PROFESSIONAL DEVELOPMENT
Written communication: from staff nurse to nurse consultant
Part 8: raising concerns John Fowler
T
his is the eighth article in the ‘staff nurse to nurse consultant’ series discussing the use of written communication by clinically based nurses. Previous articles have explored some core principles when communicating via the written word and how these can be applied to patient records, email communications, case studies, literature reviews, reflective writing and incident reports (Fowler, 2014a–g). This article explores written communication when raising concerns. Most qualified nurses I talk to are aware that there are a number of professional responsibilities and associated procedures that are similar, yet different. These include incident reports, safeguarding, complaints, grievance and raising concerns. They are similar in that they all enter the area of managerial formality, have ethical and legal implications, and usually result from an awareness that something has gone wrong. The differences involve the procedures to be followed and, at times, the legislation governing subsequent action. This article, focusing on the principles of written communication specific to raising concerns, should be read in conjunction with the Nursing and Midwifery Council (NMC) guidance document Raising Concerns (NMC, 2013), which gives guidance on what constitutes a concern, your role, responsibilities and the various stages in the process. One of the factors that the NMC makes clear in its Raising Concerns guidance is that you may not be able to prove your concern:
© 2014 MA Healthcare Ltd
‘You do not need to have all the facts to prove your concern but you must have a reasonable belief that wrongdoing is either happening now, took place in the past, or is likely to happen in the future.’(NMC, 2013: paragraph 6) This gives a different perspective to the information you would record in a raising concern document, than the purely factual information required in an incident report (Fowler, 2014g). The principle here is to record
British Journal of Nursing, 2014, Vol 23, No 22
facts when you have them, and to record information that gives you ‘a reasonable belief ’ of wrongdoing. Incident, safeguarding and complaint reporting are more likely to focus on a specific event, leading to factual recording of the event. Concerns are often, but not always, more insidious, occurring over a period of time and may incorporate a number of different elements. A concern is often difficult to pin down to one specific event. The principles of reasonable belief, insidious onset and different elements, make written records much more difficult when trying to communicate concerns in an objective manner. If you become aware that something is wrong with a patient’s care or how someone performs their responsibilities, but are not sure what, the first step is to keep a diary. Keep a record of the date, time, who was on duty and your feelings or vague concerns. The simple act of writing a diary will help you reflect on what is happening and aid your objectivity of thought. Be aware of the need to keep names confidential and record your thoughts at home. Having clarified your thoughts via this form of reflective writing it may then be appropriate to have a conversation with a colleague or line manager; the NMC process gives guidance on this (NMC, 2013). If your concerns are still vague you should continue with your diary. Record facts where you can, but also beliefs. At this stage make sure you record any actions you took relating to these concerns.This may be constructive actions such as leading an education session relating to your area of concern or informal discussions with colleagues or line managers. Keeping an ongoing diary gives you a way of collecting information that builds up a picture of what is happening. It provides evidence of what might then lead you to have ‘reasonable belief ’ of wrongdoing, e.g. staff nurse X was always on duty when there was a medication error. There are three main elements to this style of record keeping: the facts, your beliefs and your actions. Capturing concerns by using written words is difficult, even writing these guidelines
makes me feel uncomfortable, as though I’m spying or being disloyal to colleagues. This is why it is important to keep written records, even if the initial concerns are unfounded and you do nothing with them. The issues of concern often start with an intuitive or gut feeling that something is wrong. If we ignore that feeling then we potentially become part of whatever it is that is wrong.As professionals we must acknowledge the feeling, take a step back and reflect on what is making us feel that way, and using a diary will help us do that. At that stage we may be able to take some action that alleviates or reduces the concern. If that fails, or is not possible, then we need to produce our evidence of reasonable belief in the most objective, professional and appropriate way we can. BJN Fowler J (2014a) Written communication: from staff nurse to nurse consultant. Part 1: core principles. Br J Nurs 23(15): 866 Fowler J (2014b) Written communication: from staff nurse to nurse consultant. Part 2: patient records. Br J Nurs 23(16): 910 Fowler J (2014c) Written communication: from staff nurse to nurse consultant. Part 3: email communication. Br J Nurs 23(17): 958 Fowler J (2014d) Written communication: from staff nurse to nurse consultant. Part 4: case studies. Br J Nurs 23(18): 1004 Fowler J (2014e) Written communication: from staff nurse to nurse consultant. Part 5: literature reviews. Br J Nurs 23(19): 1046 Fowler J (2014f) Written communication: from staff nurse to nurse consultant. Part 6 Reflective writing. Br J Nurs 23 (20):1092 Fowler J (2014g) Written communication: from staff nurse to nurse consultant. Part 7: Incident reports. Br J Nurs 23 (21):1153 Nursing and Midwifery Council (2013) Raising Concern. Guidance for nurses and midwives. http://tinyurl.com/8nh2cxn (accessed 25 November 2014)
Dr John Fowler is a general and mental health nurse. He has worked as an Educational Consultant to primary care trusts and as a Principal Lecturer in Nursing for many years. He has published widely on educational and professional topics and is series editor of the Fundamental Aspects of Nursing Series and the Nurse Survival Guide Series for Quay Books
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
