-fenced’ time for FTSUGs. 15 One of the four original FTSUGs was appointed as lead Guardian, with the other three Guardians assuming supporting FTSUG roles. The lead guardian was allocated 1 day per week for the role, alongside their busy band 7 clinical role. The medical director and director of nursing and midwifery operated as joint FTSU executive leads. The FTSUG was located and line managed within HR.

The case study was undertaken during version 3 of the FTSUG role, which was a substantially different FTSUG role from the previous versions. Notably, the source of these changes was internal, rather than external, triggered by the following events:

• the FTSUG role becoming vacant

• staff whistleblowing to external agencies, avoiding contact with the FTSUG owing to concerns about the confidentiality of the FTSU service

• Raquel being appointed as Director for People and the new FTSU executive lead.

Version 3 of the role also consisted of a number of key operational changes, including an open recruitment process, the adoption of a stand-alone FTSUG model, rather than an adjunct FTSUG, and increased time for the role (3 days per week, from 1 day per week). Hannah was appointed the FTSUG at band 6 from a clinical role within Providence. She had no previous involvement in FTSU and was line managed by the Deputy Director of People (Delyth). These significant alterations to the FTSU role were intrinsically linked to key internal operational changes occurring within Providence in 2018, which are further explored in the next section.

Case study: Concord (Box 9)

There appeared to be little in terms of a pre-Francis Review organisational strategy or associated resource to support speaking up in Concord, beyond the customary access to trade unions and HR. However, the critical CQC inspection rating in mid-2018 resulted in the replacement of many of the senior leaders who were in post during the pre-implementation phase of the FTSUG role. An executive who was appointed following the CQC report outlined the severely critical nature of the CQC inspection findings:

Systems and processes weren’t in place. How we investigate and learn from incidents, none of that’s been done properly. Basic things like board governance and the governance within divisions. Basic standards of care not being done properly. Chaos. It’s a nice place to work, but people have been here a very long time. They don’t see things . . . they have no idea of what good looks like.

Executive

The trust was also beset by debt and underinvestment, resulting in an estate described as ‘crumbling’. Repair costs were estimated to be £250M, equal to the total annual operating budget for the organisation. Decaying buildings and wards were described by another executive as ‘appalling, they’re awful environments for staff and patients . . . if our staff feel rubbish that’s a patient safety issue’.

Another executive voiced a common theme that was identified during fieldwork, explaining that environmental contingencies normalised poor working conditions at Concord, which blinded many to the consequences of their actions or inactions:

It’s quite hard when things have been that way for a long time for staff to actually see it and recognise that actually this is unacceptable and glossing over it results in bigger problems.

Executive

One original initiator of the FTSUG role remained in post during fieldwork, although the departure of the Director of People/FTSU executive lead was also imminent and was described by a colleague as ‘currently winding down’ (fieldnotes, 21 January 2020). The FTSU executive lead identified a prevailing blame culture within the organisation as a key challenge to implementing a FTSUG, which, unsurprisingly, resulted in ‘a kind of reticence to tackle issues’. A culture of blame and the sightlessness and/or sense of helplessness resulting from chronically poor working conditions were significant barriers to speaking up.

Compared with the other case studies, there was little pre-implementation preparation or forward planning undertaken for the FTSUG role. A board member explained how they were mostly informed of implementation actions, rather than directly contributing to them:

We were all told after they employed someone what their remit was. The execs were paying lip service, I would say it’s almost a tick box exercise.

Board member

The Director of People’s preference was to recruit a FTSUG who had a clinical background, thus representing the largest staff group in the trust that was ‘normally not afraid to speak truth to power’. The initial FTSUG recruitment process generated no applicants. A second recruitment process, supported by increased advertising of the vacancy and directed at clinical staff, eventually resulted in the appointment of Carly as a part-time (2 days per week, band 8a) stand-alone FTSUG in January 2017. Carly described the interview, which was undertaken by a panel featuring three executives, as ‘a grilling’. Carly, who was considering retirement or changing from her specialist clinical role in Concord, explained being very hesitant when initially applying for and then undertaking the role. This was due, in part, to her awareness that the organisation had planned little for how FTSU would evolve or unfold. Carly agreed to take on the role only when the trust approved her request to work 2 days per week, the maximum hours that Carly was prepared to work.

Carly’s line manager embarked on integrating FTSU into existing processes within the ‘People Directorate’, which was mostly referred to as ‘HR’ within Concord. Workers broadly associated the FTSUG with a HR role, which had implications for the Guardian, which will be discussed later. Early deliberations about how to triangulate FTSU data with various other data sources, such as adverse incident reporting, was also facilitated.

Frequent meetings between Carly and the FTSU executive lead became the norm, alongside less frequent, but nonetheless regular, meetings with the CEO. Carly and the FTSU NED also delivered speak-up training for other NEDs, who became active supporters of FTSU across the organisation. As a result, the FTSUG role became ‘increasingly integrated into the organisational workings’ (FTSU executive lead), while Carly also liaised closely with the FTSU NED, who described their relationship with Carly and the FTSU executive lead as an ‘important triangle based on trust’. Carly frequently described being well supported by both FTSU leads.

