Table 2.

Themes with illustrative quotations

ThemeSub-themeQuotation
Past experience of teachingUndergraduate We had three afternoons… a pilot coming in to do fairly structured human practice training, which obviously included raising concerns…for example, medical student being the one that notices you’re cutting off the wrong leg. FG1P1.
Postgraduate It comes in that massive induction day where you do lose interest after the first hour. FG2P1.
We had a session when we were F2s I think from the GMC and it was talking about, you know, these formal mechanisms…but the problem they don’t acknowledge the complexities and how difficult it is to actually raise a concern within the team that you’re working in. FG2P3.
I think often the scenarios aren’t nuanced enough. So the reality of when you’re faced with this scenario is it’s not someone has done these bad things and therefore you follow these steps. FG2P3.
Suggested teachingDesire I think if a consultant sat down with you or at the beginning of your training … and said in this trust we have been trained how to raise concerns. I am the lead for raising concerns in our department. This is how you would raise it. These are the people who you could go to. These are the kind of things the raising concern consultant is looking for. FG1P2.
Timing If you foster that culture in the beginning, we are a trust that supports this and endorses this. G3P4.
Modality If you’re going to encourage everybody to raise concerns, it has to be trust-wide. Your background doesn’t matter. FG1P6.
Content It would be useful to … do Balint … where people bring the real-life situation and then discuss how they managed it, would be useful and more systemic as well. FG1P4.
I think people learn more from positive examples and actually having some real stories of when you have raised a concern in a way that has a positive outcome and these are the potential benefits of doing so … I think if you can bring that into it and really motivate people. FG2P3.
The introduction to the freedom to speak up guardian is a very useful thing and knowing that person and having them speak to me even if it’s only a 5-minute thing in a hospital-wide grand round or something. FG2P3.
Specifics I’m just trying to think because obviously there’s quite a gap between trainees and consultants. So, I was wondering if you had a senior registrar who took on the role, who would liaise with the consultants, but acts in the department as that role and led this teaching. FG1P2.
And I think, to drop the cliché of MDT, you kind of need everyone to be having the same culture … So, the training probably needs to, probably, focus on everyone at the same time in the same way. FG3P4.
Reporting mechanismsDatix reporting I think what it’s meant to be used for sometimes are things like if you’ve arrived on a shift and it’s understaffed. But I mean it’s just such a joke … Sorry, give me 20 minutes while I fill in one of these forms. FG1P5.
Other channels for reporting So if there is a patient safety issue and it’s black and white then I definitely would, and I have many times … But it’s when it’s much greyer and it’s those interpersonal things that it’s actually very difficult to do it. FG2P3.
We all said we must report this person … but by the end of the shift … everyone was completely fed up, but no one really knew who to contact. FG3P2.
Perhaps if you have a named person that you would go to in your department … Who would, maybe, much better trained in dealing with these things, could then decide is this something that needs to be formally escalated? FG3P5.
Educational barriersPersonal barriers You also need to feel safe … that you’re not going to be persecuted, victimised, something bad is going to happen to you as a result of raising a concern … it might impact on your training and where you go for your next jobs and things like that. FG3P4.
You need to know that it can be anonymous and managed anonymously. The problem is that in small specialties maintaining that anonymity is quite difficult, isn’t it? FG3P4.
Organisational barriers I almost feel like it’s so endemic in the culture of consultants … if you filter people in who are about to become consultants it will like slowly change. FG1P2.
Sometimes trainees are bit apathetic about raising concerns because they’re like, oh we’ll have to live with it for another six weeks. I’ll just live with it and then it won’t be my problem anymore. FG1P5.
They don’t have time to invest in our story because we move around for our training. FG3P4.
Hierarchy The attitude of people saying … it’s been like that for ages or they’ve been like that for years … then you feel like, you know, no one really cares. FG2P2.
It has to come from the top down. If it comes from seniors being educated who then filter that down to us, that would work. FG1P2.
I have worked in one department where … there’s a flat hierarchy. You feel able to constantly question things and talk, and you call the consultants on a first name, all those kinds of things that make it … easier. FG2P3.
  • F2 = foundation year 2; GMC = General Medical Council; MDT = multidisciplinary team.