Reporting poor practice is a professional and moral obligation for nurses, yet they do not always do so. This article explores possible reasons for this failure
Ann Gallagher, PhD, MA, PGCEA, BA, RMN, SRN, is reader in nursing ethics, and director, the International Centre for Nursing Ethics, University of Surrey, and editor, Nursing Ethics.
Gallagher A (2010) Whistleblowing: what influences nurses’ decisions on whether to report poor practice? Nursing Times; 106: 4, early online publication.
Several recent high profile examples demonstrate that nurses fear and have reason to fear the consequences of reporting poor practice. This article examines the ethical issues surrounding whistleblowing, discussing in detail the reasons for and against reporting concerns about poor practice, and how nurses can be supported to do this.
Keywords Whistleblowing, Ethics, Reporting, Poor practice
- This article has been double blind peer reviewed
- Insights from research on whistleblowing can help nurses develop strategies to raise concerns about unethical healthcare practices. Reporting concerns is both a professional and ethical obligation.
- Nurses need to be aware of internal and external resources that will guide, support and protect them should they become aware of unethical practices.
- Organisations have a responsibility to ensure that reporting frameworks are clear, accessible and understood by staff at all levels. They also need to demonstrate that they will support staff who bring concerns to their attention.
- Consideration should also be given to other resources within organisations; for example, clinical ethics committees can provide a forum for practitioners to discuss concerns about practice and how to respond.
- Professional organisations can support staff who have practice concerns, for example the Royal College of Nursing provides a telephone helpline (0845 772 6300).
- Nurses should also be aware of additional external routes for reporting concerns and seeking advice, for example, the National Patient Safety Agency (click here to report a patient safety incident) and Public Concern at Work.
Truth, according to the American poet Emily Dickinson, “is a rare thing, it is delightful to tell it”. However, nurse whistleblower Graham Pink begged to differ with Dickinson’s assertion. After losing his job for going public with concerns about staffing levels and standards of care for older patients in hospital he said: “Telling the truth of what I witnessed has been a wretched, distressing and costly business” (Pink, 1994; 1993
Some 16 years later another nurse, Margaret Haywood, was struck off the professional register for a breach of confidentiality (Nursing and Midwifery Council, 2009). She covertly filmed unethical care practices at a Brighton Hospital for a television documentary, and claimed that filming was the “only option” (BBC News, 2009). Ms Haywood was reinstated following an appeal. The striking off order was replaced with a one year caution (nursingtimes.net, 2009).
Serious failings are estimated to have resulted in 400-1,200 deaths at Mid Staffordshire Foundation Trust (Healthcare Commission, 2009). Then health secretary Alan Johnson said he was “amazed” that nurses and doctors “failed to blow the whistle on poor practice” (Moore and Smith, 2009). He was accused by clinicians of “being out of touch” (Snow and Doult, 2009).
Similarly, in relation to misconduct spanning a 25 year period at an Irish hospital, the Lourdes Hospital inquiry report team (Harding-Clark, 2006) stated it “had difficulty understanding why so few had the courage, insight, curiosity or integrity to say ‘this is not right’”.
Findings from a recent Royal College of Nursing (2009) survey revealed the majority of nurse respondents (78%) were concerned about negative consequences from reporting concerns to employers. Almost a quarter (21%) had been discouraged from doing so and, although almost all (99%) understood their professional obligation to report concerns, 43% would “think twice” before doing so. Fewer than half (46%) felt confident enough to report concerns and believed their employer would be supportive, while some 45% did not know whether their employer had a whistleblowing policy.
The examples above and findings from the RCN survey suggest not only that nurses fear the consequences of whistleblowing but also that their fears may be justified.
Speaking out or raising concerns about unethical practices is both challenging and complex. If practitioners blow the whistle on poor practice, no action may follow or they may conclude, as Pink did, that telling the truth is costly. If they do not take action, unethical practices continue and questions will be asked about why they have failed in their professional responsibilities. This is perhaps a case of professionals feeling “damned if they do raise concerns and damned if they don’t” (Gooderham, 2009).
It is timely to reconsider whistleblowing with a view to gaining a deeper understanding of the phenomenon. This article considers ethical aspects of whistleblowing and looks at the ethical reasons for raising concerns in response to unethical practices. Responses to such situations will be informed by professional virtues, organisational ethics and an awareness of internal and external resources to guide, support and protect nurses who raise concerns.
