Whistle-blowing and workplace culture in older peoples' care: qualitative insights from the healthcare and social care workforce

The moderating role of work experience in the effect of ethical culture on whistleblowing in healthcare professionals and the effect of organizational trust on whistleblowing

OBJECTIVE

This study aims to determine the moderator role of work experience in the impact of ethical culture perceptions of healthcare professionals on their whistleblowing tendencies. It is also to reveal the effect of organizational trust on whistleblowing.

METHODS

The population of the study consists of health personnel working in the public or private sector in Turkey. The sample of the study consists of 481 health workers who voluntarily participated in the survey. Data were collected using the convenience sampling technique. In collecting data, whistleblowing, organizational trust, and ethical culture scales were used. In the analysis of the data, descriptive statistics, factor analysis, correlation analysis, and path analysis in the structural equation model were performed.

RESULTS

The findings reveal that organizational trust has an impact on ethical culture and that some sub-components of organizational trust and ethical culture have an impact on whistleblowing. In addition, it has been determined that the group of health professionals with low work experience has a moderating role in the effect of applicability on internal whistleblowing.

CONCLUSION

To handle the whistleblowing mechanism internally in health institutions, it is important to clearly show the ethical rules to the employees. On the other hand, it has been seen that the professional experiences of the employees can be used as a tool for whistleblowing to work.

Making Neglect Invisible: A Qualitative Study among Nursing Home Staff in Norway

BACKGROUND

Research shows that nursing home residents' basic care needs are often neglected, potentially resulting in incidents that threaten patients' safety and quality of care. Nursing staff are at the frontline for identifying such care practices but may also be at the root of the problem. The aim of this study was to generate new knowledge on reporting instances of neglect in nursing homes based on the research question "How is neglect reported and communicated by nursing home staff?"

METHODS

A qualitative design guided by the principles of constructivist grounded theory was used. The study was based on five focus-group discussions (20 participants) and 10 individual interviews with nursing staff from 17 nursing homes in Norway.

RESULTS

Neglect in nursing homes is sometimes invisible due to a combination of personal and organizational factors. Staff may minimize "missed care" and not consider it neglect, so it is not reported. In addition, they may be reluctant to acknowledge or reveal their own or colleagues' neglectful practices.

CONCLUSION

Neglect of residents in nursing homes may continue to occur if nursing staff's reporting practices are making neglect invisible, thus proceeding to compromise a resident's safety and quality of care for the foreseeable future.

'Guiding Lights for effective workplace cultures': enhancing the care environment for staff and patients in older people's care settings

While much attention has been given to organisational culture, there has been less focus on workplace culture. Yet workplace culture strongly influences the way care is delivered, received and experienced. An effective workplace culture is crucial for the well-being of individual staff members and teams as well as for patients' experiences and outcomes of care. This article describes the 'Guiding Lights for effective workplace cultures' which were developed by the authors and provide a framework to assist in understanding and promoting effective workplace cultures and creating environments where staff and patients feel safe and valued. There are four Guiding Lights: 'collective leadership', 'living shared values', 'safe, critical, creative learning environments' and 'change for good that makes a difference'. Each one articulates what good workplace cultures are through descriptors and intermediate outcomes and together produce a set of ultimate outcomes. The Guiding Lights provide nurses working in older people's care settings with an opportunity to learn from, and celebrate, what is going well in their workplaces and to consider areas that require further development.

Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service

Employee voice is an important source of organizational intelligence about possible problems in quality and patient safety, but effective systems for encouraging and supporting those who seek to speak up have remained elusive. In the English National Health Service, a novel role known as the 'Freedom to Speak Up Guardian' has been introduced to address this problem. We critically examine the role and its realization in practice, drawing on semi-structured interviews with 51 key individuals, including Guardians, clinicians, managers, policymakers, regulators and others. Operationalizing the new role in organizations was not straightforward, since it had to sit in a complex set of existing systems and processes. One response was to seek to bound the scope of Guardians, casting them in a signposting or coordinating role in relation to quality and safety concerns. However, the role proved hard to delimit, not least because the concerns most frequently voiced in practice differed in character from those anticipated in the role's development. Guardians were tasked with making sense of and dealing with issues that could not always straightforwardly be classified, deflected to the right system or escalated to the appropriate authority. Our analysis suggests that the role's potential contribution might be understood less as supporting whistleblowers who bear witness to clear-cut wrongdoing, and more as helping those with lower-level worries to construct their concerns and what to do with them. These findings have implications for how voice is understood, imagined and addressed in healthcare organizations.

