Degradación e interconversión

InChapters 2and3, we outlined how whistleblowing has developed as a distinct field of academic enquiry and identified the seminal publications that have influenced and shaped the contours of debate in this area. An important finding from our review of the literature is that whistleblowing research in health care has developed separately and has therefore not drawn on the theoretical and empirical insights of mainstream whistleblowing research published in the management and organisation literature. We reviewed the different theoretical approaches that have been used in the management and social sciences literature as conceptual lenses to understand whistleblowing. The key conceptual and empirical issues uncovered by our review, with practical import for understanding, designing and improving whistleblowing and speaking up policies in the NHS, include the following important observations.

Silence and voice

There is no simple dichotomous choice between whistleblowing and silence (the collective-level phenomena of doing or saying very little in response to significant problems or issues facing an organisation). Policy

prescriptions have tended to conceive the issue of raising concerns about unsafe or poor-quality care as a simple (individual) choice between deciding to‘blow the whistle’or determining to remain silent. Yet research suggests that such simple dichotomies are unhelpful; for example, health-care professionals may raise concerns internally within the organisation in more informal ways before (or instead of) utilising whistleblowing processes. Before coming to any decision on whether or not to blow the whistle, employees usually find themselves trying to work out exactly what is happening, often through engaging in dialogue with colleagues and seeking a‘second opinion’. Other informal strategies may include the use of humour or sarcasm to signal discontent or the use of ‘off-the-record’discussions with managers and employees. This kind of behaviour is framed sometimes as a prelude to whistleblowing and sometimes as a substitute. It also draws attention to the fact that the process of raising concerns about unsafe care may be largely hidden from view (apart from those participating directly in the dialogue) and may therefore not readily be identifiable as voicing concern, much less‘whistleblowing’. Such a view highlights the different routes through which health-care employees are able to articulate their ‘voice’and challenges the pejorative notion, often promoted in the media, that health-care professionals are culpable bystanders who tolerate poor standards of care and are‘silent witnesses’to malpractice and mistreatment. Silence or voice, then, is not a binary choice but more of a spectrum. It is also about more than just individuals: it is collective and cultural (see later discussion of culture in this chapter).

Hearing and acting

Effective voicing of concerns is but the first stage in reshaping better safer health care: those with influence have to hear, and they have to act. In this regard we discussed the‘deaf effect’, a concept that has been used in the management and organisation literature to describe the reluctance of senior managers to hear, accept and act on concerns by those raised by employees lower down the hierarchy. In some cases it is clear that senior players seek to ostracise and isolate individuals by undermining their concerns. In extreme cases, health-care professionals have been disciplined, suspended or reported for misconduct to professional

bodies on pretexts derived from a very particular and partisan reading and framing of events. In an intensely hierarchical organisation such as the NHS, entrenched status and power differences between different professional and occupational groups (e.g. between nurses and doctors or between front-line staff and managers) that have been affirmed over decades and woven into the fabric of health-care delivery can serve to limit or attenuate the development of open reporting cultures.

Any articulation of a whistleblowing strategy must deal with the challenging organisational dynamic of resistance to bad news, especially by those in positions of power who may already be vested in narratives of success. Just as whistleblowers’actions may be complex, variably motivated, ambiguous and contested, so too can be the responses of those in authority (within and outside the organisation) when confronted with new information and demands for action. Although an unwillingness to hear and resistance to change are commonplace, other responses may be seen: from shifts in attitudes and understanding to direct actions; from actions that support beneficial change to those that denigrate and damage the whistleblowers. Thus, we need as sophisticated an understanding of these response dynamics as we do of the dynamics of whistleblowing itself.

In this respect, the work of Dixon-Woodset al.301_{can be used to shed light on this issue. On the basis of}

empirical work in the NHS, the study grouped senior management’s responses into two broad categories of behaviour:‘problem-sensing’and‘comfort-seeking’. Problem-sensing was assessed to occur when senior managers actively sought out problems in their organisations using a blend of hard and soft intelligence.302

Comfort-seeking arose when managers sought information from only a range of limited sources and had a preoccupation with compliance, meeting external requirements and receiving positive news that served to provided‘reassurance that all was well’. Managers actively disassociated themselves from issues raised by front-line staff and perceived any reported problems as‘whining or disruptive behaviour’. Such comfort- seeking (as opposed to problem-seeking) behaviours among senior managers in the NHS may, therefore, serve to support the‘deaf effect’.148_{Senior management may sometimes also suffer from‘collective}

myopia’,25_{a shared inability to see a problem. This is potentially even 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. Moreover, powerful systematic biases in group and team decision-making, including Groupthink, can serve to suppress the willingness of health-care professionals to report, hear and respond to concerns about unsafe care.303,304

Interactional processes

Linked to the above is the recognition that whistleblowing is an interactional process and not just a one-off act by an identifiable whistleblower. The process is better seen as a dynamic and recursive interaction between whistleblower and recipient: it is not just that the speaker requires the courage to speak up but also the recipient(s) need to hear what is being said and to take appropriate action.24_{Most previous}

research and policy around whistleblowing have focused on the whistleblower, in particular the factors that inhibit whistleblowing and determine who has‘the courage’to speak up and under what circumstances. This has traditionally led to policies and interventions designed to lower the speaker-courage threshold in health-care contexts, such as legal protection, anonymous reporting channels and attempts to nurture ‘no-blame’cultures. However, more focus needs to be placed on why some managers respond effectively and others do not, and the personal and organisational factors that can contribute to lowering the hearer-courage threshold.

