Appendix 14: Never walking past poor practice: escalating concerns and whistle-blowing

If any learner or trainee is aware of troubling practice in placement/practice settings, they have a duty to report and take action. Faculty guidance was triggered by our need to respond to the Francis Report and the Berwick Report (following the enquiry into abuse and neglect at Mid-Staffordshire). If any trainee has concerns, having witnessed poor practice on placement, they must report this totheir placement supervisor, and also to a programme team member - we are here to support you in our shared commitment to maintaining safe, effective and compassionate practice, and we are very aware of how difficult it can be to raise ethical issues, especially given the power dynamics for you as learners in complex settings. This is a conversation in progress, part of addressing the recognised need for culture change in the NHS.

Students must be encouraged and supported to swiftly report any incident, as a student health professional’s first priority is to protect the public.

1. The Faculty of Health and Human Sciences hasproduced a set of guidelines, and a flow chart of actions, forwhen learners or staff being involved in a serious untoward incident (SUI). They are appended.

This is in relation to any incident as defined by the National Patients’ Safety Agency (NPSA) asa serious incident that involves unexpected or avoidable death, serious harm, a scenario that threatens the organisation’s ability to deliver services, allegations of abuse, adverse media, a ‘Never Event’. The NPSA recognises that first priority of the organisation is to meet the needs of affected individuals, then re-establish a safe environment, followed by information provision and staff involvement. Depending on the seriousness of the event first notification to senior staff must happen as quickly as possible, ideally within hours! Once a 'root cause analysis' (RCA) has been undertaken, then an action plan should be drawn up which leads to learning and avoidance of a repeat occurrence.

2. Serious untoward incidents are rare, however, and there is also a Faculty flowchart on witnessing poor practice, whether or not it reaches the level of criticality of a SUI.

Faculty guidance states that:“Occasionally healthcare students on placement may witness what they perceive to be poor practice or practice they believe to be below an expected standard. This may include unprofessional behaviour or unsafe systems of work and the University has an obligation to follow this up effectively.”

Practice that should raise concerns includes:

· Poor or unsafe clinical practice

· Professional misconduct

· Health and safety risks, including risks to clients, patients, visitors and staff

· Bullying of patients, clients, visitors, staff or students

· Drug or alcohol abuse

· Verbal, mental, physical or sexual abuse

· Damage to the environment

· Conduct that is an offence or breach of the law

3. Practice that is at the margins of acceptability is hard to define, however, and many concerns are at a borderline or grey area, and require careful debate and reflection. The general guidance is to please raise concerns directly with the person involved wherever if feels possible to do so, or then your supervisor, and/or clinical tutor or other team member. We (supervisors, the Programme team and experienced colleagues elsewhere in the Faculty from other professions) are here to support one another in raising, discussing and addressing concerns.

We are committed to promoting cultures of compassionate care and mutual respect, valuing diversity, with our patients and clients, their carers and with one another as colleagues. We know that given the constraints and pressures we and colleagues work under, we may witness, and indeed may be party to, care that may not reach our highest ethical standards and expectations but that equally may not reach a threshold that triggers a need for the clear action outlined above. We also recognise that sustaining staff well-being and resilience requires safe opportunities to process our complex ambivalent feelings in dealing with distress, suffering and grief. We are committed to working together to promote strong and value based “communities of practice”.

As psychologists, our ethical practice should be informed by our knowledge of relevant psychological theory and evidence, and social identify theory is particularly relevant here. Such “communities of practice” extend beyond the training community and into the settings in which learners are placed.

We want to promote transparent, robust and vigorous debate and safe reflection with one another aboutthe care we provide, so as to raise standards and expectations. There are usually no hard and fast answers or quick fit solutions in complex situations.

We therefore encourage reflections and challenges with one another in an atmosphere of mutual respect when learners feel that appropriate ethical standards are not being met in practice. The phrase that was used in a recent Service Receiver and Carer Consultative group is that learners should be encouraged to be able to do “elegant challenging” in oppressive systems, for example understanding how language and terminology may (or may not) perpetuate deep prejudices and assumptions in ourselves, our colleagues and the people we work with.

We therefore welcome debate, in teaching, tutorials, appraisals and informal conversations, about how best to do this, - about what “elegant challenging” might involve - and about how “elegant challenges” can best be responded to - while living and working with uncertainty, taking into account issues of power, of difference, and of vulnerability.