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

Abstract

In many health-care systems, 'whistleblowing' has gained popularity as a technique of discovering and correcting quality and safety issues. Whistleblowing – and the reactions to it – has a number of complex and confusing characteristics that must be considered in the context of the larger (organizational) cultural dynamics of healthcare organizations.

Speaking Truth to Power?

Healthcare crises in several nations have shown that when the organizational setting is improper, cruel and unproductive practices can thrive. 1-4 When employees notice poor quality treatment and/or harmful practices, it's critical that they feel empowered to speak up and express their concerns. It's even more critical that businesses respond favorably to such issues when they arise, learn from past mistakes, and implement effective rules to prevent such incidents from occurring in the future. Unfortunately, there have been far too many high-profile examples of front-line workers raising severe concerns that were not effectively addressed by the organization. As a result, patients have suffered, and workers may suffer as well. As a result, patients have suffered, and personnel may have suffered as a result of the direct and indirect effects of their expressing concerns.

 

Employee whistleblowing – informally defined as the disclosure of information about hazardous, unethical, or unlawful behaviors to a person or public entity outside of normal channels and management structures – has arisen as a significant topic in disputes about quality and safety in many health systems.

 

1 Recent public inquiries and reports exposing inadequate standards of care in the English National Health Service (NHS), for example, have underlined the critical role that staff whistleblowing may play in the discovery and prevention of patient harm. 2.5%: "When a member of the NHS speaks up, they are contributing to the quality and safety of patient care." This is true for all NHS staff, regardless of status, not just physicians, nurses, and other licensed healthcare professionals." 5 p.m.

 

However, how can we comprehend such whistleblowing techniques and position them in the correct organizational context?

Safe, or Sorry?

For many years, healthcare employers, regulators, and professional organisations have legislated and supported whistleblowing policies with the goal of ensuring safe and effective services. Nonetheless, a mismatch exists between whistleblower regulations in theory and how such arrangements work in practice, according to a number of polls conducted by various professional groups. One likely cause for this is the widespread belief among health professionals that if they express real concerns about colleagues' work or inadequate care, they would be victimized, ostracized, or intimidated. In the United Kingdom, for example, a 2012 NHS staff survey found that while the majority of NHS staff (90 percent) would know how to report any concerns they might have, only 72% said they would "feel safe raising these concerns," and only 55% said they would "feel confident" that their organization would address them. 6 Furthermore, when the Royal College of Nursing surveyed its members in 2013, nearly a quarter (24%) reported they had been 'warned off' or otherwise discouraged from whistleblowing. Furthermore, 45 percent of respondents reported their company 'took no action' after they spoke up in the same study. Doctors are not immune to such concerns: according to a survey of medical practitioners conducted by the Medical Protection Society (MPS) in 2012, just 11% of respondents said they would be confident in the process if they blew the whistle, and 49% of doctors said the whistleblowing process is ineffective due to 'fear of consequences.' Just a third of doctors who had blown the whistle (33%) stated their colleagues had backed them up in their decision. 7

 

If whistleblowing is to be an effective element of any national strategy for better, safer care, employees must believe that their complaints will not only be heard and addressed, but that their personal safety will not be jeopardized.

Heroes, or Villains?

Individual whistleblowers may be viewed as heroes by some (for advocating for patients' rights; encouraging better care; questioning management), but villains by others (for stepping outside of usual proceses; for denigrating services; for damaging professional and organisational reputations). Whistleblowers are frequently portrayed as either "courageous employees" who act to maintain standards at great personal cost, or as "disloyal malcontents" who "snitch" or "grass" on colleagues and pursue their own interests regardless of the dysfunctional consequences for individuals and organizations in the literature and popular media. 8 Furthermore, it would be naive to believe that all whistleblowers are motivated solely by genuine concerns about patient care: Some may also be motivated by work complaints or personality issues; some of the concerns stated may even be malevolent (probably rare, but certainly possible).

 

In fact, distinguishing between these designations is difficult. Whistleblowing is associated with persons having (often) complex personal and professional histories, as well as (like all of us!) certain personal idiosyncracies. Binary distinctions (such as hero/villain; loyal/disloyal; warranted/unwarranted) are typically ineffective because they obscure the complexity and ambiguity of whistleblowers and whistleblowing. It's difficult to tell whether someone is a "hero" or a "troublemaker" (or, more problematically, both). Prior knowledge, preferences, and interests are likely to impact interpretations of the local service context, as well as the personal history and traits of the whistleblower in light of whistleblowing acts. Local discursive practices (e.g., on the nature of success, failure, risk, and performance) as well as operational variables (such as resource restrictions, service rivalry, stakeholder pressures, and so on) are likely to play a significant impact in determining outcomes. Power will be determined by who has the knowledge, status, and position to assert one narrative over another. Such evaluations are based on discursive power rather than 'facts.' Controlling the narrative, dealing with ambiguity, and dealing with contestation are all likely to be important.

