ANALISIS EXTERNO MATRIZ EFE

Academics typically define a given social phenomenon more narrowly and precisely than the way in which lay people talk about the phenomenon. Whistleblowing represents an unusual reversal of that pattern, as the most widely used definition12_{incorporates behaviour that most employees or citizens would be unlikely}

to label whistleblowing. Parket al.,14_{who developed a typology of whistleblowing based on a decision}

tree, illustrate this. They suggest that individuals who have decided to raise concerns face three key choices: to raise issues (1) informally or formally, (2) anonymously or on the record and (3) internally or externally. This typology suggests eight types of whistleblowing, only some of which would fit with how most people would understand the concept. For example, before deciding to blow the whistle employees usually find themselves trying to work out exactly what is happening, often through engaging in dialogue with colleagues.15_{Such behaviour could be consistent with the informal/identified/internal whistleblowing}

pathway,14_{but it seems unlikely that staff would perceive such conversations as a form of whistleblowing.} Table 1details how the Parket al.14_{typology might translate into a health-care context.}

Notwithstanding the Parket al.14_{typology detailed above, the academic literature has traditionally focused}

on a dichotomous choice between whistleblowing and silence; that is, when faced with wrongdoing, an employee makes a conscious choice either to remain silent or to act by raising concerns.16_{Yet, as}

highlighted by Jones and Kelly,17_{this simplistic dichotomy obscures a range of alternative strategies to}

TABLE 1 Types of whistleblowing (from Parket al.14

)

Type of whistleblowing Examples

Informal

Anonymous, internal Unsigned note sent to a manager in the internal mail; telephone call to HR (or similar) giving no name

Anonymous, external Tip-off to a journalist; anonymous web postings Identified, internal Discussing one_’s concerns with a colleague Identified, external Posts on social media criticising one’s employer Formal

Anonymous, internal Leaving a message on a drug error hotline Anonymous, external Medication error reporting programmes Identified, internal Raising concerns with a Speaking Up guardian

Identified, external Raising concerns with a regulator; approaching a MP; speaking to a journalist HR, Human Resources; MP, Member of Parliament.

whistleblowing that may be just as effective in identifying and preventing wrongdoing. Such strategies might include interpersonal approaches such as the use of humour or sarcasm to signal discontent, or informal and off-the-record discussions with managers and employees. Jones and Kelly17_{suggest that these‘informal and}

circumlocutory’channels of communication may be valuable organisational mechanisms for addressing poor standards of care. Indeed, they argue that these can prove more effective than formal reporting systems, as they are more likely to circumvent the‘deaf effect’(see below). This fits with the current emphasis in NHS policy debates on‘raising concerns’and‘speaking up’, rather than whistleblowing per se, consistent with our observations inChapter 3that the relevant literature within health care tends to emphasise voice behaviours rather than formal whistleblowing.

Francis11_{notes that many staff appear unhappy with the term whistleblowing, hence the suggestion that}

terms like‘raising concerns’and‘speaking up’are to be preferred. However, it is useful to think of raising concerns, speaking up and whistleblowing as a continuum, even though, arguably, all can be subsumed under the academic definition of whistleblowing. We can differentiate between them in various ways, but it may be most useful to think about how employees might distinguish between them. An employee who has concerns about a particular issue that affects quality and safety of patient care might‘raise concerns’ with their line manager, possibly informally. If they get no response, they may choose to‘speak up’, potentially talking again to the same manager, but this time more formally and perhaps making clear that they expects their concerns to be a matter of record. If the issue is still not resolved, they may choose to ‘blow the whistle’to someone more senior, or perhaps go outside the organisation.

From an employee perspective, the act of‘raising concerns’may be relatively low risk, something that might be done routinely, perhaps even just in passing (e.g.‘I think the new health-care assistant is a little brusque with the older patients’). Speaking up is more serious: the very phrasing implies raising one’s voice or breaking a silence. The perceived level of risk may not be very great; in some cases the employee may only risk feeling foolish if they are mistaken, although their concern about this may, in itself, be enough to ensure that they remain silent.15_{Whistleblowing is a more significant act, to which the organisation may respond}

negatively. Alford18_{has argued that whistleblowers are defined post hoc, by the organisation’s response to}

their action. Using the NHS terminology, someone who thought they were just‘raising concerns’or‘speaking up’can discover that they are a whistleblower if the organisation responds negatively. The general perception among NHS staff and the wider public is that NHS whistleblowers tend to fare badly,19_{so staff thinking about}

speaking up may, from the outset, be concerned that they will receive a very negative response. This may lead individuals with relatively low-level concerns to refrain from raising them.