Unprofessional conduct by nurses: A document analysis of disciplinary decisions

Background:

A small minority of nurses are investigated when they fail to meet the required professional standards. Unprofessional conduct does not just affect the nurse but also patients, colleagues and managers. However, it has not been clearly defined.

Objective:

The objective was to identify unprofessional conduct by registered nurses by examining disciplinary decisions by a national regulator.

Design:

A retrospective document analysis.

Data and research context:

Disciplinary decisions delivered to 204 registered nurses by the Finnish national regulatory authority from 2007 to 2016. The data were analysed with quantitative statistics.

Ethical consideration:

The study received permission from the Finnish National Supervisory Authority for Welfare and Health and used confidential documents that were supplied on the basis of complete anonymity and confidentiality.

Findings:

The mean age of the registered nurses who were disciplined was 44 years and 81% were female. Two-thirds had worked for their employer for 5 years or less, 53% had two or more employers and 18% had a criminal history. All the decisions included a primary reason for why the nurses were investigated, but there were also 479 coexisting reasons. In most cases, unprofessional conduct was connected to substance abuse (96%). In addition, stealing of medicine, a decreased ability to work and neglect of nursing guidelines were reported.

Discussion:

We found that the nurses were investigated for unprofessional conduct for complex combinations of primary and coexisting reasons. Our study highlighted that more attention needs to be paid to the key markers for unprofessional conduct.

Conclusion:

Unprofessional conduct is a complex phenomenon that is connected to nurses’ individual and working backgrounds and has an impact on their work performance. More research is needed to identify how nursing communities can detect, manage and limit the serious effects and consequences of unprofessional conduct.

Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualitative study

Healthcare organisations' responses to concerns and complaints often fall short of the expectations of patients and staff who raise them, and substandard responses to concerns and complaints have been implicated in organisational failures. Informed by Habermas's systems theory, we offer new insights into the features of organisations' responses to concerns and complaints that give rise to these problems. We draw on a large qualitative dataset, comprising 88 predominantly narrative interviews with people raising and responding to concerns and complaints in six English NHS organisations. In common with past studies, many participants described frustrations with systems and processes that seemed ill-equipped to deal with concerns of the kinds they raised. Departing from existing analyses, we identify the influence of functional rationality, as conceptualised by Habermas, and embodied in procedures, pathways and scripts for response, in producing this dissatisfaction. Functionally rational processes were well equipped to deal with simple, readily categorised concerns and complaints. They were less well placed to respond adequately to concerns and complaints that were complex, cross-cutting, or irreducible to predetermined criteria for redress and resolution. Drawing on empirical examples and on Habermas's theory of communicative action, we offer suggestions for alternative and supplementary approaches to responding to concerns and complaints that might better address both the expectations of complainants and the improvement of services.

The role of the informal and formal organisation in voice about concerns in healthcare: A qualitative interview study

The importance of employee voice-speaking up and out about concerns-is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation-the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity-could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice.

Perceived barriers to whistle blowing in healthcare amongst healthcare professionals: An integrative review

Purpose

Whistleblowing is a procedure where an existing or past participant of an establishment reveals actions and practices believed to be illegal, immoral or corrupt, by individuals who can influence change. Whistleblowing is an important means of recognising quality and safety matters in the health-care system. The aim of this study is to undergo a literature review exploring perceived barriers of whistleblowing in health care among health-care professionals of all grades and the possible influences on the whistleblower.

Design/methodology/approach

An integrative review of both quantitative and qualitative studies published between 2000 and 2020 was undertaken using the following databases: CINAHL Plus, Embase, Google Scholar, Medline and Scopus. The primary search terms were “whistleblowing” and “barriers to whistleblowing”. The quality of the included studies was appraised using the Critical Appraisal Skills Programme criteria. The authors followed preferred reporting items for systematic review and meta-analysis (Prisma) in designing the research and also reporting.

Findings

A total of 11 peer-reviewed articles were included. Included papers were analysed using constant comparative analysis. The review identified three broad themes (cultural, organisational and individual) factors as having a significant influence on whistleblowing reporting among health-care professionals.

Originality/value

This study points out that fear is predominantly an existing barrier causing individuals to hesitate to report wrongdoing in care and further highlights the significance of increasing an ethos of trust and honesty within health care.

Interventions promoting employee "speaking-up" within healthcare workplaces: A systematic narrative review of the international literature

BACKGROUND

Healthcare systems worldwide increasingly value the contribution of employee voice in ensuring the quality of patient care. Although employees' concerns are often dealt with satisfactorily, considerable evidence suggests that some employees may feel unable to speak-up, and even when they do their concerns may be ignored. As a result, in addition to trans-national and national policies, workplace interventions that support employees to speak-up about their concerns have recently increased.

