Exploring the influence of leadership, culture and hierarchy on raising concerns relating to patient deterioration: Report to NHS England Worry & Concern Steering Group (April 2023)

Summary

The early recognition and treatment of deterioration in patients in clinical settings can help reduce avoidable deaths. NHS England commissioned Florence Nightingale Foundation (FNF) to examine the barriers which prevent worries and concerns being raised about a deteriorating patient. Evidence suggests that organisational culture, professional hierarchies, and the nature of leadership in healthcare environments are the three key factors behind this reluctance. The findings highlight the importance of psychological safety which is highly influenced by authentic leadership in overcoming these barriers.

Content

Clinical staff often recognise deterioration in patients by using their intuition. This frequently involves them expressing worries and concerns about a patient based on a ‘gut feeling.’ Since family members, non- clinical team members, health care assistants and nurses have more consistent, direct contact with patients they are often the best placed to raise or escalate any intuitively based concerns.

However, these groups often face barriers to raising or escalating these kinds of concerns. To better understand these, NHS England’s Acute Deterioration Board (ADB) convened a national “Worry and Concern” Task and Finish Group (WCG). As part of this, the WCG and Nursing Directorate commissioned FNF to working in partnership with The Kings Fund to carry out a qualitative study with clinical staff, patients, family members and carers to understand their experiences of raising worries and concerns, and to identify interventions or actions that can be taken to address obstacles.

The findings highlight elements of the healthcare environment that influence the quality of the care delivered to the patient. Leadership that role models multi-disciplinary team working, values the expertise of all stakeholders, and champions person-centred practice can create a psychologically safe working culture. This culture creates an environment in which clinical staff, patients, carers, and family members feel confident and less hesitant in raising worries and concerns.

In healthcare environments where these characteristics are not present, staff training and development alongside access to, and the availability of feedback avenues can provide the right conditions for all to escalate concerns and improve patient safety.

Recommendations

1. Provide adequate avenues for feedback
2. Ensure closure of feedback loops
3. Promote and facilitate patient involvement in their own care
4. Provide and promote opportunities for patients, carers, and family members feedback
5. Provide and promote patient safety partner involvement
6. Provide training sessions for all clinical staff, relevant non-clinical staff, and students on detecting and escalating recurrent and major patient deterioration incidents
7. Prioritise staff wellbeing in healthcare environments
8. Empower newly registered staff and students practice
9. Commission further research to explore cultural background influences
10. Commission further research to explore generational differences
11. Commission further research to explore consultants’ perspectives.