Raising concerns toolkit

NMC Code

Raising and escalating concerns is a central clause in the Nursing and Midwifery Council (NMC) Code, which says nurses must “act without delay if you believe that there is a risk to patient safety or public protection” (NMC, 2018). Read more about this in the NMC's Raising concerns: Guidance for nurses, midwives and nursing associates (2018). 

All nursing associates and HCSWs have a duty to raise concerns. 

If you are manager, please also see our section on manager's responsibilities.

The requirement to report concerns is often included in employment contracts, and within the roles and responsibilities set out in job descriptions.

These usually state that staff members must notify relevant managers, leaders, educators or regulating organisations or authorities, if they have any concerns relating to the health, safety and wellbeing of themselves, colleagues, or those in their care.

You should be confident that your team and organisation will focus on system learning, not individual blame and you should be psychologically safe when raising concerns. Psychological safety relates to an individual’s perspective on how threatening or rewarding it is to take interpersonal risks at work. 

For instance, is this a place where new ideas are welcomed and built upon? Or picked apart and ridiculed? Will my colleagues embarrass or punish me for offering a different point of view or for admitting I don’t understand?

A key component of psychological safety is it is usually experienced at group level – most people in a team tend to have the same perceptions of it, so if you feel unsupported at work your colleagues probably feel that as well. In some teams and/or organisations the prospect of raising a concern about care being delivered or the environment you are working in can be daunting to contemplate. 

It has long been recognised within health care that a culture that promotes learning is required to ensure patient safety and promote high-quality person-centred care.

You should therefore be confident that doing the right things like reporting incidents, near misses and concerns, being candid about mistakes, talking openly about errors and sharing ideas for improvements, are all welcomed and encouraged.

We know raising concerns or speaking up is not always easy, however the health, safety and wellbeing of those around you, including yourself, must be a priority and any delay in reporting your concerns could have a negative impact for those people.

It is important to remember that it is in everyone’s best interest (patients, staff and managers) to identify when something isn’t right, learn from this and make improvements. 

Staffing and patient safety:

• unsafe patient care or dignity being compromised 
• inability to meet the care of patients in your caseload (remember to document missed care in patients record and in the organisation’s risk management system) 
• increased workloads
• reduced or insufficient staff numbers and/or skill mix 
• inadequate response to a reported patient safety incident.

Our Nursing Workforce Standards have been created to explicitly set out what must happen within workplaces to ensure the delivery of safe and effective patient care. Please see the responsibility and accountability sections which outline where the responsibility lies for setting and reviewing the nursing workforce.

If you are facing unsustainable pressures in work, see our guidance on this, along with our raising concerns letter.

Health and safety:

• unsafe working conditions 
• infection control.

Please also see our health and safety advice guide. 

Lack of support or training:

• inadequate induction or training for staff or support for students.

Culture:

• bullying towards patients or colleagues, or a bullying culture.

Please also see our bullying advice guide.

Criminal:

• suspicions of criminal activity such as fraud 

See our section below on how to report. Remember, at any stage when raising or escalating a concern, you can always contact us or talk to your local RCN Safety Representative or Steward.

Raising a concern is not always easy so getting support is important. This may be from a colleague or your local RCN Safety Representative or RCN Steward. 

You can always contact us for advice and it is important to do so before escalating your concerns externally.

We are in the process of adding further letters which will appear shortly.

If you have concerns about PPE, specifically in relation to COVID-19, please use our template, Raising Concerns about PPE, which has been designed to copy and paste into your local reporting system to raise a concern quickly and easily. 

You can also access our COVID-19 workplace risk assessment toolkit. This supports all health care professionals manage risks associated with respiratory infections, specifically COVID-19, and aid local decisions about the level of PPE required at work.

As a student you should initially raise your concern with your practice supervisor/practice assessor, or the clinical manager of the practice learning environment.

If for any reason you are reluctant to raise a concern with clinical staff, you should follow your HEI institution’s raising concerns guidance, seek support from the RCN and raise your concern with the academic lecturer designated to your practice learning experience. 

Concerns must be raised verbally with your academic lecturer. You should keep a factual record of the events at the time of the event, a copy of which will be placed in your file.

You may be asked at a later date to write a factual statement with the help of your academic lecturer and/or the RCN. The earlier an expression of concern is made, the easier it is to take action.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. 

Our student advice guide may also be helpful.