METHODS

A systematic narrative review, informed by complex systems perspectives addresses the question: "What workplace strategies and/or interventions have been implemented to promote speaking-up by employees"?

RESULTS

Thirty-four studies were included in the review. Most studies reported inconclusive results. Researchers explanations for the successful implementation, or otherwise, of speak-up interventions were synthesised into two narrative themes (Braithwaite et al., 2018 (a)) hierarchical, interdisciplinary and cultural relationships and (Francis, 2015 (b)) psychological safety.

CONCLUSIONS

We strengthen the existing evidence base by providing an in-depth critique of the complex system factors influencing the implementation of speak-up interventions within the healthcare workforce. Although many of the studies were locally unique, there were international similarities in workplace cultures and norms that created contexts inimical to speaking-up interventions. Changing communication behaviours and creating a climate that supports speaking-up is immensely challenging. Interventions can be usurped in practice by complex, emergent and contextual issues, such as pre-existing socio-cultural relationships and workplace hierarchies.

Lost in the shadows: reflections on the dark side of co-production

This article is a response to Oliver et al.'s Commentary 'The dark side of coproduction: do the costs outweigh the benefits for health research?' recently published in Health Research Policy and Systems (2019, 17:33). The original commentary raises some important questions about how and when to co-produce health research, including highlighting various professional costs to those involved. However, we identify four related limitations in their inquiry, as follows: (1) the adoption of a problematically expansive definition of co-production that fails to acknowledge key features that distinguish co-production from broader collaboration; (2) a strong focus on technocratic rationales for co-producing research and a relative neglect of democratic rationales; (3) the transposition of legitimate concerns relating to collaboration between researchers and practitioners onto work with patients, service users and marginalised citizens; and (4) the presentation of bad practice as an inherent flaw, or indeed 'dark side', of co-production without attending to the corrupting influence of contextual factors within academic research that facilitate and even promote such malpractice. The Commentary's limitations can be seen to reflect the contemporary use of the term 'co-production' more broadly. We describe this phenomenon as 'cobiquity' - an apparent appetite for participatory research practice and increased emphasis on partnership working, in combination with the related emergence of a plethora of 'co' words, promoting a conflation of meanings and practices from different collaborative traditions. This phenomenon commonly leads to a misappropriation of the term 'co-production'. Our main motivation is to address this imprecision and the detrimental impact it has on efforts to enable co-production with marginalised and disadvantaged groups. We conclude that Oliver et al. stray too close to 'the problem' of 'co-production' seeing only the dark side rather than what is casting the shadows. We warn against such a restricted view and argue for greater scrutiny of the structural factors that largely explain academia's failure to accommodate and promote the egalitarian and utilitarian potential of co-produced research.

Whistleblowing over patient safety and care quality: a review of the literature

PURPOSE

The purpose of this paper is to review existing research on whistleblowing in healthcare in order to develop an evidence base for policy and research.

DESIGN/METHODOLOGY/APPROACH

A narrative review, based on systematic literature protocols developed within the management field.

FINDINGS

The authors identify valuable insights on the factors that influence healthcare whistleblowing, and how organizations respond, but also substantial gaps in the coverage of the literature, which is overly focused on nursing, has been largely carried out in the UK and Australia, and concentrates on the earlier stages of the whistleblowing process.

RESEARCH LIMITATIONS/IMPLICATIONS

The review identifies gaps in the literature on whistleblowing in healthcare, but also draws attention to an unhelpful lack of connection with the much larger mainstream literature on whistleblowing.

PRACTICAL IMPLICATIONS

Despite the limitations to the existing literature important implications for practice can be identified, including enhancing employees' sense of security and providing ethics training.

ORIGINALITY/VALUE

This paper provides a platform for future research on whistleblowing in healthcare, at a time when policymakers are increasingly aware of its role in ensuring patient safety and care quality.

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect

BACKGROUND

The definition and understanding of elder abuse and neglect in nursing homes can vary in different jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge about nursing home leaders' perceptions of elder abuse and neglect is of particular interest since their understanding of the phenomenon will affect what they signal to staff as important to report and how they investigate adverse events to ensure residents' safety. The aim of the study was to explore nursing home leaders' perceptions of elder abuse and neglect.

METHODS

A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role of care managers was conducted. Nursing home leaders' perceptions of different types of abuse within different situations were explored. The constant comparative method was used to analyse the data.