Despite a slow early implementation period, there were indications that momentum was building around FTSU. Plans for a longer-term FTSU strategy, focusing on further data triangulation and concerns about bullying and harassment, were being discussed when the critical CQC inspection report was published in mid-2018. The report proved to be a turning point for FTSU within Concord. Many of the initial FTSU stakeholders left the trust and, although they were eventually replaced, a significant amount of the trust’s energy and resource was diverted to addressing a number of remedial actions required by CQC. Progress with developing and implementing a longer-term FTSU strategy faltered significantly. Consequently, as the following sections demonstrate, the Guardian role and FTSU more generally struggled to be integrated into Concord’s working practices as a coherent presence amid an organisational climate and culture that was described by a board member as ‘bleak’.

National stakeholder interviews

Interviews with national stakeholders about FTSUG implementation provided insights that were additional to, and possibly less invested than, the insights of those already interviewed, who work more closely and directly with FTSUGs. The seven interviews occurred between May and August 2020, and offered an opportunity for participants to reflect on their own experiences of the FTSUG role, the early findings of the study and the effect of the COVID-19 pandemic on FTSUGs. Two prominent and somewhat overlapping themes, ‘scratching the surface’ and ‘expectation management’, were identified during analysis, and are now discussed further.

Comparing congruence with role expectations between trusts: Normalisation Process Theory-inspired insights

Concord had the least congruence between FTSUG role expectations and implementation decisions (CR = 5), with Columbus (CR = 16) and Albany (CR = 15) demonstrating the most congruence. Some of the different CRs between these three sites are explained in Table 19 and are further discussed below in relation to the other three sites: Montgomery, Olympia and Providence.

Interpreted through a NPT lens, Table 19 establishes that FTSU stakeholders in Albany and Columbus responded positively during the pre-implementation and early implementation phases to a clear sense of what they were contractually required to do (FTSU coherence: see Table 19, column 3). As the implementation unfolded, their subsequent responses to this (their collective action: see Table 19, columns 4 and 5) were monitored and measured against the expectations of internal and external observers (reflexive monitoring: see Table 19, column 5). Allocating adequate resources (see Table 19, column 2) was an integral component of enabling and supporting these mechanisms. Increased resourcing at Columbus and Albany as the implementation unfolded (e.g. significant uplift in FTSUG hours, appointing FTSU support staff) was a by-product of actively monitoring the role’s ongoing effectiveness in relation to the shared understanding of the role’s potential contribution to the organisation. In Concord, pre-implementation, early or ongoing sense-making and reflexive monitoring were not evident and resources were limited for FTSUG implementation.

Establishing collective coherence was an important element as a necessary precursor to collective participation, monitoring and action, and, therefore, in creating a receptive FTSU ‘implementation climate’ in Albany and Columbia. Implementation climate is defined by Damschroder et al. 26 as the shared receptivity of involved individuals to an intervention. Importantly, receptivity and climate are both enhanced by adequate resources and the extent to which policies, procedures and related relationships support the implementation. In addition, our analysis suggests that the process and climate of implementation in these sites was also enhanced by various feedback loops prompting learning and adaptation as the implementation unfolded (both sites CR = 2 for learning and improvement). The implementation in Albany and Columbus could, therefore, be characterised as non-linear and interacting dynamically with factors that emerged as the FTSUG role became embedded.

By contrast, the implementation climate in Concord was characterised by a lack of shared receptivity, with minimal resourcing (see Table 19, column 2) and a lack of coherence, supportive relationships, policies and monitoring (see Table 19, columns 3–5). Pre-existing and extremely challenging contextual issues, allied (and possibly contributing) to the absence of pre-implementation and minimal early-implementation sense-making and a related leadership vacuum, derailed the implementation of the FTSUG role. Relational work (cognitive participation) with senior leaders (CR = 0) was particularly unproductive: a characteristic that seemed deeply entrenched in the culture of the organisation. This even extended to those recently appointed to senior roles being critical of FTSU, but with no related attempts to resolve obvious implementation problems (CR = 0 for learning and improvement), individually or collectively. For this reason, the implementation climate for FTSU was extremely unconducive to change, despite (or perhaps because of) major change occurring elsewhere in the trust.

Normalisation Process Theory helps us to draw out, as others have previously shown,120,121 that each normalisation mechanism works not through an aggregate effect of individual parts but because parts link together to form social systems that promote the embedding of interventions. For example, there is obvious synergy present when clear and collectively coherent FTSU processes and strategies co-exist with supportive/robust boundaries and relationships and monitoring.

The implementation of the FTSUG role at Olympia and Montgomery further reinforces these insights. For example, both trusts produced coherent FTSU processes and policies, but this coherence co-existed with deficits in resourcing the role, relational disputes and/or limitations to reflexive monitoring of FTSU performance. FTSU implementation in Providence similarly demonstrated strengths in relation to certain role expectations, such as achieving an effective balance of close engagement with, but also operational independence from, senior leaders (CR = 2). However, FTSU implementation paid less attention to other expectations, such as ensuring that FTSU data and monitoring processes for speaking up fed into service improvement and organisational learning (CR = 1). Implementation of the FTSUG role at these trusts can, therefore, be characterised as less dynamic and responsive to feedback mechanisms. Although these three trusts established coherence early in the implementation process, this overshadowed or occurred at the expense of some other activities. There was a sense that some FTSU stakeholders in Montgomery and Olympia were reluctant to question how the role was initially specified and understood, despite emergent feedback that some aspects of the role were not functioning optimally. In Providence, the significant sense-making effort invested in implementing an independent FTSUG and FTSU system had occurred somewhat at the expense of embedding the role into improvement and learning mechanisms or promotional activities.

These insights also resonate with our literature review findings (see Chapter 3), in which certain interventions were considered partially or fully ineffective when researchers conceptualised speaking up as consisting of unconnected individual actions, rather a system of interconnected parts; for example, communication training was introduced to improve raising concerns by workers, with no related efforts to improve the way that concerns were responded to by managers.