Written communication: from staff nurse to nurse consultant
Part 8: raising concerns John Fowler
T
his is the eighth article in the ‘staff nurse to nurse consultant’ series discussing the use of written communication by clinically based nurses. Previous articles have explored some core principles when communicating via the written word and how these can be applied to patient records, email communications, case studies, literature reviews, reflective writing and incident reports (Fowler, 2014a–g). This article explores written communication when raising concerns. Most qualified nurses I talk to are aware that there are a number of professional responsibilities and associated procedures that are similar, yet different. These include incident reports, safeguarding, complaints, grievance and raising concerns. They are similar in that they all enter the area of managerial formality, have ethical and legal implications, and usually result from an awareness that something has gone wrong. The differences involve the procedures to be followed and, at times, the legislation governing subsequent action. This article, focusing on the principles of written communication specific to raising concerns, should be read in conjunction with the Nursing and Midwifery Council (NMC) guidance document Raising Concerns (NMC, 2013), which gives guidance on what constitutes a concern, your role, responsibilities and the various stages in the process. One of the factors that the NMC makes clear in its Raising Concerns guidance is that you may not be able to prove your concern:
© 2014 MA Healthcare Ltd
‘You do not need to have all the facts to prove your concern but you must have a reasonable belief that wrongdoing is either happening now, took place in the past, or is likely to happen in the future.’(NMC, 2013: paragraph 6) This gives a different perspective to the information you would record in a raising concern document, than the purely factual information required in an incident report (Fowler, 2014g). The principle here is to record
British Journal of Nursing, 2014, Vol 23, No 22
facts when you have them, and to record information that gives you ‘a reasonable belief ’ of wrongdoing. Incident, safeguarding and complaint reporting are more likely to focus on a specific event, leading to factual recording of the event. Concerns are often, but not always, more insidious, occurring over a period of time and may incorporate a number of different elements. A concern is often difficult to pin down to one specific event. The principles of reasonable belief, insidious onset and different elements, make written records much more difficult when trying to communicate concerns in an objective manner. If you become aware that something is wrong with a patient’s care or how someone performs their responsibilities, but are not sure what, the first step is to keep a diary. Keep a record of the date, time, who was on duty and your feelings or vague concerns. The simple act of writing a diary will help you reflect on what is happening and aid your objectivity of thought. Be aware of the need to keep names confidential and record your thoughts at home. Having clarified your thoughts via this form of reflective writing it may then be appropriate to have a conversation with a colleague or line manager; the NMC process gives guidance on this (NMC, 2013). If your concerns are still vague you should continue with your diary. Record facts where you can, but also beliefs. At this stage make sure you record any actions you took relating to these concerns.This may be constructive actions such as leading an education session relating to your area of concern or informal discussions with colleagues or line managers. Keeping an ongoing diary gives you a way of collecting information that builds up a picture of what is happening. It provides evidence of what might then lead you to have ‘reasonable belief ’ of wrongdoing, e.g. staff nurse X was always on duty when there was a medication error. There are three main elements to this style of record keeping: the facts, your beliefs and your actions. Capturing concerns by using written words is difficult, even writing these guidelines
makes me feel uncomfortable, as though I’m spying or being disloyal to colleagues. This is why it is important to keep written records, even if the initial concerns are unfounded and you do nothing with them. The issues of concern often start with an intuitive or gut feeling that something is wrong. If we ignore that feeling then we potentially become part of whatever it is that is wrong.As professionals we must acknowledge the feeling, take a step back and reflect on what is making us feel that way, and using a diary will help us do that. At that stage we may be able to take some action that alleviates or reduces the concern. If that fails, or is not possible, then we need to produce our evidence of reasonable belief in the most objective, professional and appropriate way we can. BJN Fowler J (2014a) Written communication: from staff nurse to nurse consultant. Part 1: core principles. Br J Nurs 23(15): 866 Fowler J (2014b) Written communication: from staff nurse to nurse consultant. Part 2: patient records. Br J Nurs 23(16): 910 Fowler J (2014c) Written communication: from staff nurse to nurse consultant. Part 3: email communication. Br J Nurs 23(17): 958 Fowler J (2014d) Written communication: from staff nurse to nurse consultant. Part 4: case studies. Br J Nurs 23(18): 1004 Fowler J (2014e) Written communication: from staff nurse to nurse consultant. Part 5: literature reviews. Br J Nurs 23(19): 1046 Fowler J (2014f) Written communication: from staff nurse to nurse consultant. Part 6 Reflective writing. Br J Nurs 23 (20):1092 Fowler J (2014g) Written communication: from staff nurse to nurse consultant. Part 7: Incident reports. Br J Nurs 23 (21):1153 Nursing and Midwifery Council (2013) Raising Concern. Guidance for nurses and midwives. http://tinyurl.com/8nh2cxn (accessed 25 November 2014)
Dr John Fowler is a general and mental health nurse. He has worked as an Educational Consultant to primary care trusts and as a Principal Lecturer in Nursing for many years. He has published widely on educational and professional topics and is series editor of the Fundamental Aspects of Nursing Series and the Nurse Survival Guide Series for Quay Books
1223
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