RESULTS

The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three analytical categories emerged from the analyses: 1) Abuse from co-residents: 'A normal part of nursing home life'; resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had no strategy for handling it; 2) Abuse from relatives: 'A private affair'; relatives with abusive behaviour visiting nursing homes residents was described as difficult and something that should be kept between the resident and the relatives; 3) Abuse from direct-care staff: 'An unthinkable event'; staff-to-resident abuse was considered to be difficult to talk about and viewed as not being in accordance with the leaders' trust in their employees.

CONCLUSIONS

Findings in the present study show that care managers lack awareness of elder abuse and neglect, and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes.

Raising concerns in the current NHS climate: a qualitative study exploring junior doctors' attitudes to training and teaching

Background

High profile cases continue to demonstrate failures to raise concerns with detrimental effects on patient safety. This research sought to establish what educational support junior doctors needed to effectively raise clinical and professional concerns.

Study design

A qualitative study with 16 participants taking part in three focus groups. The transcripts were thematically analysed.

Results

All the data could be coded into four themes: past experiences of teaching; suggested teaching; reporting mechanisms and educational challenges. Most participants were dissatisfied with the teaching they had received on raising concerns. Current systems were thought to be good for raising patient safety issues but not for concerns about professional behaviour of healthcare staff.

Conclusions

There is a need for improved education to tackle the way this is taught in postgraduate curricula. Frequent rotations and a lack of meaningful relationships left junior doctors feeling less invested in improving organisational culture. Junior doctors are apprehensive about raising concerns because of personal risk to their career trajectory.

Failure to report poor care as a breach of moral and professional expectation

Cases of poor care have been documented across the world. Contrary to professional requirements, evidence indicates that these sometimes go unaddressed. For patients, the outcomes of this inaction are invariably negative. Previous work has either focused on why poor care occurs and what might be done to prevent it, or on the reasons why those who are witness to it find it difficult to raise their concerns. Here, we build on this work but specifically foreground the responsibilities of registrants and students who witness poor care. Acknowledging the challenges associated with raising concerns, we make the case that failure to address poor care is a breach of moral expectation, professional requirement and, sometimes, legal frameworks. We argue that reporting will be more likely to take place if those who wish to enter the profession have a realistic view of the challenges they may encounter. When nurses are provided with robust and applied education on ethics, when "real-world" cases and exemplars are used in practice and when steps are taken to develop and encourage individual moral courage, we may begin to see positive change. Ultimately however, significant change is only likely to take place where practice cultures invite and welcome feedback, promote critical reflection, and where strong, clear leadership support is shown by those in positions of influence across organisations.

Clinical governance breakdown: Australian cases of wilful blindness and whistleblowing

BACKGROUND

After their attempts to have patient safety concerns addressed internally were ignored by wilfully blind managers, nurses from Bundaberg Base Hospital and Macarthur Health Service felt compelled to 'blow the whistle'. Wilful blindness is the human desire to prefer ignorance to knowledge; the responsibility to be informed is shirked.

OBJECTIVE

To provide an account of instances of wilful blindness identified in two high-profile cases of nurse whistleblowing in Australia.

RESEARCH DESIGN

Critical case study methodology using Fay's Critical Social Theory to examine, analyse and interpret existing data generated by the Commissions of Inquiry held into Bundaberg Base Hospital and Macarthur Health Service patient safety breaches. All data was publicly available and assessed according to the requirements of unobtrusive research methods and secondary data analysis.

ETHICAL CONSIDERATIONS

Data collection for the case studies relied entirely on publicly available documentary sources recounting and detailing past events.

FINDINGS

Data from both cases reveal managers demonstrating wilful blindness towards patient safety concerns. Concerns were unaddressed; nurses, instead, experienced retaliatory responses leading to a 'social crisis' in the organisation and to whistleblowing.

CONCLUSION

Managers tasked with clinical governance must be aware of mechanisms with the potential to blind them. The human tendency to favour positive news and avoid conflict is powerful. Understanding wilful blindness can assist managers' awareness of the competing emotions occurring in response to ethical challenges, such as whistleblowing.

Exploring the utility of internal whistleblowing in healthcare via agent-based models

OBJECTIVE

The benefits of internal whistleblowing or speaking-up in the healthcare sector are significant. The a priori assumption that employee whistleblowing is always beneficial is, however, rarely examined. While recent research has begun to consider how the complex nature of healthcare institutions impact speaking-up rates, few have investigated the institutional processes and factors that facilitate or retard the benefits of speaking up. Here we consider how the efficacy of formal inquiries within organisations in response to employees' speaking up about their concerns affects the utility of internal whistleblowing.

DESIGN

Using computational models, we consider how best to improve patient care through internal whistleblowing when resource and practical limitations constrain healthcare operation. We analyse the ramifications of varying organisational responses to employee concerns, given organisational and practical limitations.