Whistleblowing has been described as the activity whereby “organisation members […] disclose employers’ illegal, immoral, or illegitimate practices that are under the control of their employers to persons or organisations who may be able to effect action” (Miceli and Near, 1984). A distinction is made between internal and external whistleblowing. Internal whistleblowing is when people report or whistleblow within their own organisation and external whistleblowing is when they use channels external to their organisation (Miceli and Near, 1984).
Whistleblowers may report to a range of people and bodies. Internally this may, for example, be a unit manager, senior professional, human resources department or chief executive. Externally, it could be a professional body or trade union, a politician, inspection body or the media.
Perry (1998) restricted whistleblowing to the process whereby “insiders ‘go public’ with their claims of malpractices by, or within, powerful organisations”. He distinguished between whistleblowing (necessarily external) and the internal reporting of concerns. This more restrictive use of whistleblowing is helpful as it may reduce some of the more negative associations of a stigmatising and dramatic term, replacing it with a sense of everyday professional obligation to draw attention to unethical practices.
The history of whistleblowing
Whistleblowing has been discussed extensively in business and healthcare literature. Gualtieri (2004) looked at examples dating back to the 1960s relating to nuclear facilities, toxic waste and dangerous drugs. Public concerns resulted in laws to protect workers who report unethical practices as well as in an increased regulation of industry.
Examples in the 1970s and 1980s included the “Pentagon papers”, detailing escalating casualties during the Vietnam War; the papers were leaked to TheNew York Times and The Washington Post. Following the 1986 explosion of the space shuttle Challenger, which resulted in the death of seven crew, it became known that engineers who had tried to stop the launch were overruled by managers (Gualtieri, 2004).
Whistleblowing had a high profile when accounting misconduct was disclosed in the Enron and WorldCom “corporate scandals” (BBC News, 2002). These activities contributed to the development of US legislation emphasising corporate ethics and protecting whistleblowers.
In the UK, the discussion of whistleblowing gained momentum in response to several high profile cases in the early 1990s: nurse Graham Pink, referred to above; Dr Helen Zeitlin, who expressed concern about the shortage of nurses in the hospital where she worked; and Chris Chapman, a biochemist, who disclosed scientific fraud. All three were dismissed from their job. Hunt (1995) wrote of the background to these cases:
“Whistleblowing surfaced in the UK health service in an atmosphere of apprehension and anxiety. Economic recession and public expenditure cuts, combined with the imposition of commercial-style management in the National Health Service, have threatened standards of care, disempowered health professionals and almost certainly created new conditions for negligence and abuse, and new opportunities for fraud and corruption.”
The conditions described by Hunt (1995) above seem familiar during the current economic situation. Findings from research reports and from whistleblower disclosures suggest that few areas of healthcare practice can afford to be complacent.
The Mencap (2007) report Death by Indifference and its subsequent campaign detailed unequal treatment in the NHS of people with learning disabilities, resulting in death in some instances. The Mental Health Act Commission’s (2009) report was described as “damning” and as presenting a “bleak picture” of mental health practice (Bowcott, 2009).
In addition to the confirmation of avoidable patient deaths at Mid Staffordshire foundation trust, nurses reported they were expected to “fabricate patient records” and had been “advised to lie” about situations where the four hour waiting target was breached (Waters, 2009). Such reports detail a wide range of individual and organisational failings.
Practitioners may feel that they have to compromise professional values to meet organisational and government targets. Some 80% of nurses who participated in a survey relating to dignity in care said they sometimes or always left work feeling distressed that they were unable to deliver the quality of care they would have liked to (RCN, 2008). A survey conducted by the International Council of Nurses in 13 countries found 92% reported facing “time constraints that prevented them from spending sufficient time with individual patients”. Almost half said their workload was heavier now than five years ago (Nursing Times, 2009).
Such reports are cause for concern and many suggest situations where patients receive inadequate care and are subject to neglect and abuse. Nurses and nursing, therefore, encounter many significant threats to commitment to care.
Whistleblowing and ethics
There is a professional and ethical obligation to report concerns about unethical practice. The NMC (2008) code of conduct makes this obligation explicit (Box 1).
Box 1. The NMC code of conduct
- The introductory statements emphasise the importance of being trustworthy and of making the care of people one’s first concern, respecting their dignity and individuality and ensuring their health and wellbeing is promoted.
- There is also an obligation to “be open and honest, to act with integrity and uphold the reputation of the profession” (NMC, 2008).
