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NMC: giving nurses the confidence to voice concerns



Nursing and midwifery professionals working in primary and community care can be presented with particular challenges when it comes to speaking up.

As the regulator of almost 732,000 nurses, midwives and nursing associates, the NMC wants every registrant to have the confidence to speak up about any matter of concern that they consider may get in the way of providing safe, kind and effective care – no matter how small it may seem.

What should nurses, midwives and nursing associates speak up about?

It is important to remember that speaking up if you witness or suspect poor practice or a risk to patient safety is part of the day-to-day professional practice expected of everyone on our register.  

But we acknowledge how important it is to ensure nursing and midwifery professionals feel supported if you do raise a concern. While our standards are clear on what is expected from those on our register, we have published a series of animations that bring our Code to life, as well as launching our new campaign – Caring with Confidence: The Code in Action. We encourage all registrants to view these and hope this will help to improve your understanding and confidence.

We know nurses, midwives and nursing associates – whether you work in hospitals, the community or care homes – have the widest reach and interface of all healthcare professionals. You are with people all day, every day and have the professional insight, knowledge and skills to recognise when something is not right, and importantly, to do something about it to ensure people receive the care they deserve.

Primary and community care

However, nursing and midwifery professionals working in primary and community care can be presented with particular challenges when it comes to speaking up, due the complexities of their roles. Staff can be working in more isolated roles than colleagues in other settings, and may feel at greater risk of personal repercussions for speaking up about poor care or other situations. Indeed, when Sir Robert Francis published his Freedom to Speak Up review in 2015, he identified those working in primary care as a ‘vulnerable group’ in terms of reporting issues. He pointed out that workplaces are much smaller than NHS trusts, for example, which makes it harder to raise concerns outside of line management arrangements.

This resulted in NHS England publishing primary care-specific guidance, Freedom to speak up in Primary Care. This includes guidance for all providers of NHS primary care services, specifying principles and actions to support staff to raise concerns, and about how those concerns should be managed.

What the NMC Code says

The importance of raising concerns, and the rights of our professionals to do so, is enshrined in our Code and set out in the document Raising concerns: Guidance for nurses, midwives and nursing associates. There are three important elements to bear in mind:

  • You should act without delay if there are risks to patient safety or public protection, remembering that this may be in any setting: clinical practice, research, education, policy or management. 
  • You shouldn’t hinder anyone else from raising a concern if they wish to do so.
  • You should protect anyone for whom you have management responsibility from any unwarranted treatment if they raise a concern. 

The requirements around speaking up therefore have implications for all of us, in terms of our professional duty as practising registrants, colleagues, managers or leaders.

We also know there are times when things have gone wrong, sometimes over a long period of time, where nursing and midwifery professionals have not felt able to speak up because other colleagues do not seem concerned. There are lots of possible explanations for this, such as a lack of confidence or thinking that more senior staff or other professionals know best. We know people may even fear they will be treated differently if they speak up or risk being branded a ‘troublemaker’.

We have seen from past reviews and inquiries that people stop speaking up when they are not listened to, or if nothing changes in response to concerns raised. In those instances, solutions cannot be found and risks can be left unmanaged. Staff may ‘give up’ or move on to new roles in an organisation where they believe there is a better safety culture in which staff will be listened to, and where learning and improvement are more valued.

So deciding whether something really poses a risk or not, and then deciding if, when and how to speak up, is not easy and it can be stressful. However, it matters that professionals do speak out and do so in a timely way. 

What if you do need to speak up?

There are many things you can do, but the important things to focus on are:

  • Don’t delay.
  • Find out all you can about the issue – know the facts.
  • Decide the best way to address your concern – do you just need to have a conversation with someone about their behaviour or practice?
  • Speak to your manager and/or your professional leader – remember they are bound by the NMC Code too.
  • If you are unable to speak to your manager or you feel your concern is not being listened to, you should refer to your employer’s policies and procedures for supporting staff to speak up. The National Guardian’s Office has published a new report supporting the Freedom to Speak Up Guardian role in primary care and integrated settings.
  • Don’t allow your concern to spill over into anger and frustration – try to be as objective and constructive as possible.
  • Seek support from your professional body or trade union.

Looking ahead

This year has presented new challenges and extremely difficult situations for health and care professionals during the pandemic. As nurses, midwives and nursing associates, you have put the interests of people in your care first.

Now, more than ever, members of the public recognise you for your commitment, professionalism and compassion. Unsurprisingly we’ve seen different concerns raised as you deal with a range of additional challenges that may impact negatively on the care of people, and on your own mental and physical health. We’ve heard concerns about the availability of PPE, the management of DNACPR orders, and professional accountability on a range of issues. There haven’t been any easy or quick solutions, but nurses have been urged to speak out if concerns are not addressed. It is encouraging that you have been doing so.

The NMC’s Speaking Up animation, and the other resources we’ve created as a part of the Caring with Confidence: The Code in Action campaign, provide more guidance and information and can be shared with colleagues, students and anyone else you think may benefit. 

We hope these resources will help you to feel confident about your knowledge and skills as a professional and how the Code can support you. 

Additional resources 

Other organisations that nurses can contact: 

  • Speak Up Direct also provides free, independent, confidential advice on the process of speaking out.
  • The charity Protect provides confidential and legal advice on speaking up across the UK.
  • The Trades Union Congress provides information on how to join a trade union.
  • The Law Society may be able to point you to other sources of advice and support.
  • The Advisory, Conciliation and Arbitration Service (ACAS) gives advice and assistance, including on early conciliation regarding employment disputes.
  • In Scotland, you can reach out to Healthcare Improvement Scotland, which has implemented a new whistleblowing policy, providing protection and promoting a culture of speaking up in the NHS.
  • In Wales, you can contact the Healthcare Inspectorate Wales with any concerns about poor care, wrongdoing, illegality or risk. The service is there if you have raised a concern internally that has not been addressed, or if you feel unable to raise your concern at any level in your organisation.
  • The National Guardian’s Office has published a report illustrating the challenges and benefits of implementing Freedom to Speak Up in different primary care settings.
  • The Regulation and Quality Improvement Authority provides whistleblowing guidance for nursing and midwifery professionals in Northern Ireland. You can also read more about how to raise concerns via the Northern Ireland Practice & Education Council for Nursing and Midwifery

The NMC would like to hear nursing professionals’ views on our draft standards, set out in our post-registration consultation, which is open until 2 August 2021.

PJ Mansell has more than 30 years’ experience as a nurse, with a background in operating theatre and day surgery management, and various patient safety roles. PJ is the NMC’s designated patient safety representative and is part of a working group led by the National Guardian’s Office to align the support provided for people who speak up.