In summary, Figure 3 maps differences and similarities in the implementation of the FTSUG role in terms of NPT mechanisms across sites. Columbus and Albany are shown to have closely grouped NPT mechanisms, which are also in dynamic interaction (signified by the central four-way arrow). Implementation elsewhere is characterised by more fractured grouping, with some implementation mechanisms working closely (e.g. coherence and relational work in Olympia and Montgomery) and other aspects of implementation mapped as less connected and embedded. In Concord’s case, the mechanisms are disconnected, reflecting the troubled implementation of the role.

FIGURE 3.

Mapping similarities and differences in NPT mechanisms across sites.

The significant influence of resources and reflexive monitoring

Resources allocated to the FTSUG role are further considered here given their significant impact on implementation. Compared with the other four case sites, Columbus and Albany invested significantly more resource (CR = 2) in supporting FTSU and their Guardians. In addition to investing in full-time FTSUG roles, other resources that were made available at initial implementation or added later included employing FTSU administrative assistants and a data analyst, purchasing a wide range of FTSU promotional material (e.g. mugs, cups and pens) and procuring sessional supervision and debriefing sessions for the FTSUGs with an external counsellor, among other things.

As noted in the preceding section, many of these resources were invested in response to monitoring (CR = 2) the role’s ongoing implementation, for example the provision of administrative support in the light of the unexpected and increasing demand of FTSU administration or counselling for Guardians in response to the emotionally exhausting work. Providence had also, to a lesser extent (CR = 1), augmented FTSUG resource, increasing the allocated hours from 1 to 3 days per week and allocating a dedicated workspace, as a direct response of monitoring earlier versions of the role.

Echoing our WP2 findings on the frustrating effects of time/resource scarcity on FTSUGs’ work, increased resources extended the Guardians’ capacity to undertake more proactive working (e.g. raising awareness of FTSU, culture building and triangulating data) rather than being restricted to reactive working (e.g. responding/supporting and documenting concerns). This is demonstrated in Figure 4 as a positive, ‘virtuous’, loop: reflexive monitoring led to the identification of operational gaps in provision, and this, allied with the availability of additional resources, led to the deployment of FTSUGs who more fully met the expectations of the role, including increased capacity to undertake more reflexive monitoring.

FIGURE 4.

Positive/virtuous feedback loop in Albany and Columbus.

It is worth recalling that central funding was not made available to trusts to support the introduction of FTSU. This may have been particularly telling for resourcing decisions during the implementation of FTSU in Concord (CR = 0 for resourcing, CR = 1 for time). Dire financial circumstances and an estate that was undersized and unfit and in which office or meeting spaces were at a premium were instrumental in creating practical difficulties for the FTSUG and a broader context of low workforce moral and scarce innovation.

Although Montgomery had allocated an additional 2 hours per week to the FTSUG role (increasing the total to 6 hours per week, CR = 0), it along with Olympia and Concord, had maintained the status quo since implementation, and pre-implementation and early implementation resource assumptions and decisions remained largely intact. As was discussed in detail in Chapter 5, there were issues with reflexive monitoring, learning and improving (CR = 1) of the FTSU role in each of the sites that were potentially problematic.

For example, the decision by FTSU decision-makers not to increase FTSU resources in Montgomery was underpinned by the rationale that an optimal FTSU process would result in a small number of concerns being raised with the Guardian, thus obviating the need to increase FTSUG hours. As detailed in the case study, however, despite one confirmatory indicator (small numbers of concerns raised), FTSU decision-makers within Montgomery were also aware of evidence suggesting that the FTSU process was not functioning optimally or resourced adequately. Despite this, key decision-makers maintained that role reconfiguration was not required.

Similarly, in Olympia, although the FTSUG role was implemented as a role embedded within staff engagement and service improvement, our evidence (including the view of the Guardian) suggested that the role seemed to have minimal input into these areas; despite this, FTSU stakeholders insisted differently. Monitoring at both sites seemed to operate mostly to reassure stakeholders that their initial implementation decisions remained correct, rather than prompting a robust review based on the realities of undertaking the role.

Freedom to operate independently: a case of interdependence and independence?

The FTSUG job description highlights the ‘expectation’ that the role should ‘operate independently, impartially and objectively, while working in partnership with individuals and groups throughout their organisation, including senior leadership’ (contains public sector information licensed under the Open Government Licence v3.0). 15 The extent to which an employee, who is embedded, remunerated and managed within an organisation’s managerial structures and processes, can fully ‘operate independently, impartially and objectively’ is a question that is beyond the remit of this project to fully answer. However, our case study data provide useful insights into some tensions inherent to implementing a FTSUG who can operate independently. ‘Operating independently’ was allocated a CR score of 1 across most case sites, with the exception of Providence (CR = 2) and Concord (CR = 0).

It is useful to briefly reflect on certain features of the implementation of the FTSUG role at Providence that resulted in the allocation of the highest CR for this role expectation. For example, the appointment of a Guardian with little prior experience of corporate roles, strategy and organisational management contrasted with the Guardians who were appointed at the other sites. This point will be expanded on below. In addition, the Guardian in Providence was encouraged by key FTSU stakeholders to align the role with the recommendations published in the NGO’s guidance and the FTSU review’s ethos. These FTSU tenets, and the FTSUG’s understanding of them, acted as a metaphorical compass for the Guardian to navigate the many interdependencies, boundaries and complexities intrinsic to the FTSUG role. They also served to remind the FTSUG of the potential dangers of too much ‘alliance’ (a phrase used by the Guardian) with the trust at the cost of undermining the interests of those speaking up and the perceived legitimacy and independence of the role within the broader workforce.