SETTING

Drawing on evidence from international research, we test the utility of whistleblowing policies in a variety of organisational settings. This includes institutions where whistleblowing inquiries are handled with varying rates of efficiency and accuracy.

RESULTS

We find organisational inefficiencies can negatively impact the benefits of speaking up about bad patient care. We find that, given resource limitations and review inefficiencies, it can actually improve patient care if whistleblowing rates are limited. However, we demonstrate that including softer mechanisms for internal adjustment of healthcare practice (eg, peer to peer conversation) alongside whistleblowing policy can overcome these organisational limitations.

CONCLUSION

Healthcare organisations internationally have a variable record of responding to employees who speak up about their workplace concerns. Where organisations get this wrong, the consequences can be serious for patient care and staff well-being. The results of this study, therefore, have implications for researchers, policy makers and healthcare organisations internationally. We conclude with a call for further research on a more holistic understanding of the interplay between organisational structure and the benefits of whistleblowing to patient care.

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews

Background

There is compelling evidence to suggest that some (or even many) NHS staff feel unable to speak up, and that even when they do, their organisation may respond inappropriately.

Objectives

The specific project objectives were (1) to explore the academic and grey literature on whistleblowing and related concepts, identifying the key theoretical frameworks that can inform an understanding of whistleblowing; (2) to synthesise the empirical evidence about the processes that facilitate or impede employees raising concerns; (3) to examine the legal framework(s) underpinning whistleblowing; (4) to distil the lessons for whistleblowing policies from the findings of Inquiries into failings of NHS care; (5) to ascertain the views of stakeholders about the development of whistleblowing policies; and (6) to develop practical guidance for future policy-making in this area.

Methods

The study comprised four distinct but interlocking strands: (1) a series of narrative literature reviews, (2) an analysis of the legal issues related to whistleblowing, (3) a review of formal Inquiries related to previous failings of NHS care and (4) interviews with key informants.

Results

Policy prescriptions often conceive the issue of raising concerns as a simple choice between deciding to ‘blow the whistle’ and remaining silent. Yet research suggests that health-care professionals may raise concerns internally within the organisation in more informal ways before utilising whistleblowing processes. Potential areas for development here include the oversight of whistleblowing from an independent agency; early-stage protection for whistleblowers; an examination of the role of incentives in encouraging whistleblowing; and improvements to criminal law to protect whistleblowers. Perhaps surprisingly, there is little discussion of, or recommendations concerning, whistleblowing across the previous NHS Inquiry reports.

Limitations

Although every effort was made to capture all relevant papers and documents in the various reviews using comprehensive search strategies, some may have been missed as indexing in this area is challenging. We interviewed only a small number of people in the key informant interviews, and our findings may have been different if we had included a larger sample or informants with different roles and responsibilities.

Conclusions

Current policy prescriptions that seek to develop better whistleblowing policies and nurture open reporting cultures are in need of more evidence. Although we set out a wide range of issues, it is beyond our remit to convert these concerns into specific recommendations: that is a process that needs to be led from elsewhere, and in partnership with the service. There is also still much to learn regarding this important area of health policy, and we have highlighted a number of important gaps in knowledge that are in need of more sustained research.

Future work

A key area for future research is to explore whistleblowing as an unfolding, situated and interactional process and not just a one-off act by an identifiable whistleblower. In particular, we need more evidence and insights into the tendency for senior managers not to hear, accept or act on concerns about care raised by employees.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Investigating Physicians' Views on Soft Signals in the Context of Their Peers' Performance

BACKGROUND

Physicians are responsible for delivering high quality of care. In cases of underperformance, hindsight knowledge indicates forewarning being potentially available in terms of concerns, signs, or signals. It is not known how the physicians involved perceive such signals.

PURPOSE

To openly explore how physicians perceive soft signals and react on them.

METHODS

In-depth interviews with 12 hospital-based physicians from various specialties and institutions following the interpretative phenomenological analysis approach.

RESULTS

Physicians perceive soft signals as an observable deviation from a colleague's normal behavior, appearance, or communication. Once observed, they evaluate the signal by reflecting on it personally and/or by consulting others, resulting in either an active (i.e., speaking up) or passive (i.e., avoidance) reaction. Observer sensitivity, closeness to the peer, and cohesion of the physician group influence this observation-evaluation-reaction process.

CONCLUSIONS AND IMPLICATIONS

Physicians perceive soft signals as indicators of well-being and collegiality, not as concerns about performance or patient safety. They feel it is their responsibility to be sensitive to and deal with expressed signals. Creating a psychological safe culture could foster such an environment. Because a threat to physicians' well-being may indirectly affect their professional performance, soft signals require serious follow-up.