- The sub section of the code entitled “manage risk” makes explicit the obligation to act and to inform and report concerns.
- The code emphasises patients’ right to confidentiality and to receive information about the sharing of information. There is an obligation to disclose information if it is believed someone is at risk of harm, in line with the laws of the country.
Source: NMC (2008)
Arguments in favour
Raising concerns or failing to raise concerns about poor practice is necessarily and primarily an ethical issue. There are at least five persuasive ethical reasons that support the reporting of unethical practice.
To prevent harm to others: the consequences of harm and wrongdoing in healthcare are well documented. Unethical practices can result in patients and others losing their dignity, being neglected and abused and, in some instances, dying. Such activities are contrary to the service ideals of nursing and other healthcare professions. Reporting unethical practice is, therefore, supported by the ethical principle of non-maleficence (do no harm). Examples of rules related to this principle are:
- Do not kill;
- Do not cause pain or suffering;
- Do not incapacitate;
- Do not cause offence; and
- Do not deprive others of the goods of life (Beauchamp and Childress, 2009).
To do good: nurses are charged with maintaining and promoting patients’ health and welfare. Unethical practice prevents patients from flourishing, rendering them more vulnerable and making it unlikely that the broader goals of nursing and healthcare will be achieved. Rules relating to doing good (beneficence) are:
- Protect and defend the rights of others;
- Prevent harm from occurring to others;
- Remove conditions that will cause harm;
- Help people with disabilities;
- Rescue people in danger (Beauchamp and Childress, 2009).
To treat people justly: treating people justly or fairly may manifest in quite different ways. For example, distributive justice requires that benefits and burdens are distributed fairly; distribution of goods on the basis of need is the most common criterion. Justice also relates to care and treatment that can give some individuals or groups more advantage or disadvantage than others. Is it the case, for example, that people of a certain age, class, gender, sexual orientation or ethnicity are treated more favourably than others? Reporting unjust and discriminatory practices may, therefore, restore justice. Another aspect of justice relates to maintaining academic and practice standards.
To fulfil the role of patient advocate: Ohnishi et al (2008) stated that “whistleblowing is now recognised as an act of advocacy, which is a designated role of nurses”. Nurses’ role as patient advocate is both contested and accepted. However, such a role is in keeping with the three principles above and is fundamentally an ethical role.
This is what a virtuous professional would do: the previous points have focused on what nurses should do, on ethical prescriptions for action or conduct. Another approach to ethics focuses on the character or ethical qualities of the individual nurse rather than solely on conduct. Virtuous or ethically good nurses will respond appropriately in situations where the reporting of concerns is called for. To do
this they require a range of virtues or dispositions to act, think and feel ethically.
At the very least, people who report internally or whistleblow externally require:
- Professional wisdom (to ensure they have perceived the salient features of the situation; that they have deliberated appropriately; and acted ethically);
- Courage (to have the wherewithal to speakout when others may remain silent and when there may be negative consequences);
- Integrity (to be able to maintain professionalism and uphold the values of the nursing profession) (Banks and Gallagher, 2009).
Arguments against reporting
Arguments against the reporting of malpractice are less persuasive but none the less familiar and worthy of consideration.
Loyalty to the organisation: those who draw attention to unethical practices within their organisation by reporting concerns (particularly externally) may be accused of disloyalty to the organisation and perhaps to their team. Loyalty can be described as a virtue but a challenging one when, for example, we consider ideas such as “loyal terrorist” or “loyal Nazi”. Loyalty by itself may support unethical activities and needs to be accompanied by virtues such as professional wisdom and integrity.
Nurses and others need to consider carefully and honestly questions relating to loyalty and the reporting of unethical practice. As Kleinig (2007) reminds us: “When an organisation wants you to do right, it asks for your integrity; when it wants you to do wrong, it demands your loyalty.”
Self interest: Dobson (1998) cited Geoffrey Hunt as saying that there is “plenty of evidence that whistleblowing affects health. When people are put under that kind of stress in highly charged atmospheres, it can cause all kinds of illness”. It might be argued, therefore, that self interest is a good reason not to raise concerns. However, it is important to emphasise that, from an ethical perspective, it need not be a choice between the welfare of patients and the welfare of staff; the welfare of both parties needs to be taken seriously.
Confidentiality: balancing the obligation to report concerns that prevent further harm to patients with the obligation to maintain confidentiality is one of the most challenging ethical issues in relation to whistleblowing. Confidentiality is an important ethical principle and contributes to maintaining trusting relationships between patients and nurses. The principle is not, however, absolute and has to be weighed against the public interest to disclose information that prevents serious harm to others.