We do not claim that other FTSUGs were not also guided by similar principles. However, notable at other case sites was the extent to which Guardians had to counterbalance the ethos of the FTSU role with competing organisational strategies and senior leaders’ expectations. For example, the FTSUGs in Albany, Olympia, Montgomery and Columbus operated, to varying degrees, within narrow role boundaries and organisational expectations originating from pre- and early-implementation coherence-setting activities. Corrective steps were taken by stakeholders to ensure that FTSUGs operated within organisational expectations to maintain, rather than disrupt, existing relationships and disciplinary boundaries. FTSUGs at Albany and Concord were, however, compelled periodically to disrupt these boundaries and relationships, but the resulting stress and conflict had a telling effect on both Guardians’ well-being, who described symptoms akin to burnout. FTSUGs at Olympia and Montgomery were less disruptive and, as discussed in the preceding section, the role was largely unchanged from how it was conceived in these trusts.

Other implementation factors that could weaken claims of the FTSUGs’ independence were the various prior associations between Guardians and FTSU stakeholders:

• In Montgomery and Columbus, the FTSUGs previously held supporting FTSUG roles (both were previously FTSU Champions).

• In Albany and Columbus, the FTSUGs had previously worked closely with senior organisational leaders as project managers.

• In Olympus, the FTSUG previously occupied a senior management role, during which she wrote the FTSUG role specification and led initial discussions about the role’s introduction with senior leaders.

Each of the above FTSUGs, for different reasons, was known to organisational leaders and familiar with organisational expectations and boundaries. All were also fluent in the dialect of organisational strategy, improvement and project management. Again, we are keen to stress that we do not claim that such prior association renders these FTSUGs as lacking in independence or objectivity. However, the accounts of FTSU stakeholders were inconsistent; on the one hand they described wanting to appoint Guardians who could independently and robustly represent the workforce, but on the other hand known ‘insiders’ accustomed to the organisation’s ways of working were appointed.

It was evident that there were benefits to this ‘insider-ness’ and prior exposure and immersion to organisational processes and members, including Guardians being considered as a known and trusted person by workers in the organisation. It was evident that FTSUGs capitalised on their in-group knowledge of the distinctive language, behaviours and organisational rituals used by the people who FTSU interfaced with, which resulted in Guardians being privy to informal discussions and insider information beneficial to the work of FTSU. However, although building cohesive and strong connections with a variety of organisational stakeholders is an essential skill for a FTSUG, caution is needed to ensure that group dynamics do not inhibit the expression of dissenting views and, in doing so, undermine the delivery of safe care. 28 Reflexive monitoring can ensure that ‘insider-ness’ does not result in unquestioning acceptance of tacit understandings and business as usual, which could easily tip insider-ness towards groupthink, such that a sense of loyalty means group members avoid raising controversial issues. 122

Some of these points are surfaced when we further consider the FTSUG at Providence, which offers an interesting contrast to the discussion of insider-ness. Prior to being appointed, the Guardian was unacquainted with individuals working at the managerial and/or executive level and was unfamiliar with the various taken-for-granted language and concepts used during interactions at this level (describing having to learn a new language and having to clarify the meaning of the term ‘comms’ during a meeting). As a result, the FTSUG negotiated boundaries and relationships with key stakeholders on their own terms, independent of prior associations and relationships, which may restrict as well as enhance interactions.

In the case of Concord’s FTSUG, as has often been described in this report, there was no strategic direction or planning to guide FTSUG implementation. However, similar to Providence’s Guardian, being a clinician prior to appointment provided useful distance from the potential complications of previous associations with senior stakeholders and strategies. It could be argued, therefore, that the lack of prior association, the ‘light touch’ and inconsistent contact with senior leaders and the low-level organisational expectations meant that Concord’s Guardian was well positioned to operate independently and objectively. To some extent there was independence of action, with the Guardian ensuring that many concerns were managed effectively despite the considerable challenges identified in the preceding chapter. However, the lack of strategy and guidance for FTSU increasingly rendered the Guardian isolated from organisational overview, resulting in the development of operational practices that were revealed as problematic only when the Guardian interacted with recently appointed senior leaders who had worked with FTSUGs elsewhere.

Figure 5 summarises the preceding discussion of the independence–dependence/insider–outsider dynamic. The notion of independence is represented here on the x-axis, which indicates the extent to which FTSU issues were aligned with NGO and Francis Review expectations and principles or, alternatively, where FTSU principles could be intermittently overshadowed by organisational strategic priorities. The insider–outsider dynamic on the y-axis represents the extent of a Guardian’s prior associations with organisational stakeholders, processes and structures. An insider’s awareness could avail the FTSUG role of potentially valuable insights and opportunities, but the appointment of outsiders offered a fresh perspective on taken-for-granted working practices and expectations, which were more openly questioned and challenged. The positioning of FTSU at each trust is further discussed below, with brief reference to the CR for the ‘operating independently’ role expectation.

FIGURE 5.

The position of FTSU within case site trusts on the independence–dependence/insider–outsider dynamic. a, Concord’s position represents the Guardian’s status as a relative outsider, but also indicates that FTSU sits beyond the x-axis parameters, being simultaneously adrift of organisational strategy within Concord, as well as functioning outside most of the Francis Review’s/NGO’s expectations (CR = 0).

