NHS staff who spot a safety risk or a broken process often stay silent because they doubt anyone will listen—and too often, they are right. This study tackles that failure head-on by examining the full chain of events that determines whether a staff member’s concern gets raised, heard, and acted upon. Rather than focusing only on encouraging people to speak up, the researchers will also investigate what happens next: how organisations filter, interpret, and sometimes ignore the insights their employees offer. Through interviews, ethnographic case studies in six NHS organisations, and video-based experiments with diverse staff, the team will identify the features of good practice and why some hospitals manage voice well while others do not. The final stage involves co-designing practical interventions—such as new stewardship frameworks or communication tools—that NHS leaders can adopt or adapt. If successful, this work could shift healthcare organisations from merely tolerating dissent to actively mining it for improvements in patient safety, staff retention, and operational efficiency. The project runs for 30 months from early 2025.
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BACKGROUND There is extensive evidence of the benefits that organisations derive from listening to the views of their staff, and healthcare is no exception. Yet despite the insights it offers and demonstrable associations between speaking up and outcomes including patient safety and staff experience, many organisations struggle to encourage staff voice—and to make use of the insights it offers. AIMS AND OBJECTIVES This study aims to generate new knowledge on how to improve the articulation, transmission and utilisation of issues raised by healthcare staff, and develop new interventions to enhance the impact of voice. We focus on the full ‘voice pathway’, including not only the conditions that encourage speaking up in the first place, but the influences on what is heard, how it is communicated through organisations, and how organisations can improve their ‘stewardship’ of this important resource. We will pursue three objectives: • To undertake a programme of linked, mixed-methods studies examining the influences on speaking up, listening and organisational response, and co-designing interventions to help organisations improve their voice stewardship and voice pathways. • To collaborate closely with a range of stakeholders to ensure that the study is informed by their insights and draw on their expertise in developing interventions. • To produce practically useful outputs that will help to improve voice pathways. METHODS Our programme incorporates four workstreams. Workstream 1 will use qualitative interviews with senior stakeholders and people with recent experience of speaking up to give an authoritative overview of current influences on voice in healthcare, including challenges and examples of innovative practice. Workstream 2 will build on this foundation with ethnographic work in organisational case studies—four exemplifying innovation or good practice, and two facing persistent challenges in encouraging voice—with a particular emphasis on the features of good practice and its transferability. Workstream 3 will further examine how characteristics of the concern raised and the person raising it affect the response of others, through online video vignettes presented to a diverse range of NHS staff using a discrete choice experiment design. Drawing on findings from the earlier workstreams, Workstream 4 will use participatory methods, including in-person workshops and online co-design activities, to draw on the insights of a wide range of relevant stakeholders to develop a framework for voice stewardship, along with interventions that might address challenges across the voice pathway, ready for adoption, adaptation or further evaluation. TIMELINES FOR DELIVERY The study will be delivered over 30 months from early 2025. ANTICIPATED IMPACT AND DISSEMINATION Close collaboration in developing and delivering the study with a wide range of stakeholders and organisations with an interest in speaking up across the UK will provide a sound basis for rapid dissemination to policymakers, healthcare organisations and others. The involvement of those with experience of speaking up, with responsibility for voice pathways and with policy responsibility in the study’s ‘expert collaborative group’ will help to guide it and ensure that findings and outputs are informed by their wisdom. New insights into the influences on the organisational response to voice will be accompanied by the co-designed interventions of Workstream 4.
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