• thank you for speaking up and listen carefully
• maintain your confidentiality (as far as is reasonably possible /or explain any limits to this)
• tell you what they are going to do
• advise you if it is clear that the concern does not fall within the raising concerns policy
• advise you if they need to investigate your concerns
• if you are asked to be a witness in an investigation please see our guidance for witnesses including how to write statements; please contact us if you are concerned
• explain what advice and support is available to you. 

Also see our sections on manager's responsibilities and what to do if it is not resolved.

Raising a concern is not always easy so getting support is important. This may be from a colleague or your local RCN Safety Representative or RCN Steward. 

You can always contact us for advice and it is important to do so before escalating your concerns externally.

As a clinical leader, you have an important role in ensuring staff are empowered to openly raise concerns. This includes being able to constructively question decisions and put forward ideas that can improve working environments or improve patient safety or experience.

Creating a culture of psychological safety is important so that staff at all levels are able to discuss and raise issues that are of concern to them without fear. The NMC Raising concerns: Guidance for nurses, midwives and nursing associates (2018) is clear that an open work environment in which staff are accountable and encouraged to raise concerns about the safety of people in their care will help identify and prevent more problems and will protect the public.

Please also see our section on what to expect.

The NMC's guidance on raising concerns provides information detailed below to assist clinical leaders who may have concerns brought to them.

• As a leader you should make sure appropriate systems for raising concerns are in place and that all staff can access them. Consider whether staff can gain access confidentially to your organisation’s whistleblowing or raising concerns policy.
• Make sure staff can see all concerns are taken seriously, even if they are later seen to be unfounded. 
• Tell the employee who raised the concern how it will be handled in line with local policies, and give a timeframe in which you will get back to them, both verbally and in writing.
• Investigate concerns promptly and include a full and objective assessment. 
• Keep the employee who raised the concern up to date with what’s happening. This will give them and others confidence in the system. 
• Take action to deal with the concern and, record and monitor this action. 
• Make sure staff who raise concerns are protected from unjustified criticism or actions. Have processes in place to support employees raising concerns. This support may need to be offered confidentially from outside the organisation.
• If harm has already been caused to a person in your care, explain fully and promptly what has happened and the likely outcomes. This duty is clearly supported by the NMC’s Code.

In addition to the above, as a staff manager or leader, it is important that you understand and follow your organisation’s raising concerns policy when concerns are raised. The policy should set out the difference between a personal grievance which HR can advise on, and a concern that is in the public interest. 

When discussing concerns, you will need to identify the type of concern being raised and the policy that applies. See our section on what to expect and ensure that you also:

• manage their expectations 
• assess whether immediate action is necessary to address any risk to patient safety
• record any risk as per organisational policies and procedures and put in place any mitigating action that you can reasonably undertake within the resources and authority you have 
• escalate concerns/risks and seek support if mitigating actions are outside your level of authority, or require more sustainable solutions or further resources. 

You may need to conduct an investigation. If possible, you should tell the staff member raising the concern about any outcomes or actions.

You will need to consider whether any information is confidential and whether it can be shared or not. If the individual is unhappy with the way their concern has been handled, you should tell them how to escalate their concern following your employer’s raising concerns policy.

It is important to keep notes of conversations and actions taken throughout the process.

If you feel that your concern has not been acted on, you could raise your concern with the designated person in your organisation or take your concern to a higher level (for example, a more senior manager or a senior nurse).

This should be detailed in your employer’s raising concerns or whistleblowing policy. If you want your identity to remain confidential, you should say so at this stage.

If you have raised a concern with your line manager and/or designated person but feel they have not dealt with it properly, you should raise your concern with someone more senior within your organisation.

For example, in the NHS you could take your concern to your department manager, nurse manager/matron, head of midwifery, associate director/director of nursing or chief executive.

If you feel you need support to do this, contact us for advice.

If you have raised your concern internally but feel it has not been dealt with properly, or if you feel unable to raise your concern at any level in your organisation, you may want to get help from outside your place of work. You may, for example, consider contacting a regulator of health or social care services or of health or social care professionals or a whistleblowing hotline. This is so that your concern can be investigated under current legislation and for your own protection.

Before taking this step it is important than you speak with us first.

Please see our section on how to report a concern and our raising concerns decision tree.

Raising a concern is not always easy so getting support is important. This may be from a colleague or your local RCN Safety Representative or RCN Steward. 

You can always contact us for advice and it is important to do so before escalating your concerns externally.