Providence is positioned with reference to a FTSUG who was an outsider in terms of prior associations, but also in relation to resisting close involvement in organisational or strategic initiatives that could be considered somewhat peripheral to FTSU and the interests of workers speaking up. FTSU at Providence was, therefore, strategically aligned with and practically guided by FTSU principles, with supportive line management and executive input that focused on maintaining the Guardian’s independent positioning (CR = 2).

Freedom to speak up at Albany and Columbus straddled the border between organisational priorities and expectations and FTSU principles and expectations. Guardians at both trusts had prior associations with senior stakeholders and strategic programmes before their appointment. Both were also heavily involved in a range of strategic and organisational initiatives following appointment, some of which at times appeared tangential to FTSU and would result in increased work pressures and time scarcity. Although there were indisputable benefits from involvement with organisational actors and broader strategies, FTSU principles could at times be blurred by prevailing organisational interests (both CR = 1).

Montgomery’s FTSUG positioning reflects being a relative outsider through working mostly in a clinical role, but also prior association with the FTSU programme as a Champion (CR = 1). FTSU more generally was closely aligned with organisational strategies and objectives, to the point that organisational priorities overshadowed FTSU expectations and the optimal working of the Guardian. Finally, Olympia’s (CR = 0) position reflects the FTSUG’s close and long-standing working relationships with senior organisational stakeholders and FTSU planning prior to implementation. In addition, FTSU principles, at times, struggled to gain legitimacy and independent strategic footing, being co-opted into senior leaders’ pre-existing organisational priorities rather than FTSU being represented as a key strategic imperative in its own right.

In keeping with our earlier discussion of dynamic contexts and the interplay of various factors within implementation settings, the labels of insider/outsider and aligned/not aligned should be understood as representing dynamic rather than static positions. It is not our intention to present these as binary labels that ‘freeze’ the position of FTSU and FTSUGs within trusts. Instead, we believe that it is rare within organisations for any individual to consistently remain an insider, and few remain complete outsiders. Our data have also shown how turbulent forces, triggered by internal and external events, can result in fluctuating positions along these dynamics on a daily or weekly basis, which adds enormous stresses and pressures on to FTSUGs. All FTSUGs, at times, are drawn away from FTSU principles by the strong pull and push of internal relationships, expectations and boundaries. At other times, Guardians successfully resist these internal forces (some more so than others) to productively pursue a FTSU-focused agenda of actions. External forces, such as the priorities of regulators, the NGO or national policy initiatives in response to exigent issues, such the COVID-19 pandemic, can similarly pull FTSU and FTSUGs in directions that are not always compatible with original FTSUG role expectations.

Identifying, monitoring and reflecting on these forces are key. Such increased awareness may help to forecast and possibly prevent forces pulling and pushing FTSUGs to positions that are incompatible with role expectations. Reflection by Guardians and others in the organisation using a simple tool, such as seen in Figure 5, may increase learning about stabilising forces, that is the forces that resist the displacement of FTSU and FTSUGs to positions in which they are less prevalent within the organisation or lose visibility completely.

To summarise, the FTSUG role expectations within the NGO’s job description explain that FTSUGs should operate independently, while also ‘working in partnership with individuals and groups, including senior leadership teams’ (contains public sector information licensed under the Open Government Licence v3.0). 15 This section has provided original insights into some of the difficulties and possibilities presented by FTSUGs working in partnership with others. The section shows that FTSUGs are skilled in undertaking aspects of partnership working, but also that partnership working can result in difficulties, especially when partners’ positions and views are unyielding to the views of Guardians and the principles of FTSU. Working independently and in partnership is a tricky undertaking for FTSUGs, and a process that organisational partners have to be ready and willing to participate in.

Optimal conditions for implementation of the Freedom to Speak Up Guardian role

Our study offers insights into features of implementation that seem consistently conducive with the wider ambitions of the FTSU Review and the FTSUG role. These insights stem from the careful attention invested during analysis to the interactions between coherence, relationships, operational decisions and reflexive monitoring during the process of implementation. The literature review, the breadth of our sampling and our reflexive within-case and cross-case analysis (see Chapters 5 and 6) reinforce our confidence in the rigour and transferability of our findings.

Optimal implementation has six interlinked components: (1) early, collaborative and coherent strategy congruent with the values of FTSU fosters the implementation of (2) policies and robust yet supportive practices (3) informed by frequent and reflexive monitoring of FTSU implementation, which is (4) underpinned by sufficient time and resource allocation, leads to (5) a positive implementation climate, which is best placed to engender sustainable FTSU culture and the well-being of a FTSUG.

Although the first four steps can occur simultaneously, the early establishment of a collaborative and coherent strategy for FTSU and the Guardian role set the context that fostered agreement about and alignment of productive policies, supportive practices and ongoing reflexive monitoring of the implementation. However, as the role is progressively embedded and implemented, reflexive monitoring emerges as being key to ensuring that implementation remains embedded within the values and expectations of FTSU, rather than becoming overly co-opted or lost to senior leaders or organisational priorities that may not be congruent with these values. Given the stressful nature of Guardians’ work, monitoring should also be extended to ensuring their well-being. Underpinning all of the above is sufficient resourcing to enable FTSUGs to undertake proactive practices that support speaking up, to build and maintain productive relationships with key stakeholders, and to collect and triangulate data to monitor FTSU across the organisation. Resources should also be allocated to ensure the personal and professional development of the FTSUG.

