A number of human factors influence the way managers within organisations address patient safety concerns. One is wilful blindness.
The phenomenon of wilful blindness has been described by Heffernan (2011, p. 3) as “shirking” the “opportunity for knowledge, and a responsibility to be informed”. When faced with unsettling reports about substandard care and/or patient safety breaches, some health service managers prefer ignorance to knowledge.
The human tendency to favour positive news and avoid conflict is powerful. Managers deal with these reports by filtering and editing the information received, preferring that which supports a previously held belief, while conveniently filtering out that which unsettles (Heffernan, 2011).
This human reaction to avoid reports of unprofessional and unethical conduct that results in adverse clinical events can lead to whistleblowing.
In Australia, there have been two high-profile cases where wilful blindness contributed to nurse whistleblowing: Bundaberg Base Hospital in Queensland and Macarthur Health Service in NSW (Davies, 2005; HCCC, 2003). Both whistleblowing incidents resulted in widespread media attention and the establishment of commissions of inquiry.
The proceedings from these cases provided a unique opportunity to examine questions related to factors influencing whistleblowing and were the focus of a PhD study (Cleary, 2014). In these cases, nurses who reported patient safety concerns were hampered by the misguided belief (false consciousness) that organisational processes would be ‘on their side’ and action would be taken to address their concerns. The nurses mistakenly believed that reporting through internal channels would result in censure of individual practitioners and/or a change in processes that would mitigate the risks of patient injury or death.
Instead, the nurses experienced retaliatory responses to their internal reporting which contributed to a “social crisis” and the rare act of whistleblowing (Cleary &Duke, 2017).
Examination of the two cases uncovered the conditions under which nurses who reported failure felt morally compelled to report outside their organisations. This was particularly so when the observational gaze and consequent sanctions were turned back upon the whistleblowing nurses, rather than upon the inadequacies and transgressions that they had uncovered.
Retaliation against whistleblowers has been well documented and involves managers who attempt to deal with the disclosure by discrediting the whistleblower, rather than dealing with the information disclosed (Attree, 2007; Jackson et al, 2014; Jackson et al, 2010). When the attention is focused more on the messenger than the message, the ability to capture and learn from the concerns raised is hampered.
Whistleblowers report incompetent, unethical or illegal situations in the workplace to an authority who has the power to stop the wrong (McDonald & Ahern, 2002). In healthcare, this authority is someone outside the healthcare organisation, as internal reporting is not considered whistleblowing but an essential component of clinical governance and the first essential step in the identification of systemic gaps and weaknesses to improve patient safety (World Health Organisation, 2005).
However, in order to prevent external reporting, i.e. whistleblowing, a feedback loop that provides constructive, responsive communication back to those who report is essential. Repeated inaction, or a culture of blame and retaliation, will contribute to the difficult decision to either remain silent or escalate the concern, first to a higher authority within the organisation, and, if unresolved, outside the organisation.
Researchers have repeatedly found that internal inaction and a lower level of trust in, and support from, management can be a significant motivating factor to report to an external body who may be able to affect action (Hunt, 1995; Miceli, Near & Dworkin, 2008; Wortley, Cassematis & Donkin, 2008).
In this context, the human factor responses of managers to internal reporting is essential.
In light of the codified obligation that nurses have to ‘take appropriate action’ when patient safety and quality care are placed at risk, a critical investigation is required. Whistleblowing need never occur if those responsible for receiving and acting on patient safety reports adequately address them in a culture of transparency, trust and accountability. The way forward requires attention and research, not just on clinicians at the sharp end of patient care but also on the managers who receive reports of failure.
Schein’s (2016) key message to managers who receive reports of patient safety concern is “to become more mindful of how they react to subordinate comments about safety or quality”. He acknowledges the failure of upward communication related to safety and quality concerns and challenges managers to be vulnerable and accept the fact that their subordinates will know and see systemic things that would improve quality and safety.
Schein also recommends learning to pay attention to “weak signals” which are “small problems that are detected, but are less likely to be reported or taken seriously” (p. 266). These weak signals often precede whistleblowing events in healthcare. He uses the example of tensions between surgeons and nurses as a weak signal that is often ignored.
In the Bundaberg case, it was tensions between a surgeon and senior nurses from perioperative, intensive care, infection control and renal that could have been conceived as weak signals.
In the Macarthur case, tensions between an anaesthetist and two senior clinical nurse specialists was a weak signal not recognised, and it set the path to the whistleblowing action (Cleary, 2014).
Dixon-Woods et al (2014) recommended managers and leaders in healthcare actively seek out weaknesses in their organisations. Defined as “problem sensing”, they suggest that this information come from not only the formal incident reporting systems, but also “softer intelligence” such as listening to staff and patients as well as making informal, impromptu visits to the clinical areas.