In a health-care context, another important distinction between raising concerns/speaking up and whistleblowing may be the focus of the concern. The classic definition of whistleblowing specifies that it is about‘illegal, immoral or illegitimate practices’.20_{Many issues that could affect care quality and patient}

safety, and about which we would hope staff would raise any concerns, do not necessarily come under any of those headings. Staffing levels, poor practice or poor performance (e.g. from a colleague dealing with personal problems) are all issues that could have a detrimental effect on patient care, but that staff would probably not view as‘wrongdoing’(see below for a more detailed discussion). Nevertheless, such issues may eventually lead to whistleblowing if they are not properly addressed. If a junior doctor raised concerns about a colleague’s confidence in dealing with challenging patients, they are clearly not concerned about‘illegal, immoral or illegitimate’behaviour. However, if those concerns are not addressed, and problems continue, a decision to speak to someone more senior about the issue is implicitly speaking up about the failure to address the problem. Such action is more consistent with whistleblowing. This is a subtle but important point that is often missed: whistleblowers are often described as blowing the whistle about a specific issue (e.g. poor practice), but they are often effectively blowing the whistle on management’s failure to act once made aware of the original issue.

Recent discussion of speaking up2,21,22_{has tended to frame the problem in terms of creating environments}

in which staff feel more able to voice their concerns. Yet, as Francis11_{and Kelly and Jones}19_observe,

This is consistent with the‘deaf effect’, a term originally coined by Keil and Robey23_{to describe the}

reluctance of senior managers to hear, acceptand act onchallenging observations from lower down the organisation. Vandekerckhoveet al.24_{suggest that researchers need to pay more attention to the question}

of how recipients of whistleblowing respond, and in particular to‘hearer action’, which we might view as the antithesis of the deaf effect. Whereas it is widely recognised that it takes a degree of courage for someone to blow the whistle, it is less immediately obvious that it may also take courage for a manager to take on board the issues and act on them. Just as the whistleblower knows that the line manager may not want to hear bad news, so the line manager knows that more senior management may be similarly reluctant to be informed of breaches or the requirements of remediation. Whistleblowing recipients in management roles know that their actions in raising the whistleblower’s concerns may receive a negative response and may even lead to the sort of retaliation and victimisation that can sometimes be experienced by whistleblowers themselves. For this reason, Vandekerckhoveet al.24_{suggest that there is a need for}

research into‘hearer courage’to understand‘which managers have the courage to hear, under which circumstances, and with regard to which wrongs’(p. 316). The same issues may pertain to the new Speaking Up guardian roles in the NHS, for whom a whistleblower’s report may feel like the whistleblower taking a burden off their own shoulders and placing it on the guardian’s.

Our analysis of the various public inquiries (seeChapter 4) suggests that senior management may sometimes also suffer from‘collective myopia’,25_{a shared inability to see a problem. This is potentially}

more problematic than the deaf effect, as it leaves those in management positions genuinely unable to see what the whistleblower is trying to bring to their attention. This could lead an individual to proceed from raising concerns to speaking up to internal whistleblowing, not in search of‘someone willing to listen’but in search of‘someone able to see’. However, the NHS can be viewed as a single large organisation in many ways, and criticisms of regulator responses to cases such as that at the centre of the Mid Staffordshire NHS Foundation Trust Public Inquiry11_{suggest that even when the individual goes outside the immediate}

organisation, they may still find people unable to see/unwilling to listen. There is a sense in which raising concerns and speaking up in health care adhere to both organisational‘etiquette’and the hierarchical chain of command, which inevitably means that management can choose to ignore the issue. There is also a sense that individuals may feel that they have done their duty in raising the issue.26_{Blowing the whistle, especially}

externally, raises the stakes and is much harder to ignore.