'Escalating concerns' is defined as taking a concern further by submitting evidence and going through a formal processes. The type of formal process will depend on the situation, but it could include:

• escalating through your employer's whistleblowing policy
• raising a grievance
• using a 'respect and resolution' process
• following a safeguarding process, or
• whistleblowing to a third party (such as a regulator).

A note about ‘public interest disclosure’

You may have heard of cases where staff have spoken up (perhaps to the media) about concerns about their workplace, justifying this as ‘in the public interest’. 

The Public Interest Disclosure Act 1998 (PIDA) protects most workers in the public, private and voluntary sectors from detrimental treatment or victimisation from their employer if, in the public interest, they ‘blow the whistle’ on wrongdoing. Raising concerns externally (for example, to the media, a politician or on social media) without clear evidence of first raising the concern internally or with a regulatory organisation, would only be considered appropriate and give you protection under the PIDA in the most extreme circumstances and if it could clearly be shown that you were acting in the public interest. 

If you’re considering escalating your concern to a third party/disclosing it publicly, it is very important you seek advice from the RCN first. Read about what to do if it is unresolved and contact us for further advice.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. A student version of the decision tree is also available.

The how to report section will also be helpful.

If in doubt, you should always err on the side of caution and raise your concern following your employer’s (or if you are a student, your Approved Education Institution's) policy.

NMC Code

Raising and escalating concerns is a central clause in the Nursing and Midwifery Council (NMC) Code, which says nurses must “act without delay if you believe that there is a risk to patient safety or public protection” (NMC, 2018). Read more about this in the NMC's Raising concerns: Guidance for nurses, midwives and nursing associates (2018). 

All nursing associates and HCSWs have a duty to raise concerns. 

As aspiring registrants, students also have a duty to raise concerns.

If you are manager as well as a registrant, please also see our section on managers' responsibilities below.

The requirement to report concerns is often included in employment contracts, and within the roles and responsibilities set out in job descriptions.

These usually state that staff members must notify relevant managers, leaders, educators or regulating organisations or authorities, if they have any concerns relating to the health, safety and wellbeing of themselves, colleagues, or those in their care.

For students, it may be part of the responsibilities outlined in your placement contract/ information 

You should be confident that your team and organisation will focus on system learning, not individual blame and you should be psychologically safe when raising concerns. Psychological safety relates to an individual’s perspective on how threatening or rewarding it is to take interpersonal risks at work. 

For instance, is this a place where new ideas are welcomed and built upon? Or picked apart and ridiculed? Will colleagues embarrass or punish someone for offering a different point of view or for admitting they don't understand something?

A key component of psychological safety is it is usually experienced at group level – most people in a team tend to have the same perceptions of it, so if you feel unsupported at work your colleagues probably feel that as well. In some teams and/or organisations the prospect of raising a concern about care being delivered or the environment you are working in can be daunting to contemplate. 

It has long been recognised within health care that a culture that promotes learning is required to ensure patient safety and promote high-quality person-centred care.

You should therefore be confident that doing the right things like reporting incidents, near misses and concerns, being candid about mistakes, talking openly about errors and sharing ideas for improvements, are all welcomed and encouraged.

We know raising concerns or speaking up is not always easy, however the health, safety and wellbeing of those around you, including yourself, must be a priority and any delay in reporting your concerns could have a negative impact for those people.

It is important to remember that it is in everyone’s best interest (patients, staff and managers) to identify when something isn’t right, learn from this and make improvements. 

• what best practice would look like in this situation
• what ‘acceptable’ looks like in this situation (i.e. legally, professionally, and ethically acceptable or permissible. What is ‘good enough’?)
• ‘who is responsible for what’ in this situation (i.e. what is your responsibility, what is your line manager/employer’s responsibility and so on), and
• the correct policy or process to follow in order to raise your concern.

Staffing and patient safety:

• unsafe patient care or dignity/privacy being compromised
• nursing patients/service users in inappropriate settings, such as corridors, waiting rooms, additional beds in bays, additional chairs, car parks or rooms not designed for clinical care
• inability to meet the care of patients in your caseload (remember to document missed care in patients record and in the organisation’s risk management system) 
• increased workloads
• reduced or insufficient staff numbers 
• reduced or insufficient staff skill mix
• inadequate response to a reported patient safety incident
• compromised supra numerary status of students
• compromised supernumerary status of team mangers
• students expected to work outside their level of competence 
• students used for operational work, as health care support workers
• students used to plug gaps in staffing rotas.