The self-reflection exercise demonstrated in Table 20 could be utilised by all trusts to review the current standing of the role’s implementation. Figure 5 could also be utilised during the exercise to plot and discuss the current positioning of the FTSUG and the forces that fix or challenge this position. Such reflective exercises are important because they reinforce the fact that FTSUG role implementation does not end when it is introduced into practice; in many ways, the introduction of the role into practice heralds the beginning, not the end, of the process.

The exercise in Table 20 could be completed each quarter alongside the NGO’s data return: trusts score their degree of agreement with each statement, from 0 (low) to 4 (high). The exercise should be a collaborative and reflexive process undertaken over ‘360 degrees’ by all FTSU stakeholders before totals are reviewed. Such an exercise can elicit constructive and reflexive conversations based on experiences and data, not preconceived ideas or assumptions about how the implementation of the FTSUG role has progressed, or not. It is clear from our data that many FTSUGs currently lack such a reflexive mechanism to trigger discussion and self-awareness with FTSU stakeholders.

Many of these factors mirror the NGO expectations for the FTSUG role, although documents, such as the job description that we have frequently referred to, are devoid of detail and a clear, coherent explanation (or ‘theory of change’) why all of the above factors are important, both individually, and perhaps even more so, collectively. It is the interconnectedness of these implementation factors that provides strength to the foundations and the structures that are required to fully implement this challenging role.

Research objective 1: assess the scale and scope of the deployment and work of Freedom to Speak Up Guardians

Although all organisations had appointed FTSUGs soon after being notified of the requirement to do so, our findings in Chapters 4 and 5 painted a mixed picture, revealing wide variability in how the role had been implemented, resourced and deployed. We could discern no apparent pattern according to type of trust (acute or mental health), size (large or small) or CQC rating. We concluded that such was the variability in the implementation of the role that the FTSUG title is best considered as an umbrella term, covering the multiple versions of the role that exist simultaneously within each region and also across England.

Most trusts underestimated both the resources required by FTSUGs and (relatedly) the unmet need for speaking up within their workforce. The roots of such disparity lay in the absence of detailed specifications issued to trusts to guide the role’s introduction. However, it is striking that, given the freedom to choose how to implement the FTSUG role, most trusts opted to invest minimal resources to support the role’s implementation. Alarmingly, many FTSUGs clearly identified how the lack of available resources, especially time scarcity, directly and negatively affected their ability to respond to concerns, analyse and learn from speaking-up data, and, more generally, the extent to which FTSUGs developed their role and FTSU culture adequately and effectively. These may all negatively impact on workers’ intentions to speak up. Furthermore, undertaking such a complex and demanding role often resulted in Guardians experiencing significant levels of stress and emotional upheaval which led to deterioration in their psychological and physical well-being. This raises questions about the long-term sustainability of the role, especially in trusts that invest little resource in the role and where there is little specific psychological support for FTSUGs (as was often the case).

It is also striking that Guardians often felt unable to or simply did not raise these issues with FTSU stakeholders, or felt ignored when they did. This is partly explained by FTSUGs, trusts and the NGO equating the Guardian’s worth with the numbers of concerns raised, which is regarded as the primary indicator of FTSU culture. Trusts, the NGO and FTSUGs need to address this over-reliance on monitoring FTSU through counting: knowing the number of concerns raised is a necessary but not sufficient condition for understanding FTSU within trusts.

Reflexive monitoring of the ongoing implementation of the role by all FTSU stakeholders is, therefore, fundamentally important to ensuring that FTSU is properly resourced and undertaken in a way that is consistent with the Francis Review’s focus on protecting workers who speak up, ensuring learning from speaking up and promoting a culture in which workers feel free to speak up without fear of detriment.

Research objective 2: assess how the work of Freedom to Speak Up Guardians is organised and operationalised alongside other relevant roles with responsibilities for workers’ concerns

The variability in the role, outlined in research objective 1 above, also extended to how the role was organised and operationalised alongside other roles with responsibilities for concerns. FTSUGs were variously located and subsequently line manged within HR or OD, service improvement, or patient safety teams. Many were located within a corporate/executive infrastructure, for example with office space allocated alongside executive and/or corporate management teams and line managed by a chief executive or other executive board members (e.g. chief nurse). There were both positives and negatives to each of these locations; for example, being closely located within HR provided useful opportunities for shared learning, but could also raise questions about the independence of Guardians. Similarly, close association with executives afforded the role a certain amount of legitimacy and kudos, but also risked tarnishing FTSUGs’ credibility and independence through the appearance of being overly aligned with the interests of organisational leaders.

One of the key determinants of the extent to which the FTSUG role was operationalised into the everyday working of trusts was the degree of curiosity shown by trusts towards FTSU. Curious trusts, especially FTSU stakeholders (e.g. FTSU executive and non-executive leads, chairpersons, CEOs, directors/executives and staff-side leads), demonstrated a problem-sensing approach to FTSU and the Guardian role, consistently undertaking reflexive monitoring of the contribution of speaking up to the organisation and normalising rigorous analysis of FTSU data and triangulating with various other data sources. Demonstrable benefits of curiosity included improving the experiences of minority communities and workers who may otherwise be seldom heard from, alongside learning that fed into service improvements, including updating and improving the Guardian role. Curiosity also normalised an environment in which Guardians probed and enquired beyond established disciplinary boundaries and routine ways of working.

