In uncharted waters: confronting the culture of silence in a residential care institution

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.

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.

Whistleblowing propensity in power distance societies

Purpose

This study aims to examine the link between power distance culture and whistleblowing intention or propensity in the African context.

Design/methodology/approach

The study achieves its aim by reviewing literature on power distance culture and whistleblowing, and it draws on the outcomes of relevant previous studies. It then reflects on some cultural practices in Africa in relation to the topic and uses examples from Ghana to exemplify the discussions.

Findings

It is considered unacceptable and disrespectful for subordinates to challenge or question their superior’s actions and decisions in high power distance societies. High power distance culture increases the perception of the negative consequences of whistleblowing, as whistle-blowers are regarded as traitors instead of civic heroes. These issues consequently provide major disincentives to subordinates engaging in whistleblowing, leading to low whistleblowing propensity in high power distance societies and implications for the increasing rate of corruption in Africa.

Practical/implications

The study findings imply that high power distance culture creates a “culture of silence”, which in turn provides fertile grounds for corporate crimes and unethical conducts. Authorities in high power distance societies should therefore institute adequate incentive schemes and shields to encourage and safeguard the safety of whistle-blowers.

Originality/value

In this era, where corporate scandals have become the order of the day and indeed a global canker, this study brings to the fore the destructive and limiting roles of culture, specifically power distance culture on the global war against unethical corporate practices and scandals.

Conflict of roles: a conflict of ideas? The unsettled relations between care team staff and independent mental health advocates

Drawing on a national study of independent mental health advocacy, we explored the social relations of independent advocacy. The study was commissioned by the Department of Health (England), and involved a case study design covering eight different geographies and service configurations, and interviews or focus groups with a total of 289 stakeholders across two phases of inquiry. This paper focused on the analysis of qualitative data relevant to the relationship between mental health-care services and independent advocacy services, drawn from interviews with 214 participants in phase two of the study. Discussion of these particular findings affords insights into the working relations of independent advocacy within mental health services beset by reorganizational change and funding cuts, and increasing levels of legally-sanctioned compulsion and coercion. We offer a matrix, which accounts for the different types of working relationships that can arise, and how these are associated with various levels of understanding of independent advocacy and appreciation for the value of advocacy. The discussion is framed by the wider literature on advocacy and the claims by practitioners, such as nurses, for an advocacy role as part of their professional repertoire.

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

Inquiries in the UK into mistreatment of older people by healthcare employees over the last 30 years have focused on introducing or supporting employee whistle-blowing. Although whistle-blowers have made an important contribution to patient safety it remains a controversial activity. The fate of whistle-blowers is bleak, often resulting in personal and professional sacrifices. Here we draw on the views of healthcare and social care employees working with older people to explore perceptions of whistle-blowing as well as alternative strategies that may be used to raise concerns about the mistreatment of patients by co-workers. Whistle-blowing was perceived as a negative term. Managers said they promoted open cultures underpinned by regular team meetings and an open-door ethos. Others described workplace norms that were somewhat at odds with these open culture ideals. Whistle-blowing was considered risky, and this led to staff creating informal channels through which to raise concerns. Those who witnessed wrongdoing were aware that support was available from external agencies but preferred local solutions and drew upon personal ethics rather than regulatory edicts to shape their responses. We argue that the importance of workplace relationships and informal channels for raising concerns should be better understood to help prevent the mistreatment of vulnerable groups.

Nursing Advocacy in Procedural Pain Care

In nursing, the concept of advocacy is often understood in terms of reactive or proactive action aimed at protecting patients' legal or moral rights. However, advocacy activities have not often been researched in the context of everyday clinical nursing practice, at least from patients' point of view. This study investigated the implementation of nursing advocacy in the context of procedural pain care from the perspectives of both patients and nurses. The cross-sectional study was conducted on a cluster sample of surgical otolaryngology patients ( n = 405) and nurses ( n = 118) from 12 hospital units in Finland. The data were obtained using an instrument specially designed for this purpose, and analysed statistically by descriptive and non-parametric methods. According to the results, patients and nurses have slightly different views about which dimensions of advocacy are implemented in procedural pain care. It seems that advocacy acts are chosen and implemented rather haphazardly, depending partly on how active patients are in expressing their wishes and interests and partly on nurses' empowerment.

Nursing advocacy—a review of the empirical research 1990–2003

This paper provides an overview of the empirical research literature on nursing advocacy. It offers a description of the contexts, methods and issues of validity and reliability used in studies of nursing advocacy, as well as advocacy definitions, activities and consequences as results of those studies. The review focuses on empirical articles retrieved from the CINAHL and MEDLINE databases published between 1990 and 2003. It draws attention to complexity the concept of advocacy, difficulties in operationalisation, and concentration on reactive advocacy from nurses' perspective. There is a lack of research on patients' perspectives of nursing advocacy in general hospital settings.

A balanced approach to dealing with violence and aggression at work

The Government has introduced tough measures in dealing with violence and aggression in the workplace. Employers have a duty to provide adequate safety measures and training to reduce risks and ensure, where possible, the health, safety and welfare of their employees. This article highlights the responsibilities of employers and the pressures in both hospital and community environments on staff at risk from violent or abusive incidents. The patient's perspective is discussed, suggesting that more understanding between patients and staff is needed. The article looks at the "NHS Zero Tolerance Zone Campaign" and whether this can be enhanced by introducing training of an empathetic nature along with other practical environmental issues. It suggests that there are alternative and more effective, techniques in dealing with violence and aggression that can be used to defuse a situation before it ever becomes a physical altercation. The philosophies of eastern martial arts can teach us a lot about personal self-esteem and confidence which are two key elements in managing conflict situations.

Postacute care for older aboriginal people: an exploratory-descriptive study

Many Aboriginal people reside in rural and remote Australia. Aboriginal health workers were the informants in this exploratory-descriptive study, which explored issues pertaining to postacute care for older Aboriginal people. Qualitative analysis of interview data revealed several issues were viewed as being of crucial importance in the provision of effective postacute services to older Aboriginal people. These were: (i) identification of Aboriginality; (ii) perceived racism and stereotypical attitudes among hospital staff and healthcare workers; and (iii) effective discharge planning. Other issues which were believed to impact upon service use were identified as: (i) availability of services; (ii) knowledge of services and level of use; and (iii) the notion of mainstream versus Aboriginal-specific services. Findings are discussed in relation to available literature. Implications for further research are drawn from the findings of this exploratory study.