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Given the interdisciplinary nature of whistleblowing research, it is perhaps unsurprising that our review of the literature, as with previous reviews (e.g. Kelly and Jones19_{), did not identify a universal or shared}

underpinning theoretical framework for whistleblowing research. We can, however, identify a number of different theoretical perspectives that provide useful lenses through which to view the phenomenon (Figure 2). Note that these are not distinct‘schools of thought’, and researchers often borrow ideas from several perspectives in developing their research. The figure should be viewed as a useful heuristic, rather than a strict mapping of the position of each perspective on some notionalx- andy-axes.

In their seminal paper, from which much other work has derived its definition of whistleblowing, Near and Miceli20_{identified the steps involved in the whistleblowing process (Table 3). This framework has been}

widely used in whistleblowing research. At one level, it is simply a description of a sequence of events, but, by emphasising decisions, the framework reinforces a focus on decision-making, which in part explains the dominance of the cognitive perspective in the whistleblowing literature.

Taking each of the perspectives shown inFigure 2in turn, we can see that each has distinctive foci of interest, and that each brings to the fore specific insights about the whistleblowing process.

Cognitive perspective Values and beliefs Prosocial behaviour Justice and institutional theory Power and politics

FIGURE 2 Theoretical perspectives on whistleblowing.

TABLE 3 Steps in the whistleblowing process (from Near and Miceli12

)

Step 1 Step 2 Step 3 Step 4

Observer’s decision 1: is the observed activity illegal, immoral or illegitimate?

Observer’s decision 2: should the activity be reported?

Organisation’s decision 1: should the action be halted?

Organisation’s decision 2: should the whistleblower be punished?

Cognitive perspective

The cognitive view within psychology has been a major influence on whistleblowing research. Considering its relevance to the understanding of how stakeholders respond to misconduct, Barnett35_{highlights two}

key assumptions, namely that‘people cannot attend to all the stimuli competing for their limited attention’ and‘factors particular to the person and the situation influence how one allocates his or her attention and responds to stimuli’. Many whistleblowing researchers emphasise the importance of the decision-making process that takes place after an event of potential wrongdoing is witnessed, typically at stage 2 of Near and Miceli’s12_{model of the whistleblowing process. The implication is that observers consciously weigh the}

factors for and against blowing the whistle, such as wanton violation of rules and laws, negligence in a duty of care or abuse of power. However, a cognitive perspective recognises that the decision to blow the whistle is also influenced by factors of which the individual may be largely unaware. Research from this perspective explores whistleblowing as a deed that results from the confluence of an individual’s values and beliefs, and the context in which a problematic act occurs, that is, what behaviours‘fit’within the potential whistleblower’s personal paradigm. Whistleblowing research adopting a cognitive perspective recognises that, although the observer may not be fully aware of all of the various influences on their decision, such influences must be accounted for if our understanding of the topic is to be improved.15,36

Values and beliefs

Research adopting this perspective is concerned with how externally derived values and beliefs influence whistleblowing. These values and beliefs may come from macro-level societal-level influences (e.g. religious teachings or national culture) or by more meso- or micro-level influences, such as the local organisational culture, rules and regulations, or the influence of dominant team leaders. A key assumption is that guidance relating to what is right and wrong is a principal driver of whistleblowing behaviour. This guidance is potentially captured by organisational policies, but also by the teachings and traditions from other occupations. There is a connection here with the cognitive view through cultural influence. However, with the values and beliefs perspective, the distinction is that other parties create the influence on whistleblowing for the individual, whereas the cognitive view presents the influences on the whistleblowing decision as being internally

constructed, albeit influenced by a myriad of other overlapping factors. InFigure 2, we located the values and beliefs perspective wholly inside the cognitive perspective, reflecting the fact that values and beliefs can be viewed as an influence on the decision-making process. Thus, religious beliefs may have a strong influence on what individuals perceive as wrongdoing, and their perceptions of their own responsibilities as observers of this wrongdoing, but ultimately the individual still has a decision to make.

For example, Rothwell and Baldwin,37_{examining whistleblowing in police agencies in Georgia, USA,}

noted that uniformed staff, in spite of close personal relationships with colleagues, were more likely than civilian employees to blow the whistle on wrongdoing, suggesting that the external values and formal regulation associated with uniformed service were important. Indeed, Alford38_{discusses the threat posed}

to organisations by the‘ethical autonomy’(cf. Kant) of their members. Organisations, therefore, would find work from this perspective useful, as it could provide clues as to how to inculcate values and beliefs that the organisation and wider society deem appropriate to encourage whistleblowing behaviour when necessary. The review by Trevinoet al.39_{contributes to this perspective by exploring individual behaviours}

that were judged as ethical or otherwise when measured against the norms in which those behaviours occur. Sekerkaet al.40_{note that organisations typically encourage individuals to behave ethically by}

imposition of external‘rules and legal standards’, rather than by encouraging professional moral courage. One of the key insights of this perspective is the importance of setting out clear rules, standards and norms regarding what employees are expected to do if they encounter wrongdoing.

Justice and institutional theories

This perspective considers the impact that the legal system and organisational rules and regulations have on the whistleblowing process. Embedded within the concept of‘justice’is that of‘fairness’, and although recognising the importance of the topic, a number of authors emphasise the range of perceptions of fairness as a factor in whistleblowing. For example, Alleyneet al.,41_{following Rawls,}42_{suggest that‘justice}

disadvantageous’. They suggest that perception of injustice is a key driver of the act of whistleblowing, a view supported by Nearet al.43_{Gundlachet al.}44_{note that‘looking fair may be more important than}

being fair’, and, for this reason, there is clear overlap with other theoretical perspectives, given that the cognitive perspective relies on individual perceptions, and what is perceived as prosocial behaviour will vary from one context to another. This raises the difficult question ofperceptionof fairness, a perception that inevitably interacts with national differences. In this review, we have focused on Western cultures, as this is where the bulk of whistleblowing research has been undertaken. However, given the marked cultural and national diversity of the NHS workforce, there is potential for considerable cultural differences in attitudes towards whistleblowing, which may be highly significant.