A qualitative study of speaking out about patient safety concerns in intensive care units

Much policy focus has been afforded to the role of "whistleblowers" in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 h of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), we studied how personnel gave voice to concerns about patient safety or poor practice. We observed much low-level social control occurring as part of day-to-day functioning on the wards, with challenges and sanctions routinely used in an effort to prevent or address mistakes and norm violations. Pre-emptions were used to intervene when patients were at immediate risk, and included strategies such as gentle reminders, use of humour, and sharp words. Corrective interventions included education and evidence-based arguments, while sanctions that were applied when it appeared that a breach of safety had occurred included "quiet words", bantering, public exposure or humiliation, scoldings and brutal reprimands. These forms of social control generally functioned effectively to maintain safe practice. But they were not consistently effective, and sometimes risked reinforcing norms and idiosyncratic behaviours that were not necessarily aligned with goals of patient safety and high-quality healthcare. Further, making challenges across professional boundaries or hierarchies was sometimes problematic. Our findings suggest that an emphasis on formal reporting or communication training as the solution to giving voice to safety concerns is simplistic; a more sophisticated understanding of social control is needed.

Whistle-blowing process in healthcare: From suspicion to action

Background:

Whistle-blowing is an ethical activity that tries to end wrongdoing. Wrongdoing in healthcare varies from inappropriate behaviour to illegal action. Whistle-blowing can have negative consequences for the whistle-blower, often in the form of bullying or retribution. Despite the wrongdoing and negative tone of whistle-blowing, there is limited literature exploring them in healthcare.

Objective:

The aim was to describe possible wrongdoing in Finnish healthcare and to examine whistle-blowing processes described on the basis of the existing literature in healthcare as perceived by healthcare professionals.

Research design:

The study was a cross-sectional descriptive survey. The data were collected using the electronic questionnaire Whistle-blowing in Health Care and analysed statistically.

Participants and research context:

A total of 397 Finnish healthcare professionals participated, 278 of whom had either suspected or observed wrongdoing in healthcare, which established the data for this article.

Ethical considerations:

Ethical approval was obtained from the Ethics Committee of the University (20/2015). Permission to conduct the study was received according to the organisation’s policies.

Findings:

Wrongdoing occurs in healthcare, as 96% of the participants had suspected and 94% had observed wrongdoing. Regarding the frequency, wrongdoing was suspected (57%) and observed (52%) more than once a month. Organisation-related wrongdoing was the most common type of wrongdoing (suspected 70%, observed 66%). In total, two whistle-blowing processes were confirmed in healthcare: (1) from suspicion to consequences occurred to 27%, and (2) from observation to consequences occurred to 37% of the participants.

Discussion and conclusion:

Wrongdoing occurs in healthcare quite frequently. Whistle-blowing processes were described based on the existing literature, but two separate processes were confirmed by the empirical data. More research is needed on wrongdoing and whistle-blowing on it in healthcare.

Australian midwives' experiences of their workplace culture

BACKGROUND

A number of adverse events in Australia and overseas have highlighted the need to examine the workplace culture in the maternity environment. Little attention has been paid to the midwifery workplace culture in Australia.

AIM

The study aimed to explore the midwifery workplace culture from the perspective of midwives themselves.

METHODS

A qualitative descriptive design was used. Group and individual interviews were undertaken of urban, regional and rural-based midwives in Australia. Data were analysed thematically.

FINDINGS

The study showed that both new and experienced midwives felt frustrated by organisational environments and attitudes, and expressed strategies to cope with this. Five themes were identified from the data. These were: Bullying and resilience, Fatigued and powerless midwives, Being 'hampered by the environment', and The importance of support for midwifery.

DISCUSSION

The study discusses the themes in depth. In particular, discussion focusses on how midwifery practise was affected by midwives' workplace culture and model of care, and the importance of supportive relationships from peers and managers.

CONCLUSION

This study illuminated both positive and negative aspects of the midwifery workplace culture in Australia. One way to ensure the wellbeing and satisfaction of midwives in order to maintain the midwifery workforce and provide quality care to women and their families is to provide positive workplace cultures.