Our Nursing Workforce Standards have been created to explicitly set out what must happen within workplaces to ensure the delivery of safe and effective patient care. Please see the responsibility and accountability sections which outline where the responsibility lies for setting and reviewing the nursing workforce.

Please also see our guidance on unsustainable pressures in work and our corridor care and safe staffing member checklist.

Health and safety:

• unsafe working conditions, including issues like workplace asbestos, violence at work and working in hot weather
• personal protective equipment (PPE) at work
• personal safety when lone working
• moving and handling
• infection control

Please also see our health and safety advice guide for more information. 

Lack of support or training:

• inadequate induction or training for staff or support for students
• inadequate staff supervision.

Culture:

• bullying towards patients or colleagues, or a bullying culture.

Please also see our bullying and discrimination advice guides. Our resources on equity, diversity and inclusion may also be helpful.

Criminal:

• suspicions of criminal activity such as fraud 

Please now read the section below on how to report.

Raising a concern is not always easy so getting support is important. This may be from a colleague or your local RCN Safety Representative or RCN Steward. Students can get support from a local RCN Student Ambassador, or their country or regional RCN Student Committee member. If you're unsure who your representative is, contact us for advice.

You can contact us for advice at any stage and it is important to do so before escalating your concerns externally.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. A student version of the decision tree is also available.

The how to report section will also be helpful.

If in doubt, you should always err on the side of caution and raise your concern following your employer’s (or if you are a student, your Approved Education Institution's) policy.

If you work for the NHS in Wales, each event should be reported via DATIX. Because emails and letters are not auditable, our raising concerns letter template should not be used in the NHS in Wales.

However, if you work in the independent sector in Wales, you may use our raising concerns letter templates. 

As a student you should initially raise your concern with your practice supervisor/practice assessor, or the clinical manager of the practice learning environment.

If for any reason you are reluctant to raise a concern with clinical staff, you should follow your Approved Education Institution (AEI)/university's raising concerns guidance, seek support from the RCN and raise your concern with your academic assessor or link lecturer designated to your practice placement area. 

Concerns must be raised with your academic assessor, personal tutor or link lecturer. You should keep a factual record of the events at the time of the event, a copy of which will be placed in your file.

You may be asked at a later date to write a factual statement with the help of your academic assessor and/or the RCN. The earlier an expression of concern is made, the easier it is to take action.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. 

If you are a student in Wales, please see the Health Education and Improvement Wales (HEIW) website

Our student advice guide may also be helpful.

If you work for the NHS in Wales, each event should be reported via DATIX. Because emails and letters are not auditable, our raising concerns letter template should not be used in the NHS in Wales.

However, if you work in the independent sector in Wales, you may use our raising concerns letter templates. 

Our raising concerns and corridor care template letters are here to help you address unsafe care environments quickly and professionally. 

You can also access our respiratory risk assessment toolkit. This supports all health care professionals manage risks associated with respiratory infections, and can be used to aid local decisions about the level of personal protective equipment (PPE) required at work.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. A student version of the decision tree is also available.

The how to report section will also be helpful.

If in doubt, you should always err on the side of caution and raise your concern following your employer’s (or if you are a student, your Approved Education Institution's) policy.

• thank you for speaking up and listen carefully
• maintain your confidentiality (as far as is reasonably possible, or explain any limits to this)
• tell you what they are going to do
• advise you if the concern does not fall within the raising concerns policy (and what policy should be followed instead)
• advise you if they need to investigate your concerns, and
• explain what advice and support is available to you. 

If you are asked to be a witness in an investigation please see our guidance for witnesses, including how to write statements; please contact us if you are concerned

Please also see our sections on managers' responsibilities and what to do if it is not resolved.

Raising a concern is not always easy so getting support is important. This may be from a colleague or your local RCN Safety Representative or RCN Steward. Students can get support from a local RCN Student Ambassador, or their country or regional RCN Student Committee member. If you're unsure who your representative is, contact us for advice.

You can contact us for advice at any stage and it is important to do so before escalating your concerns externally.

As a clinical leader, you have an important role in ensuring staff are empowered to openly raise concerns. This includes being able to constructively question decisions and put forward ideas that can improve working environments or improve patient safety or experience.

Creating a culture of psychological safety is important so that staff at all levels are able to discuss and raise issues that are of concern to them without fear. The NMC Code is clear that an open work environment in which staff are accountable and encouraged to raise concerns about the safety of people in their care will help identify and prevent more problems and will protect the public.

Please also see our section above on what to expect and our advice for lead nurses in an operational crisis.

The NMC's guidance on raising concerns provides information detailed below to assist clinical leaders who may have concerns brought to them.