It has been argued that appealing to confidentiality to silence healthcare professionals is unjustifiable when, for example, “the sole or principal ground for non-disclosure is the administrative inconvenience or managerial embarrassment or supposed institutional damage which would or might result from disclosure” (Hunt, 1995). It is, therefore, crucial that individuals and organisations reflect on their motives for disclosing or preventing the disclosure of information.
What is clear is that reporting concerns involves an interaction between individuals and organisations. What is less clear is why some people speak out while many remain silent, and why some organisations respond defensively to reports of unethical practice.
Bad apples, good apples and bystanders
Hunt (1995) discussed the emergence of the whistleblower as a “fascinating hybrid” - “half trouble maker, half hero”:
“The whistleblower points out the bad apples, the bad apples fight back, the whistleblower is expelled from the applecart. There are two conclusions. The whistleblower is ruined, and we bystanders look on wringing our hands. The good apples intervene, the balance of the applecart is restored, and the bystanders applaud.”
The different players in a whistleblowing scenario might, as Hunt (1995) suggested, be viewed simplistically as whistleblower “bad apples” (people who abuse the system) and “good apples” (people who lead public inquiries and put things right).
Those labelled “whistleblower” are as likely to be stigmatised and demonised as applauded and commended for taking personal and professional risks to bring unethical practices to light.
Hunt is right to urge that more consideration should be given to the role of bystander, that is, someone who witnesses an event but does not participate in it. Whether someone who is present when unethical practice occurs could be considered an “innocent bystander” is a challenging question. On the one hand, we should be mindful of the insight of philosopher Edmund Burke who said: “The only thing necessary for the triumph [of evil] is for good men to do nothing.” It is important to try to understand why people fail to act. The roles of bystander, bad apples and good apples all deserve critical analysis and an interdisciplinary exploration.
Social psychology, for example, challenges the idea that a few bad apples in an otherwise good barrel are responsible for unethical practices. In the Stanford Prison Experiment, Zimbardo (2007) wrote:
“Our young research participants were not the proverbial ‘bad apples’ in an otherwise good barrel. Rather, our experimental design ensured that they were initially good apples and were corrupted by the insidious power of the bad barrel, the prison.”
In the introduction to this article, reference was made to comments by the Lourdes Hospital inquiry team regarding the inaction of individuals who were aware of professional misconduct that had been taking place over many years.
One response may be, as the team suggested, that bystanders lacked the “courage, insight, curiosity or integrity to say ‘this is not right’” (Harding-Clark, 2006).
McCarthy et al (2008) offer a different analysis, suggesting that the situation can be viewed through a feminist lens. They considered:
“How sex and gender feature in the Lourdes case draw attention to the deeply gendered asymmetries of power and privilege that existed between the men and women at the centre of this inquiry, and explore the impact such asymmetries had on this particular situation.”
These perspectives illustrate the need for - and potential of - philosophy and social sciences to advance our understanding of unethical practices and whistleblowing. Such situations are complex and our approach to them needs to move beyond outrage, recrimination and tabloid rhetoric. It is not a matter of understanding more and condemning less but of understanding more so we will have less to condemn.
Research on moral distress, for example, (the experience of knowing what is the right thing to do but feeling unable to do it because of institutional constraints) has the potential to broaden our understanding of the inter-relationship between individual and organisational values.
We need to continue to investigate the factors that maintain ethical practice and those that diminish it. It is also important to focus on developing the repertoire of resources and approaches necessary to ensure that those available are most helpful to practitioners when raising concerns. This development will help to support ethical practice.
The American artist Walter Anderson said: “Bad things do happen: how I respond to them defines my character and my life.”
Unethical practice is likely to continue, as will the need to report concerns within healthcare organisations and, in some instances, to whistleblow outside an organisation. Individuals have a responsibility to develop the professional wisdom required to ensure they are sufficiently courageous to speak out and to reflect on their own motives with a view to ensuring the action taken is appropriate.
Responses to unethical practice may well be said to define one’s character but there must also be some consideration of the relationship between healthcare organisations and individuals.
Practitioners are fallible and may be vulnerable to pressures that lead them to prioritise their own interests or those of the organisation over those of patients. Healthcare organisations may prioritise financial incentives and managerial values over patient care and staff welfare. l
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