Dealing with professional misconduct by colleagues in home care: a nationwide survey among nursing staff

Background

Professional misconduct in healthcare, a (generally) lasting situation in which patients are at risk or actually harmed, can jeopardise the health and well-being of patients and the quality of teamwork. Two types of professional misconduct can be distinguished: misconduct associated with incompetence and that associated with impairment. This study aimed to (1) quantify home-care nursing staff’s experiences with actual or possible professional misconduct; (2) provide insight into the difficulty home-care nursing staff experience in reporting suspicions of professional misconduct within the organisation and whether this is related to the individual characteristics of nursing staff; and (3) show which aspects of professional practice home-care nursing staff consider important in preventing professional misconduct.

Methods

A questionnaire survey was held among registered nurses and certified nursing assistants employed in Dutch home-care organisations in 2014. The 259 respondents (60 % response rate; mean age of 51; 95 % female) were members of the Dutch Nursing Staff Panel, a nationwide group of nursing staff members in various healthcare settings.

Results

Forty-two percent of the nursing staff in home care noticed or suspected professional misconduct by another healthcare worker during the previous year, predominantly a nursing colleague. Twenty to 52 % of the nursing staff experience difficulty in reporting suspicions of different forms of incompetence or impairment. This is related to educational level (in the case of incompetence), and managerial tasks (both in the case of incompetence and of impairment). Nursing staff consider a positive team climate (75 %), discussing incidents (67 %) and good communication between healthcare workers (57 %) most important in preventing professional misconduct among nursing staff.

Conclusions

Suspicions of professional misconduct by colleagues occur quite frequently among nursing staff. However, many nursing staff members experience difficulty in reporting suspicions of professional misconduct, especially in the case of suspected impairment. Home-care employers and professional associations should eliminate the barriers that nursing staff may encounter when they attempt to raise an issue. Furthermore, advocating a positive team climate within nursing teams, encouraging nursing staff to discuss incidents and facilitating this, and promoting good communication between healthcare workers may be appropriate strategies that help reduce professional misconduct by nursing staff.

Care Perceptions among Residents of LTC Facilities Purporting to Offer Person-Centred Care

Cette étude a exploré d’une manière qualitative comment les résidents des maisons de soins de longue durée (SLD) pensent et s’adaptent aux soins qu’ils reçoivent. Nous avons interrogé et observé un groupe délibérément choisi parmi des personnes âgées dans sept etablissements qui prétendent fournir des soins centrés sur la personne. Les descriptions interprétatives de la part de 43 entrevues personnelles avec 23 participants correspondaient a une réponse à la question: Comment les habitants perçoivent-ils les soins rendus dans les établissements de SLD qui se présentent comme offrant des soins centrés sur la personne? Trois thèmes dominants sont ressortis: (1) l’environnement bienveillant; (2) la préservation de la dignité; et (3) le maintien de l’autonomie personnelle. Les participants étaient sensibles à la charge de travail du personnel infirmier, mais se sentaient éloignés du personnel. Les participants ont donné des exemples de mauvais soins et une manque d’empathie, des indignités humains et des violations de l’autonomie personnelle causées par les politiques institutionnelles qu’ils se sentaient inhibiter leur capacité à recevoir des soins selon leurs propres préférences. En général, ils ont contesté les allégations de soins centrés sur la personne, mais ils s’y sont adaptés pour faire face à un environnement qui menace leur dignité et leur autonomie.

The missing two Cs – commodity and critique: Obscuring the political economy of the ‘gift’ of nursing

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under-recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part of the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist contexts that characterise many healthcare and other public sector organisations. The implications of this analysis for healthcare policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies, which may include patient groups, to put care in all its guises and consequences central to the political agenda.

Towards a sociology of healthcare safety and quality

The contributions to this collection address technologies, practices, experiences and the organisation of quality and safety across a wide range of healthcare contexts. Spanning three continents, from hospital to community, maternity to mental health, they shine a light into the boardrooms, back offices and front-lines of healthcare, offering sociological insights from the perspectives of managers, clinicians and patients. We review these articles and consider how they contribute to some of the dilemmas that confront mainstream approaches to quality and safety and then look ahead to outline future lines of sociological inquiry to progress the theory and practice of quality and safety.

Healthcare quality and safety: a review of policy, practice and research

Over the last two decades healthcare quality and safety have risen to the fore of health policy and research. This has largely been informed by theoretical and empirical ideas found in the fields of ergonomics and human factors. These have enabled significant advances in our understanding and management of quality and safety. However, a parallel and at time neglected sociological literature on clinical quality and safety is presented as offering additional, complementary, and at times critical insights on the problems of quality and safety. This review explores the development and contributions of both the mainstream and more sociological approaches to safety. It shows that where mainstream approaches often focus on the influence of human and local environment factors in shaping quality, a sociological perspective can deepen knowledge of the wider social, cultural and political factors that contextualise the clinical micro-system. It suggests these different perspectives can easily complement one another, offering a more developed and layered understanding of quality and safety. It also suggests that the sociological literature can bring to light important questions about the limits of the more mainstream approaches and ask critical questions about the role of social inequality, power and control in the framing of quality and safety.

