Raising concerns in the current NHS climate: a qualitative study exploring junior doctors’ attitudes to training and teaching

Abstract

appropriately identified, or acted on, between 2005 and 2009. Sir Robert Francis QC, who chaired the inquiry, subsequently published a report on the Freedom to speak up (FTSU) review which urged that 'every member of staff should receive training in their organisation's approach to raising concerns and in receiving and acting on them'. 2 Senior advocates suggested that the review would trigger a 'cultural turning point' within the NHS for raising concerns. 3 The barriers to raising concerns are considered to relate to organisational 'fear and hierarchy' which inhibits honest and open conversation. 2,4 The Francis report highlighted the unique value of junior doctors with respect to raising concerns as the 'eyes and ears in the hospital setting'. 5 Aim Four years have passed since the publication of the FTSU report; are the messages regarding change in culture and training in raising concerns now common practice? This qualitative exploration of junior doctors' experiences of teaching and training regarding raising concerns aimed to understand how effective current education is and to explore what educational interventions may support training junior doctors to raise concerns. Literature and policy review There are several national online learning resources for raising concerns; all freely accessible to doctors. 6-8 Despite these resources, the most recent General Medical Council (GMC) trainee survey in 2018 had a chapter dedicated to reporting and acting on concerns. 9 While 5.8% of respondents stated that they had been a victim of or witnessed bullying and undermining, only 6.4% of them chose to report it. Exploration of the facilitators and barriers to raising concerns is well researched. 10-13 The most common barriers described in literature are now explicitly cited by the GMC in their raising concerns guidance: Fear that nothing will be done; cause problems for colleagues, have a negative effect on working relationships; have a negative effect on your career; or result in a complaint about you. 1 Studies exploring junior doctor attitudes to raising concerns repeatedly highlight that improving engagement in raising concerns required leadership and education. 14,15 While education is cited as an important step towards improving reporting behaviour, few studies explicitly describe what this might involve. Background High profile cases continue to demonstrate failures to raise concerns with detrimental effects on patient safety. This research sought to establish what educational support junior doctors needed to effectively raise clinical and professional concerns. Study design A qualitative study with 16 participants taking part in three focus groups. The transcripts were thematically analysed. Results All the data could be coded into four themes: past experiences of teaching; suggested teaching; reporting mechanisms and educational challenges. Most participants were dissatisfied with the teaching they had received on raising concerns. Current systems were thought to be good for raising patient safety issues but not for concerns about professional behaviour of healthcare staff. Conclusions There is a need for improved education to tackle the way this is taught in postgraduate curricula. Frequent rotations and a lack of meaningful relationships left junior doctors feeling less invested in improving organisational culture. Junior doctors are apprehensive about raising concerns because of personal risk to their career trajectory.