Students raising concerns: what the literature tells us

14 July 2016

Aled Jones, Senior Lecturer School of Healthcare Sciences, Cardiff University and Robin Ion, Head of Division Mental Health Nursing and Counseling, Abertay University.

Aled and Robin are both members of the Steering Group overseeing the Council’s work on supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care. You can read more about the context to this review here and also download the review ‘Supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care’.

What have we learnt from the literature review?

The Council of Deans of Health commissioned a review of the literature to systematically gather and synthesise the evidence around raising concerns with regard to poor quality care witnessed by students on pre-registration healthcare programmes while on practice placement. Written by colleagues from the University of Bedfordshire, the review found some evidence to suggest that those raising concerns are generally being dealt with more positively than was once the case but that reporting remained difficult for some and did not always happen as a result. Yet it also clearly shows a need for further research in this area.

The dearth of studies is particularly concerning given that NHS organisations have been strongly encouraged, particularly since the Francis Report (2013), to tap into students ability to bring a fresh pair of eyes to practice environments which allows them to see, sometimes more clearly than permanent staff, the limitations and strengths of the care and treatment being delivered. Sadly, the review also indicates that students who raise concerns may well be placing themselves at risk of having unsatisfactory learning experiences and of being victimised. In addition, there is a lack of clarity around who students should raise their concerns with and no research on the enabling or hindering roles of key educational stakeholders that work closely with students, such as personal tutors, mentors or practice educators. Asking students to more actively raise concerns where there is such little clarity and volume of existing research is problematic and possibly unwise, especially as NHS staff who have more experience and authority often find that raising concerns is a challenge (Jones et al 2016). While there is a professional expectation that students like their registrant colleagues, should raise concerns when they see them, practically (at the moment at least) there are good reasons why students may refuse to heed this call.

What now for HEI leaders?

Higher Education Institutions (HEIs) have an important role to play in terms of ensuring and assuring that the information which students currently receive is clear and actionable and that it helps rather than hinders them to raise concerns where relevant. HEIs also have a role to ensure that they have a learning relationship with local NHS organisations. For example, HEIs have to ensure that any concerns raised by their students are communicated in a timely way to NHS organisations. Also, HEIs should seek follow-up information regarding students’ concerns, asking potentially difficult questions regarding the results of any investigations and meaningful action plans and what this may mean for future students’ clinical placements. Overall, HEIs have to ask themselves the question: ‘What evidence have we that our students are not able to raise concerns about poor care and not inhibited to do so through inadequate teaching and learning environments and unhelpful cultures in the classroom and clinical areas’? Once they have systematically addressed this question the answer should be made publically accessible, as it is in everyone’s interests that HEIs are at the forefront of creating an open culture of learning in healthcare.

Future research opportunities

One of the more “hackneyed” phrases in research circles is that “More research is needed in area x ……” (with x denoting the researcher’s area of interest/expertise). However, in the case of research on raising concerns/whistle-blowing by healthcare students this is absolutely the case. This is equally true for all varieties of healthcare students, be they nurses, physiotherapists or radiographers as it is for research in clinical areas and within HEIs. For example, we have little or no research understanding about educators’ view of this subject area or of innovative teaching and learning interventions around raising concerns. Perhaps, most surprisingly given that an act of whistle-blowing/raising concerns is particularly sensitive to hierarchical influence (i.e. perceptions of hierarchies tend to suppress concerns being raised), there is no research about the influence of hierarchy and power relations on students intentions to raise concerns/whistle-blow, or indeed their actual behaviours. Similarly we have no data around prevalence of the problem nor any empirically based case study material which explores models of good practice where these exist.

It is imperative therefore than an ambitious agenda of research in this area is agreed upon by researchers and HEIs across the UK. As research funding for educational research of this nature is in particularly short supply it is crucial that we build on this review and on existing research in the area where more data has emerged since the review was written. To avoid needlessly duplicating work that is already under-way and yet to be published and to avoid overly replicating work that may already be planned (whilst acknowledging that duplication is sometimes necessary and valuable) a priority must be to create a network or community of active researchers in the UK who are working or planning to research this area. Links with international researchers can then be forged from an initial understanding of what the UK currently has to offer, or not.

Next steps

With this in mind the Council will be holding a UK research network event in the autumn for academics, university staff and students with expertise or an interest in raising concerns. The event will bring people together to share their experience and to identify priority areas. If you would like to receive further details please register your interest here.

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