Worries and Concerns: FNF study highlights importance of authentic leadership

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The early recognition and treatment of deterioration in patients in clinical settings can help reduce avoidable deaths. NHS England recently commissioned Florence Nightingale Foundation (FNF) to examine the barriers which prevent worries and concerns being raised about a deteriorating patient. Evidence suggests that organisational culture, professional hierarchies, and the nature of leadership in healthcare environments are the three key factors behind this reluctance. Our findings highlight the importance of psychological safety which is highly influenced by authentic leadership in overcoming these barriers.

Clinical staff often recognise deterioration in patients by using their intuition. This frequently involves them expressing worries and concerns about a patient based on a ‘gut feeling.’ Since family members, non- clinical team members, health care assistants and nurses have more consistent, direct contact with patients they are often the best placed to raise or escalate any intuitively based concerns.

However, these groups often face barriers to raising or escalating these kinds of concerns. To better understand these, NHS England’s Acute Deterioration Board (ADB) convened a national “Worry and Concern” Task and Finish Group (WCG). As part of this, the WCG and Nursing Directorate commissioned FNF to working in partnership with The Kings Fund to carry out a qualitative study with clinical staff, patients, family members and carers to understand their experiences of raising worries and concerns, and to identify interventions or actions that can be taken to address obstacles.

The findings highlight elements of the healthcare environment that influence the quality of the care delivered to the patient. Leadership that role models multi-disciplinary team working, values the expertise of all stakeholders, and champions person-centred practice can create a psychologically safe working culture. This culture creates an environment in which clinical staff, patients, carers, and family members feel confident and less hesitant in raising worries and concerns.

In healthcare environments where these characteristics are not present, staff training and development alongside access to, and the availability of feedback avenues can provide the right conditions for all to escalate concerns and improve patient safety.


  1. Provide adequate avenues for feedback
  2. Ensure closure of feedback loops
  3. Promote and facilitate patient involvement in their own care
  4. Provide and promote opportunities for patients, carers, and family members feedback
  5. Provide and promote patient safety partner involvement
  6. Provide training sessions for all clinical staff, relevant non-clinical staff, and students on detecting and escalating recurrent and major patient deterioration incidents
  7. Prioritise staff wellbeing in healthcare environments
  8. Empower newly registered staff and students practice
  9. Commission further research to explore cultural background influences
  10. Commission further research to explore generational differences
  11. Commission further research to explore consultants’ perspectives.

Click here to read the full report.

Next steps

NHSE is now funding seven pilot sites – one in each region – to participate in a national Worry and Concern Improvement Collaborative. The collaborative aims to catalyse two changes:

  1. The systematic incorporation of patient worry and concern into early warning and diagnostic tools; and
  2. Contribution to a shift in culture and practice that empowers patients/families/carers to speak up about deterioration and clinicians to listen to and communicate more effectively about these matters.

FNF presented our research findings to these pilot sites to inform their implementation processes and we continue to be involved with the programme.

We will also be continuing to strengthen and grow our leadership development work, to support nurses and midwives to have the confidence and skills to speak out and share concerns.

Click here to read the full report.

“A very insightful report, the Worry and Concern steering group are very appreciative of this important work undertaken by FNF & Professor Michael West, Kings Fund. The findings, insights and learning have already been shared with our pilot sites who are participating in the national Worry and Concern Improvement Collaborative, which is aimed at implementing systems and processes to enable patients and families to escalate their worries and concerns in relation to acute illness and deterioration and to document their wellness or concerns about their health into the health record.”
Jane Murkin
Deputy Director Safety & Improvement — Nursing, NHS England
“We are really pleased to have played a part in this essential research to inform healthcare policy implementation. Our findings demonstrate the vital role that nurse leadership at every level can play in addressing patient deterioration, improving outcomes, and reducing avoidable mortality. We look forward to continuing to work with the Collaborative to empower all clinical staff and patients and their families to speak up and to improve patient outcomes.”
Greta Westwood
Professor Greta Westwood, CBE
Chief Executive Officer, FNF and co-author of the report