Within the more institutionalist strand of this perspective, recent research has specifically examined how institutional mechanisms in public sector organisations influence whistleblowing.45,46_{This work has been}

outside health care and the outside the UK, but could be very relevant to the NHS, particularly in terms of understanding the institutional processes by which policy-makers influence the process (cf. Blenkinsopp and Snowden47_).

Power and politics

This perspective explores the impact that power and political actions in all organisations have on whistleblowing. In their seminal work, Near and Miceli20_{emphasise the importance of power in the}

construction of their model of the whistleblowing process, and retaliation from organisations towards whistleblowers can be viewed as a response to the threat they pose to organisational power.48_Avakian

and Roberts49_{suggest that‘Our analysis indicates that the imbalance of power results from the way the}

whistleblower exercises the hidden knowledge in unexpected ways’. This links to recent work from a Foucauldian perspective, which introduces the concept of parrhesia to whistleblowing research.50,51

Foucault used this term to describe‘a specific modality of truth-telling (veridiction) that emerges in the context of asymmetrical power relations’.51_{This line of work offers valuable insights into the various}

difficulties faced by individuals seeking to raise concerns about matters that are (usually) factual and provide management with information that would appear useful (see Weinstein52_{and Alford}38_for

non-Foucauldian approaches to this issue).

Nearet al.43_{also explore the interface between theories of power and justice theory, and comment that}

when organisations deliberately provide their own legal protection (and hence power) to a‘role-prescribed whistleblower’(e.g. internal auditors), positive outcomes for both the whistleblowers and their organisations are experienced. Pittroff53_{supports the view of the centrality of power to successful implementation of a}

whistleblowing system within an organisation, stating that‘implementation of internal [whistleblowing] systems is ostensibly driven by power theories’.

It is clear, therefore, that the papers exploring whistleblowing through focusing on the influence of power and politics have a major role to play in developing our understanding of the topic. This perspective may be especially relevant to the NHS, which is very hierarchical in nature, with considerable variations in power between different occupational groups and different levels, and the added complication of a further powerful hierarchy above the chief executive, who is ultimately accountable to the Secretary of State for Health and Social Care.

Prosocial theory

The final theme to emerge from our review relates to works that explore the desire to‘do good for others’ by blowing the whistle. Typically, such papers explore the concept of whistleblowing as an act that benefits the welfare of others both inside and outside the organisation, even though there may be an element of self-interest driving their decision to expose wrongdoing. As Dozier and Miceli54_{state,‘[whistleblowing] is}

more appropriately viewed as‘prosocial’behaviour, involving both selfish (egotistic) and unselfish (altruistic) motives on the part of the actor’. This creates a managerial dilemma; Dunganet al.55_{state that‘people are}

moral hypocrites–espousing moral values when judging others, while actively ignoring when self-interest is at stake’. The same authors point to scientific evidence that suggests that prosocial behaviour is intrinsically rewarding, and, for this reason, imply that a natural positive predisposition towards whistleblowing exists.

This is important to any attempt to support the reporting of wrongdoing, and perhaps has the potential to challenge a common organisational perception of whistleblowers as‘trouble causers’.

Alternative perspectives

The work considered in each of the subsections above demonstrates where authors have adopted a

particular stance on the topic, and we believe that different and productive interpretations of whistleblowing can be generated by adopting different stances and using different lenses. As whistleblowing becomes more high profile, and researchers from other academic fields become interested in exploring the concept, we are witnessing the publication of articles that examine whistleblowing from new and illuminating perspectives.

Through an examination of language

The definitional complexities alluded to above draw attention to the importance of clarity in the language used, but also the influence of language on how whistleblowing situations are framed. We might describe the same behaviour as‘raising concerns about an issue affecting patient safety’or‘blowing the whistle on poor practice’, but the former phrasing may be more acceptable to staff and management, and more likely to lead to change. It is, therefore, important to consider the language used in and around the act of whistleblowing, with sensitivity to style and content. Contu56_{argues that looking at how the language}

used to explore a whistleblowing event evolves over time‘opens up an appreciation of the ethical and political valence of the process of whistleblowing’.

Through an examination of sense-making

The sense-making perspective57_{offers potentially valuable insights. Its relevance to health care has been}

acknowledged, as Weick and colleagues have examined‘high reliability organisations’; for analyses directly relevant to the NHS, see Weick and Sutcliffe30_{and Weicket al.}58_{Blenkinsopp and Edwards}15_{drew on the}

sense-making perspective to develop the concept of‘cues for inaction’. They suggest that clinical staff are very aware of the risks of whistleblowing (or even of just raising concerns) but are also aware of their responsibility for the patient (under codes of conduct and NHS policies). Caught between a‘rock and a hard place’, they are motivated to find ways of making sense of the situation that allow them to stay silent. The challenge for organisations is to find ways to create‘cues for action’, and reduce or even eliminate possible cues for inaction.

Given the diversity of conceptual lenses open to researchers, and the diverse insights thus available to date, future empirical work on whistleblowing in the NHS should carefully exploit the conceptual diversity for fresh insightful gains.