Protecting care home residents from mistreatment and abuse: on the need for policy

With a rising older person population with increasing life expectancies, the demand for care homes will increase in the future. Older people in care homes are particularly vulnerable due to their dependencies related to cognitive and/or functional self-care challenges. Although many care homes provide good care, maltreatment and abuse of older people can and does occur. One major step in preventing and addressing maltreatment in care homes is having comprehensive and responsive policy, which delineates national expectations that are locally implemented. This paper examines the literature related to maltreatment in care homes and argues for policy based on a multisystems approach. Policy needs to firstly acknowledge and address general societal issues which tacitly impact on older person care delivery, underpin how care homes and related systems should be operationalized, and finally delineate expected standards and outcomes for individual experience of care. Such a policy demands attention at every level of the health care and societal system. Furthermore, contemporary issues central to policy evolution in care homes are discussed, such as safeguarding education and training and fostering organization whistle-blowing protection.

When Whistle-blowers Become the Story: The Problem of the 'Third Victim': Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

In the healthcare context, whistleblowing has come to the fore of political, professional and public attention in the wake of major service scandals and mounting evidence of the routine threats to safety that patients face in their care. This paper offers a commentary and wider contextualisation of Mannion and Davies, 'Cultures of silence and cultures of voice: the role of whistleblowing in healthcare organisations.' It argues that closer attention is needed to the way in which whistle-blowers can become the focus and victim of raising concerns and speaking up.

The Role of Employee Whistleblowing and Raising Concerns in an Organizational Learning Culture - Elusive and Laudable?: Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

It is inevitable that healthcare workers throughout their careers will witness actual or potential threats to patient safety in the course of their work. Some of these threats will result in serious harm occurring to others, whilst at other times such threats will result in minimal harm, or a 'near miss' where harm is avoided at the last minute. Despite organizations encouraging employees to 'speak up' about such threats, healthcare systems globally struggle to engage their staff to do so. Even when staff do raise concerns they are often ignored by those with a responsibility to listen and act. Learning how to create the conditions where employees continuously raise and respond to concerns is essential in creating a continuous and responsive learning culture that cherishes keeping patients and employees safe. Workplace culture is a real barrier to the creation of such a learning system but examples in healthcare exist from which we can learn.

Whistleblowing Need not Occur if Internal Voices Are Heard: From Deaf Effect to Hearer Courage: Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

Whistleblowing by health professionals is an infrequent and extraordinary event and need not occur if internal voices are heard. Mannion and Davies' editorial on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations" asks the question whether whistleblowing ameliorates or exacerbates the 'deaf effect' prevalent in healthcare organisations. This commentary argues that the focus should remain on internal processes and hearer courage .

Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations

'Whistleblowing' has come to increased prominence in many health systems as a means of identifying and addressing quality and safety issues. But whistleblowing - and the reactions to it - have many complex and ambiguous aspects that need to be considered as part of the broader (organisational) cultural dynamics of healthcare institutions.

Junior doctors' views on reporting concerns about patient safety: a qualitative study

BACKGROUND

Enabling healthcare staff to report concerns is critical for improving patient safety. Junior doctors are one of the groups least likely to engage in incident reporting. This matters both for the present and for the future, as many will eventually be in leadership positions. Little is known about junior doctors' attitudes towards formally reporting concerns.

AIMS

To explore the attitudes and barriers to junior doctors formally reporting concerns about patient safety to the organisations in which they are training.

METHODS

A qualitative study comprising three focus groups with 10 junior doctors at an Acute Teaching Hospital Trust in the Midlands, UK, conducted in 2013. Focus group discussions were transcribed verbatim and analysed using a thematic approach, facilitated by NVivo 10.

RESULTS

Participants were supportive of the idea of playing a role in helping healthcare organisations become more aware of risks to patient safety, but identified that existing incident reporting systems could frustrate efforts to report concerns. They described barriers to reporting, including a lack of role modelling and senior leadership, a culture within medicine that was not conducive to reporting concerns, and a lack of feedback providing evidence that formal reporting was worthwhile. They reported a tendency to rely on informal ways of dealing with concerns as an alternative to engaging with formal reporting systems.

CONCLUSIONS

If healthcare organisations are to be able to gather and learn from intelligence about risks to patient safety from junior doctors, this will require attention to the features of reporting systems, as well as the implications of hierarchies and the wider cultural context in which junior doctors work.