As a leader you should,

• make sure appropriate systems for raising concerns are in place and that all staff can access them. Consider whether staff can gain access confidentially to your organisation’s whistleblowing or raising concerns policy
• make sure staff can see all concerns are taken seriously, even if they are later seen to be unfounded
• tell the employee who raised the concern how it will be handled in line with local policies, and give a timeframe in which you will get back to them, both verbally and in writing
• investigate concerns promptly and include a full and objective assessment
• keep the employee who raised the concern up to date with what’s happening. This will give them and others confidence in the system
• take action to deal with the concern and, record and monitor this action
• make sure staff who raise concerns are protected from unjustified criticism or actions. Have processes in place to support employees raising concerns. This support may need to be offered confidentially from outside the organisation
• if harm has already been caused to a person in your care, explain fully and promptly what has happened and the likely outcomes. This duty is clearly supported by the NMC Code.

In addition to the above, as a staff manager or leader, it is important that you understand and follow your organisation’s raising concerns policy when concerns are raised. The policy should set out the difference between a personal grievance which HR can advise on, and a concern that is in the public interest. 

When discussing concerns, you will need to identify the type of concern being raised and the policy that applies. See our section above on what to expect and ensure that you also:

• manage their expectations 
• assess whether immediate action is necessary to address any risk to patient safety
• record any risk as per organisational policies and procedures and put in place any mitigating action that you can reasonably undertake within the resources and authority you have, and 
• escalate concerns/risks and seek support if mitigating actions are outside your level of authority, or require more sustainable solutions or further resources. 

You may need to conduct an investigation. If possible, you should tell the staff member raising the concern about any outcomes or actions.

You will need to consider whether any information is confidential and whether it can be shared or not. If the individual is unhappy with the way their concern has been handled, you should tell them how to escalate their concern following your employer’s raising concerns policy.

It is important to keep notes of conversations and actions taken throughout the process.

If you have raised a concern with your line manager and/or designated person but feel they have not dealt with it at all, you should raise your concern with someone more senior within your organisation.

For example, in the NHS you could take your concern to your department manager, nurse manager/matron, head of midwifery, associate director/director of nursing or Chief Executive. This should be detailed in your employer's raising concerns or whistleblowing policy.

You can contact us at any time if you feel you need further support.

If you have raised a concern with your line manager and/or designated person but feel they have not dealt with it properly, you should raise your concern with someone more senior within your organisation.

For example, in the NHS you could take your concern to your department manager, nurse manager/matron, head of midwifery, associate director/director of nursing or Chief Executive. This should be detailed in your employer's raising concerns or whistleblowing policy.

You can contact us at any time if you feel you need further support.

If you have raised your concern internally but feel it has not been dealt with properly, or if you feel unable to raise your concern at any level in your organisation, you may want to get help from outside your place of work. You may, for example, consider contacting a regulator of health or social care services or of health or social care professionals or a whistleblowing hotline. This is so that your concern can be investigated under current legislation and for your own protection.

Before taking this step it is important than you contact us for advice.

Please see our decision tree to see how escalating your concern externally fits into the overall raising concerns process.

A note about ‘public interest disclosure’

You may have heard of cases where staff have spoken up (perhaps to the media) about concerns about their workplace, justifying this as ‘in the public interest’. 

The Public Interest Disclosure Act 1998 (PIDA) protects most workers in the public, private and voluntary sectors from detrimental treatment or victimisation from their employer if, in the public interest, they ‘blow the whistle’ on wrongdoing. Raising concerns externally (for example, to the media, a politician or on social media) without clear evidence of first raising the concern internally or with a regulatory organisation, would only be considered appropriate and give you protection under the PIDA in the most extreme circumstances and if it could clearly be shown that you were acting in the public interest. 

If you’re considering escalating your concern to a third party/disclosing it publicly, it is very important you seek advice from the RCN first.

Raising a concern is not always easy so getting support is important. This may be from a colleague or your local RCN Safety Representative or RCN Steward. Students can get support from a local RCN Student Ambassador, or their country or regional RCN Student Committee member. If you're unsure who your representative is, contact us for advice.

You can contact us for advice at any stage and it is important to do so before escalating your concerns externally.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. A student version of the decision tree is also available.

The how to report section will also be helpful.

If in doubt, you should always err on the side of caution and raise your concern following your employer’s (or if you are a student, your Approved Education Institution's) policy.

You can use our decision tree to help you decide whether to raise a concern and when to escalate a concern. A student version of the decision tree is also available.

The how to report section will also be helpful.

If in doubt, you should always err on the side of caution and raise your concern following your employer’s (or if you are a student, your Approved Education Institution's) policy.