A mixed methods evaluation of the implementation of 'Freedom to Speak Up Guardians' in NHS England Acute Trusts and Mental Health Trusts

Background: The introduction of “Freedom to Speak Up Guardians” (FTSUGs) into every NHSEngland Trust was intended to support workers and Trusts to better raise, respond and learn fromspeaking-up concerns. However, only broad guidance was provided on how to implement the role.As a result, there is the potential for important local differences to emerge as the role isimplemented across England.Objectives: The overall aim of this study was to better understand the implementation of Guardiansin Acute Trusts and Mental Health Trusts.Design: The FTSUG role was conceptualized as a complex intervention consisting of severalinteracting and interlocking components spanning the macro level (national organisations), themeso level (individual Trusts) and micro level (employees, teams, wards/units). A mixed methodsstudy was designed, consisting of three work packages: (1) a systematic narrative review of theinternational literature regarding interventions promoting ‘speaking-up’ by healthcare employees;(2) semi-structured telephone interviews with Guardians working in Acute Hospital Trusts andMental Health Trusts; (3) qualitative case studies of FTSUG implementation, consisting ofobservations and interviews undertaken in four Acute Trusts and two Mental Health Trusts.Interviews were also undertaken with national stakeholders.Setting: Acute Trusts and Mental Health NHS Trusts in EnglandParticipants: Work package 2: FTSUGs (n=87) were interviewed. Work package 3: 116 interviewswith key stakeholders involved in pre and early implementation decision-making and workers whohad spoken-up to the Guardian and national stakeholders.Results: Wide variability was identified in how the Guardian role had been implemented, resourcedand deployed by NHS Trusts. The role title “Freedom to Speak Up Guardian” is best considered anumbrella term, under which multiple versions of the role exist simultaneously across England. Anycomparisons of Guardians’ effectiveness are only likely to be possible, or meaningful, when thisvariability is properly accounted for. Many FTSUGs identified how a lack of available resources,especially time scarcity, negatively and significantly impacted on their ability to effectively respond 3to concerns and on their opportunities to collect, analyse and learn from speaking-up data and moregenerally the extent to which they developed their role and speak-up culture.Limitations: It is possible that those we interviewed were more receptive of FTSUGs, or may havebeen biased by ‘socially desirability’ and their answers may not always have representedrespondents’ true perceptions.Conclusions: Optimal implementation of the Guardian role has six components: 1) establishing early,collaborative and coherent strategy congruent to the values of FTSU fosters the implementation of2) policies and robust, yet supportive practices 3) informed by frequent and reflexive monitoring ofFTSU implementation, which is 4) underpinned by sufficient time and resource allocation, that leadsto 5) a positive implementation climate, which is congruent with FTSU values, and best placed toengender positive and sustainable FTSU culture and the well-being of a Guardian