A meta-ethnography of staff experiences of raising concerns about quality and safety in residential aged care.

BACKGROUND AND OBJECTIVES: Speaking up about quality and safety issues can protect older people and support learning in health and social care systems. In aged care, staff work in diverse roles to deliver care to residents with complex care needs. This meta-ethnography aimed to synthesise evidence on staff experiences of raising concerns about quality and safety in long-term residential aged care. RESEARCH DESIGN AND METHODS: We included qualitative studies examining staff experiences of speaking up, incident reporting, and whistleblowing. Five databases were searched. The seven phases of meta-ethnography were used to translate first and second order constructs into third order constructs and a line-of-argument synthesis. RESULTS: Thirteen articles of 11 studies were synthesised to reveal four third order constructs: 1. Sensemaking a concern, 2. Organisational cultures determine how they are voiced, heard and respond to, 3. Systemic resources shape and constrain possibilities for voicing, and 4. Normalisation of poor care and loss of moral agency in organisations that respond with indifference. Raising concerns was a dynamic, recursive process encompassing phases of recognising, voicing, and organisational responding. Where quality and safety issues were normalised, individualised, or met with limited action, staff described moral distress, disengagement, and, in some cases, exit from the organisation or sector. DISCUSSION AND IMPLICATIONS: Raising concerns in residential aged care is a dynamic process shaped by interrelated individual, organisational and systemic factors. Speaking up interventions need to go beyond skills training to address phases of recognising care quality issues and how organisations respond when they are raised.