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OPINION

'If the culture is unethical, acts of heroic staff may be futile'

More than lip service needs to be paid to eradicating unethical practice, says Ann Gallagher

The recent suggestion by the House of Commons’ health select committee that whistleblowing should be a statutory duty for all NHS staff stimulated a good deal of debate.

It was suggested that “whistleblowers will face bullying from every side” (editor’s view, page 1, 2 August) and atrocity stories were shared of whistleblowers who had been treated appallingly. Critics may add it is a case of damned if you do and damned if you don’t.

The trouble with the proposal, however, is not that more pressure would be exerted on health professionals to report poor practice. There is already an obligation to raise and escalate concerns when patient health and wellbeing is at stake. We know that professionals are as accountable for their omissions as for their actions.

The trouble with this proposal is that it may divert attention away from: understanding poor practice in organisations; promoting initiatives that foster self and peer review; and commending and supporting those who eliminate such practice.

“Developing and sustaining an ethical climate within organisations is as important as developing accountable and conscientious health professionals”

In addition to working towards understanding the role of individuals in poor practice, we need to consider the ethical climate of the healthcare organisation.

Is there adequate professional leadership? Are the values of the organisation directed towards patient wellbeing and dignity? Or is it focused on financial targets? Does the organisation share what has been learnt from complaints? Does it commend staff for what is done well? Is there a willingness to change and to introduce initiatives that may initially be unpopular, such as self and peer review of practice and a reconsideration of shift patterns?

Raising concerns should be considered a praiseworthy activity, particularly when patients are unable to speak for themselves.

Of course, it is more important to avoid poor practice, recognise when there is something to be concerned about and prioritise understanding and stopping it.

Sadly, some staff appear to experience moral blindness when they witness poor practice. That is, they don’t seem to appreciate the impact of negative behaviour and attitudes on patients or they may think poor practice has nothing to do with them. No health professional should be complacent, or consider themselves a mere bystander.

There is already the potential for the regulator to take action against those who collude with poor practice, and penalties may result from not reporting concerns - the stick approach. Far better would be a focus on initiatives to avoid poor practice and to reward good practice and appropriate reporting - the carrot approach.

If the climate or culture of the organisation is unethical - for example if it prioritises targets over patient and staff wellbeing and dignity, favours loyalty over integrity and deference over courage - the actions of individuals, however heroic, are likely to be futile.

By all means, call health professionals to account for actions and omissions that compromise patient wellbeing and dignity, but let’s not forget the role of organisations in all of this. Developing and sustaining an ethical climate within organisations is as important as developing accountable and conscientious health professionals.

To that end, more than lip service needs to be paid to eradicating unethical practice and promoting professionalism. Nurse leaders need to lead by example and be visible; nurse educators need to inspire and empower; and researchers need to continue to explore relationships among diverse factors that undermine or enhance care. It is misguided to pin responsibility solely on an individual without exploring the contributory and preventive factors within organisational and political contexts.

Ann Gallagher is reader in nursing ethics, International Centre for Nursing Ethics, University of Surrey

Readers' comments (5)

  • 'It is misguided to pin responsibility solely on an individual without exploring the contributory and preventive factors within organisational and political contexts.'

    I agree, so often it is the whistleblower or the person practising poorly (or both) who get the blame. The organisation neither pays little, if no, attention as to why it has happened, nor takes the correct steps to rectify the problem. Instead the blame is shifted to an individual.


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  • George Kuchanny

    "If the climate or culture of the organisation is unethical - for example if it prioritises targets over patient and staff wellbeing and dignity, favours loyalty over integrity and deference over courage - the actions of individuals, however heroic, are likely to be futile."

    This is a very important consideration and is at the core of the evolution we are seeing the beginnings of for the NHS. PCT's (the highly placed managers and directors) and their legal departments have shown an incredible lack of integrity for many years. Hence the desperate need to restructure. Enough is enough quite frankly.

    When we add the perspective of Margaret Heffernan which she sums in one memorable line so:

    "The paradox of not being open and transparent is we think it will make us safe even as it puts everyone in danger (Wilful Blindness. Margaret Heffernan. 2011)."

    It becomes very clear that evolution into a truly patient centred organisation is imperative.

    Thank you for writing the article Ann and thanks for publishing this very important perspective NT.

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  • I absolutely agree with this article and the two posts above me. There needs to be a fundamental culture change in the NHS.

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  • michael stone

    I also agree that this article is spot on.

    But this is not new ground !

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  • It is fundamentally unethical to demand something of staff that the culture of the organisation, not only doesn't support that, but actively penalises it and then persecutes those staff for raising it. Sounds almost too ridiculous to be true and yet that is what is happening.
    If this was a child's treatment by parents then we would be exploring vulnerability issues, why do we accept this as adults?
    When staff are continually battling situations and conflicts like this as a daily occurrence why on earth would anyone expect them to remain confident in their trust that their organisation would support them?
    There is something much more profoundly disturbing in not feeling able to do what you know needs doing as a moral agent because you know the cost of doing that. It would be simple to cast this as a moral blindness, it would be braver to address it and understand the deeper issues that are causing it.

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