Taking this one step further, attention should also be extended to understanding‘protector courage’, whereby managers make an effort to protect whistleblowers from adverse consequences. According to Vandekerckhoveet al.,24_{protector courage is, thus,‘a way of understanding which managers have the}

courage to stand up for, or organise interventions around those who blow the whistle within areas under their influence or control in order to reduce or combat the familiar risks of retaliation, conflict or suspicion of the reporting action’(p. 321). Managers able to effect hearer action may not always be in a position to support protector action and vice versa. An understanding of how, when and why NHS managers can

take on such roles and the organisational factors that support (or impede) them is central to the design of better whistleblowing policies in the NHS.

Whistleblowing, or bell-ringing?

As conceived in the academic literature as well as in wider public understanding, whistleblowing usually describes internal organisational members raising concerns to those who can effect action. However, ‘bell-ringing’, or outsider whistleblowing, is also a possibility, and is potentially a more significant issue for health care than for any other sector. Examples of potential outsider whistleblowers include patients, relatives and visitors, or suppliers, consultants and professionals working in other organisations (e.g. social workers, GPs or management consultants). As the NHS becomes ever more diverse in terms of collaboration with other sectors (public, private, third sector), and as social media and information-sharing technologies become more developed, external staff are increasingly exposed to, and in a position to speak up about, poor-quality care. Indeed, staff from other sectors and those from other countries may bring very different values and beliefs (for good or ill) regarding what constitutes unsafe care and this may influence the NHS staff with whom they collaborate. Our review of the literature also uncovered evidence that health-care staff coming from different countries can have very different values regarding whether or not and when it is appropriate to blow the whistle.

Policy impacts on local judgements

Notions and assumptions about what is deemed to be good or substandard care, and therefore on decisions to speak up, are not only shaped locally but also influenced by the national context including current government policy, the action of interest groups, ethical codes and guidelines promoted by professional bodies, and care standards expected by national regulators. For example, in the current financial climate in the NHS some services may be withdrawn and staff levels reduced, posing new challenges to local perceptions of care adequacy.

However, as highlighted by Hyde,137_{it is unlikely that reductions in care delivery will benefit patients;}

but when is it deemed by staff to be unacceptable practice? When, precisely, should staff raise the alarm when the level of care has deteriorated? In such situations, the best course of action is not always apparent. In addition, in an era of austerity, increasing financial constraints and job insecurity in the NHS, many staff may be reluctant to raise concerns because of potential retaliatory action by management. Any consideration of whistleblowing policy in the NHS must, therefore, be alert to the influence of such background factors on employees’willingness to speak up and the responses of organisations when they do.

Personal factors in raising concerns

There is mixed evidence on the role and impact of personal factors in raising concerns. For example, in terms of length and security of tenure, some studies have found that the more embedded and socialised into a particular culture staff are, the less likely they are to spot poor practice and report it (perhaps because of personal and social links with colleagues). Other studies have shown that newly qualified nurses are in a position to blow the whistle because of their increased knowledge and confidence as to what constitutes poor care. Similarly, the evidence is mixed on whether nurses who, over time, become more socialised and integrated members of the organisation are less likely (through de-sensitisation) or more likely (through better organisational knowledge and developed networks) to detect and report poor care. These issues are under-researched in the NHS context and require detailed local study.

Key practice action points arising from research objectives 1 and 2

l Managers should not be resistant to‘bad news’and should endeavour to seek out problems in their organisations using a blend of hard data and soft intelligence. Finding ways to encourage this will be a key challenge for management education and leadership training.

l NHS organisations should nurture cultures that are supportive of staff raising concerns and respond positively to such concerns when they are raised; greater attention should be paid to communicating such changes in culture to care staff.

l Particular attention should be focused on ensuring that staff are not penalised or‘scapegoated’for raising legitimate concerns (or perceived to be); particular attention will need to be paid to the effect that singular breaches of this will have on undermining leadership pronouncements of open cultures.

l Whistleblowing policies should take into consideration how reporting channels are opened up to external staff, how organisations respond to external concerns, and the influence of external staff and those from other countries on the values that underpin health-care delivery, including the reporting of clinical incidents.