 

Whistleblowing, then, is plagued with competing interpretations and always takes place in a highly cultural and contextualized organizational setting. Organizational rules must therefore be carefully designed, implemented, and implemented in order to safeguard people who raise valid concerns while also providing support in the event of more vexatious whistleblowing.

Cultures of Silence and Cultures of Voice in Healthcare Organisations

The problem of reporting concerns about dangerous or poor quality treatment has tended to be seen as a simple (individual) option between electing to 'blow the whistle' or deciding to keep silent in policy recommendations. However, evidence shows that such simplistic dichotomies are ineffective: for example, healthcare personnel may express concerns informally inside the organization before (or instead of) using whistleblowing protocols. 9

 

Employees frequently attempt to figure out exactly what is going on before deciding whether or not to blow the whistle, often by talking to coworkers and getting a'second opinion.' Other informal tactics include using humour or sarcasm to express dissatisfaction, as well as having 'off-the-record' conversations with managers and staff. This type of behavior is sometimes described as a precursor to whistleblowing, and other times as a replacement.

 

This shows that these informal and circumlocutory channels of communication might be useful organizational tools for addressing and avoiding hazardous care (albeit they could also operate as'safety valves' for employee dissatisfaction without resulting in meaningful action). It also highlights the reality that the process of raising concerns about dangerous treatment may be mostly concealed from view (apart from those immediately involved in the discourse) and so not easily identified as voicing concern, let alone "whistleblowing." This perspective emphasizes the various ways in which healthcare workers may express their "voice" and refutes the stereotype that they are "voiceless." The idea that healthcare personnel are guilty bystanders who tolerate inadequate standards of care and are "silent witnesses" to malpractice and cruelty is frequently pushed in the media.

 

The decision between silence and voice is thus a spectrum rather than a binary one. It is also about a social and cultural level, not simply individuals. Furthermore, while "organizational silence" – described as "the collective-level phenomenon of doing or saying very little in response to important problems or difficulties confronting an organization"11 – may be undesirable, whistleblowing is not always the best option. We should take a close look at how whistleblowing rules and practices contribute to the organizational culture of voice and quiet.

Hearing, Listening and Acting

Effectively communicating concerns is only the first step towards developing better, safer healthcare: people in positions of power must listen and act. The 'deaf effect,' as defined in management literature, occurs when a decision-maker "does not hear" and "ignores or overturns a report of bad news to continue a failed course of action." In the face of inadequate and dangerous treatment, a variety of psychological, societal, and organizational elements have been identified that cooperate to shape and perpetuate "organizational deafness." The development of open reporting cultures is limited or stifled by persistent hierarchical status and power inequalities between different professional and occupational groups (e.g., between nurses and doctors, or between frontline personnel and managers). It's not apparent how whistleblowing in organizations helps to alleviate rather than worsen the "deaf effect." After all, the more unpleasant the messages are, the less likely it is that individuals who are affected would truly hear and act on them. Any whistleblower plan must address the difficult organizational dynamic of resistance to bad news, particularly among those in positions of authority who may already be invested in success narratives. The responses of individuals in power (both inside and outside the organization) when presented with fresh information and calls for action can be complicated, differently motivated, unclear, and contentious, just as whistleblowers' acts might be. While a refusal to listen and resistance to change are prevalent, different reactions can be observed, ranging from adjustments in attitudes and understanding to direct actions; from acts that promote positive change to those that degrade and harm whistleblowers. As a result, we require a detailed knowledge of these response dynamics, just as we need of whistleblower dynamics.

Concluding Remarks

Healthcare crises in many nations demonstrate the substantial flaws in whistle-blower protection and assistance, even when they voice real concerns: healthcare organizations typically dismiss such concerns and give poor remedies to the issues revealed. Senior players have been disciplined, suspended, or reported for misconduct to professional bodies on pretexts derived from a very specific and partisan reading and framing of events in some cases; in extreme cases, healthcare professionals have been disciplined, suspended, or reported for misconduct to professional bodies on pretexts derived from a very specific and partisan reading and framing of events.

 

We believe that most of the thinking on whistle blowing misunderstands it as something distinct from regular organizational functioning, and so misses a larger chance to think about voice and quiet in the context of organizations. Whistleblowing, in our opinion, is part of a broad variety of formal and informal behaviors anchored in local organizational contexts and cultures15,16 and entangled in both formal and informal governance systems and practices. The ambiguity of judgments and behaviors that are molded by contending discourses, discourses that are shaped by local interests and power relations, is at the heart of this argument.

 

The desirable, though difficult, objective of creating the ideal organizational contexts where voices can be heard, competing narratives can be recognized, and effective action directed at better, safer care can be enacted (even in the face of uncertainty) remains the laudable, if elusive, goal. Whistleblowing can be a component of this, but it must be understood in the context of the larger organization, rather than being perceived as something independent and distinct, a 'bolt on' addition.

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