Abstract
Background: The introduction of “Freedom to Speak Up Guardians” (FTSUGs) into every NHS
England Trust was intended to support workers and Trusts to better raise, respond and learn from
speaking-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 is
implemented across England.
Objectives: The overall aim of this study was to better understand the implementation of Guardians
in Acute Trusts and Mental Health Trusts.
Design: The FTSUG role was conceptualized as a complex intervention consisting of several
interacting and interlocking components spanning the macro level (national organisations), the
meso level (individual Trusts) and micro level (employees, teams, wards/units). A mixed methods
study was designed, consisting of three work packages: (1) a systematic narrative review of the
international literature regarding interventions promoting ‘speaking-up’ by healthcare employees;
(2) semi-structured telephone interviews with Guardians working in Acute Hospital Trusts and
Mental Health Trusts; (3) qualitative case studies of FTSUG implementation, consisting of
observations 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 England
Participants: Work package 2: FTSUGs (n=87) were interviewed. Work package 3: 116 interviews
with key stakeholders involved in pre and early implementation decision-making and workers who
had spoken-up to the Guardian and national stakeholders.
Results: Wide variability was identified in how the Guardian role had been implemented, resourced
and deployed by NHS Trusts. The role title “Freedom to Speak Up Guardian” is best considered an
umbrella term, under which multiple versions of the role exist simultaneously across England. Any
comparisons of Guardians’ effectiveness are only likely to be possible, or meaningful, when this
variability 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 3
to concerns and on their opportunities to collect, analyse and learn from speaking-up data and more
generally 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 have
been biased by ‘socially desirability’ and their answers may not always have represented
respondents’ 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 of
2) policies and robust, yet supportive practices 3) informed by frequent and reflexive monitoring of
FTSU implementation, which is 4) underpinned by sufficient time and resource allocation, that leads
to 5) a positive implementation climate, which is congruent with FTSU values, and best placed to
engender positive and sustainable FTSU culture and the well-being of a Guardian.