By contrast, where incuriosity was normalised, FTSUGs often worked within restrictive boundaries and practices in which senior leaders were disengaged and limited data were collected and ‘reported’, rather than analysed, triangulated and integrated, into routine organisational processes of reflection and improvement. The intrinsic curiosity of the Guardian, FTSU stakeholders and others with a remit for concerns was more important than the physical positioning of a FTSUG on an executive corridor or whether or not the CEO’s door was ‘open’. Positioning alongside and ‘access’ to leaders were often lauded as indicators of acceptance and a positive FTSU culture, but could be present in trusts in which FTSU contributed little to organisational actions and leaders’ behaviours seldom extended beyond the ‘laminated values’123 emblazoned on walls and web pages.

Research objective 3: identify barriers to, facilitators of and unintended consequences associated with the implementation of Freedom to Speak Up Guardian roles

Many of these points and actions have been foreshadowed earlier in the chapter. To avoid overly repeating material, this section summarises the main facilitators of and barriers to the implementation of FTSUG roles, alongside key actions, where relevant:

• Facilitators –

  • Agreed and coherent strategy that is congruent with the values of FTSU, which should be regularly reflexively monitored (every quarter) and adjusted as ongoing implementation and sustainability of the Guardian role is reviewed.

  • FTSU stakeholders, the FTSUG and relevant others adopt a problem-sensing approach to speaking up.

  • Adequate resourcing to enable all aspects of the role to be undertaken, rather than a selective or partial implementation approach. Resources should enable both reactive (managing and responding to concerns and routine data requests) and proactive (raising the profile of FTSU, data triangulation, FTSU outreach activities) working practices.

  • Trusts should optimise FTSUG performance by regularly assessing and maintaining the well-being of the FTSUG. Key actions for trusts include resourcing debriefing and restorative supervision for FTSUGs, from relevant individuals internally and/or via external individuals/agencies. FTSU resourcing, including access to well-being resources, should be a focus of CQC well-led inspection criteria.

• Barriers –

  • Embedding FTSUGs within organisational strategies and traditional ways of working to the extent that FTSU is compromised by organisational demands, rather than meeting workers’ needs.

  • Recruiting FTSUGs who have prior close working relationships with senior individuals and organisational strategies to the extent that this may undermine FTSUG independence.

  • A form of retrograde and collective amnesia in that trusts and policy-makers appear to disregard or forget details of events in the NHS that occurred before the development of this role, for example detriment experienced by workers following speaking up.

  • Insufficient resources (scarcity of time, administrative support, budget for promotional activities and access to supervision).

  • NGO guidance currently allows too much FTSUG/trust interpretation, which undermines the accuracy and robustness of FTSU data collection and monitoring of concerns. Furthermore, guidance suggesting that the collection of ‘feedback’ (including key professional and personal characteristics) should follow the closure of cases significantly limits access to and use of potentially valuable data for the ongoing management and understanding of concerns.

  • FTSUG lacking an understanding of data anonymity and confidentiality and the use of data to generate reflection and learning; this should be addressed through training and clear best practice examples of the collection and use of potentially sensitive data.

  • Metrics, such as the number of concerns or the speak-up index ratings, are considered as the only indicators of FTSU culture and performance and are considered in isolation to other sources of data.

• Unintended consequences –

  • The large and unexpected numbers of FTSU concerns raised to Guardians relating to unprofessional behaviours among colleagues, for example bullying, harassment and incivility. FTSUGs expressed deep frustrations that what they considered to be a mostly patient safety role was instead addressing significant unmet demand resulting from under-resourced and/or poorly executed HR processes and related issues.

  • NGO guidance and national publication of selected FTSU data resulting in certain types of data collection by FTSUGs not being undertaken or deemed as not required (e.g. ethnicity and protected characteristics data), or certain types of concerns not being deemed or counted as ‘proper’.

  • Celebrating annual increases in speaking-up cases has driven a perception that ‘more is better’ and perversely incentivises some trusts to seek increased quarterly numbers of concerns. However, there is a poor understanding generally of what more (or fewer) cases actually mean. Fewer cases in some trusts may well be cause for celebration.

  • When adjunct FTSUGs were allocated insufficient time, there was a ‘knock-on’ effect on their colleagues, who were burdened with increased work when covering for FTSUG colleagues.

Research objective 4: evaluate the comparative effectiveness of different types of Freedom to Speak Up Guardian roles in supporting ‘freedom to speak up’

Our findings suggest that organisational histories and critical junctures were important in pre- and early-implementation decision-making. Some FTSUGs benefited, in terms of role effectiveness, when the introduction of the Guardian role was a continuation of work that had been commenced prior to the Francis Review. These early initiatives were prompted by specific internal events or by the realisation, especially following the Mid Staffordshire Inquiry, that improvements to speaking up in the NHS were long overdue. However, early gains in normalising a speak-up culture could be reversed, or derailed completely, by subsequent internal or external events. Similarly, organisations that may have initially delayed implementing or had a troubled early implementation could make rapid gains once early difficulties were navigated. The path to creating a culture of speaking up can be long and circuitous, seldom direct and linear.

Any direct comparisons of Guardians’ performance and effectiveness between trusts are unwise and fraught with difficulties owing to the marked variability in approaches to implementation, various organisational histories and unpredictable contemporary events, and diverse local interpretation of NGO guidance on counting and reporting concerns. However, FTSUGs were more likely to be effective when they were adequately resourced, supported by a clear and coherent strategy, and supported by policy that reinforced FTSU principles and was underpinned by an approach to monitoring and data that stimulated robust and transparent discussion of FTSU priorities, including future directions for the role.

Strengths and limitations of the study

Strengths of the study include that this is, to the best of our knowledge, the first study to investigate the practices of FTSUGs within their workplaces. The study is also a rare insight into how speak-up concerns are managed and ‘processed’ within a health-care system. The complex interactions, interdependencies and associated emotional turmoil have, to date, largely been communicated and understood through the specific lenses and requirements of government/regulatory bodies or public inquiries, rather than subjected to robust independent research.

A further strength is the depth and richness of the data collected, including the analysis of 206 interviews alongside approximately 240 hours of observations and a large archive of organisational documents. It is also noteworthy that the nuanced data and associated insights and observations were generated from individuals and contexts ranging from ‘board to ward’. Collectively, these make a significant contribution to the understanding of the implementation of this internationally novel role, in addition to more broadly reflecting the current state of speaking up in NHS England.

As with all research projects, it is important to acknowledge the limitations of the study. First, the participants interviewed were self-selected. It is plausible that those interviewed represented organisations that were more receptive of FTSU/FTSUGs. Similarly, a related limitation is that some of the interview responses may have been viewed as ‘socially desirable’ and, therefore, may not always represent respondents’ true perceptions. Nevertheless, the balance of both positive and negative experiences conveyed by Guardians and others during interviews suggests that participants were not overly biased by considerations of social desirability. Furthermore, although WP2 is limited to interview accounts of FTSUGs’ views, prolonged periods of fieldwork during WP3 case studies (involving the collection of observational and documentary data, in addition to interviews with a range of stakeholders) provided a richer understanding and a balance to the views captured during interviews.

In WP3, although we purposively sampled volunteering trusts according to criteria such as size and location of the trust, CQC rating and type of FTSUG recruited (adjunct or standalone), there may be some important contextual factors that we were unable to select, and we cannot state categorically that our findings are necessarily generalisable to all acute trusts and mental health trusts in England or beyond. More longitudinal case studies may have uncovered additional or even, possibly, contradictory findings. Nevertheless, we are reasonably confident that the data collected are sufficiently deep and diverse to enable us to uncover important aspects of FTSU and the FTSUG role that are transferable to hospital trusts more generally.

Recommendations for research

The following recommendations for future research are considered to be of equal priority:

• There is value in undertaking a similar study in non-hospital settings and where peripatetic working is commonplace, such as in ambulance services and in primary care settings.

• The role of HR and ‘middle managers’ in the management of concerns is an area requiring further research, especially regarding the management of concerns relating to unprofessional and transgressive behaviours, which often led to practical difficulties, boundary conflicts and suboptimal learning from concerns.

• Studies of the speaking-up experiences of minority communities and ‘seldom-heard’ workforce groups are a priority requirement.

• Devolved administrations in Scotland and Wales have adopted different approaches to speaking up. Research undertaken in these contexts would offer valuable comparative insights and lessons for speaking up in systems designed in broadly similar ways and guided by similar, or the same, legislation, regulation and principles of care.

• Studies of the Guardian role ≥ 5 years post implementation will provide an understanding of the medium-term impact of the role and further understanding of the links between pre- and early-implementation decisions and the longer-term sustainability of the role and well-being of Guardians.

Contributions of authors

Aled Jones (https://orcid.org/0000-0002-2921-8236) (Professor of Patient Safety and Healthcare Quality) designed the study, provided overall direction, conducted the narrative literature review, collected and analysed data and drafted sections of the report.

Jill Maben OBE (https://orcid.org/0000-0002-6168-0455) (Professor of Health Services Research and Nursing) designed the study, contributed to the narrative literature review, collected and analysed data and reviewed the report.

Mary Adams (https://orcid.org/0000-0003-1276-617X) (Senior Research Fellow) designed the study, contributed to the narrative literature review, collected and analysed data, drafted sections of the report and reviewed the report.

Russell Mannion (https://orcid.org/0000-0002-0680-8049) (Professor Health Systems) designed the study, contributed to the narrative literature review, analysed data and reviewed the report.

Carys Banks (https://orcid.org/0000-0002-5212-6217) (Research Fellow) collected and analysed data, drafted sections of the report and reviewed the report.

Joanne Blake (Research Associate) conducted the narrative literature review and collected and analysed data.

Kathleen Job (https://orcid.org/0000-0001-9959-2111) (Research Associate) analysed data, drafted sections of the report and reviewed the report.

Daniel Kelly OBE (https://orcid.org/0000-0002-1847-0655) (Professor of Nursing Research) designed the study, contributed to the narrative literature review, collected and analysed data, drafted sections of the report and reviewed the report.

Publications

Jones A, Blake J, Adams M, Kelly D, Mannion R, Maben J. Interventions promoting employee ‘speaking-up’ within healthcare workplaces: a systematic narrative review of the international literature. Health Policy 2021;125:375–84.

Jones A, Blake J, Banks C, Adams M, Kelly D, Mannion R, Maben J. Speaking up about bullying and harassment in healthcare: reflections following the introduction of an innovative ‘speak up’ role in NHS England. In Montgomery A, van der Doef M, Panagopoulou E, Leiter MP, editors. Connecting Healthcare Worker Well-Being, Patient Safety and Organisational Change: The Triple Challenge. Berlin: Springer; 2020. pp. 145–61.

Data-sharing statement

All data requests should be submitted to the corresponding author for consideration. Access to available anonymised data may be granted following review. Exclusive use will be retained until the publication of major outputs.

Disclaimers

This report presents independent research funded by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care.