Dixon-Woods et al recognised that all too often healthcare managers are preoccupied with compliance, external expectations and positive news. These managers were labelled “comfort seekers” who actively seek data that provide “reassurance that all was well” (p. 111), instead of hearing or seeing the weak signals.
Negative feedback was avoided by comfort-seeking managers who distanced themselves from their frontline staff. When complaints, concerns or criticisms were raised, these were perceived as merely “whining or disruptive behaviour” (p. 111).
When issues are reported, found or validated, it takes courage to upward report, effect action and bring to a close the offending practice or practices. As speculated by Mannion and Davies (2015), the “more unpalatable the message” the less likelihood of action.
Vandekerckhove, Brown and Tsahuridu (2014) believe future research to prevent whistleblowing should examine the variables that determine courage on the part of the recipient of the bad news, i.e. the manager. What influences some managers to demonstrate not only courage to hear what is being said, but to also take appropriate action and refrain from inappropriate behaviour? Behaviour such as retribution and increased surveillance on the bearer of the news.
Research on “hearer courage” will promote a better understanding of the human factors involved in “which managers have the courage to hear, under which circumstances” (p. 316) and for what wrongs.
Further work needs to be done to understand this complex phenomenon, for a failure to understand means more nurses and other health professionals having to blow the whistle.
Dr Sonja Cleary is associate dean, student experience, School of Health and Biomedical Sciences, RMIT University.
Attree, M. (2007). Factors influencing nurses’ decisions to raise concerns about care quality. Journal of Nursing Management, 15(4), 392-402. doi: 10.1111/j.1365-2834.2007.00679.x
Cleary, S, & Duke, M. (2017). Clinical governance breakdown: Australian cases of wilful blindness and whistleblowing. Nursing Ethics, 0969733017731917. doi: 10.1177/0969733017731917
Cleary, S R. (2014). Nurse whistleblowers in Australian hospitals: a critical case study. (PhD), Deakin University, Deakin Burwood Melbourne
Davies, G. (2005). Queensland Public Hospitals Commission of Inquiry Report. Brisbane: Queensland Government.
Dixon-Woods, M, Baker, R, Charles, K, Dawson, J, Jerzembek, G, Martin, G, McCarthy, I, McKee, L, Minion, J, Ozieranski, P, Willars, J, Wilkie, P, & West, M. (2014). Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality & Safety, 23(2), 106-115. doi: 10.1136/bmjqs-2013-001947
HCCC. (2003). Investigation Report Campbelltown and Camden Hospitals Macarthur Health Service. Sydney: Health Care Complaints Commission.
Heffernan, M. (2011). Willful blindness. Why we ignore the obvious at our peril. New York: Walker publishing company.
Hunt, G. (1995). Introduction: Whistleblowing and the breakdown of accountability. In G. Hunt (Ed.), Whistleblowing in the Health Service: Accountability, Law & Professional Practice. London: Edward Arnold.
Jackson, D, Hickman, L D, Hutchinson, M, Andrew, S, Smith, J, Potgieter, I, Cleary, M, & Peters, K. (2014). Whistleblowing: An integrative literature review of data-based studies involving nurses. Contemporary Nurse: A Journal for the Australian Nursing Profession, 48(2), 240-252. doi: 10.5172/conu.2014.48.2.240
Jackson, D, Peters, K, Andrew, S, Edenborough, M, Halcomb, E, Luck, L, Salamonson, Y, Weaver, R, & Wilkes, L. (2010). Trial and retribution: A qualitative study of whistleblowing and workplace relationships in nursing. Contemporary Nurse, 36(1-2), 34-44. doi: 10.5172/conu.2010.36.1-2.034
Mannion, R, & Davies, H T. (2015). Cultures of silence and cultures of voice: the role of whistleblowing in healthcare organisations. International Journal of Health Policy Management, 4. doi: 10.15171/ijhpm.2015.120
McDonald, S., & Ahern, K. (2002). Physical and emotional effects of whistleblowing. Journal of Psychosocial Nursing & Mental Health Services 40(1), 14-27.
Miceli, MP, Near, JP, & Dworkin, TM. (2008). Whistle-blowing in organizations. New York Routledge/Psychpress.
Schein, E H. (2016). Whistle Blowing: A Message to Leaders and Managers: Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organizations". International Journal of Health Policy and Management, 5(4), 265-266. doi: 10.15171/ijhpm.2015.207
Vandekerckhove, W, Brown, A J, & Tsahuridu, E. (2014). Managerial responsiveness to whistleblowing: Expanding the research horizon. In A. J. Brown, D. Lewis, R. Moberly & W. Vandekerckhove (Eds.), International Handbook on Whistleblowing Research (pp. 299-327). Cheltenham, UK: Edward Elgar.
Wortley, R, Cassematis, P, & Donkin, M. (2008). Who blows the whistle, who doesn’t and why? In A. J. Brown (Ed.), Whistleblowing in the Australian Public Sector. Enhancing the theory and practice of internal witness management in public sector organisations (pp. 53-82). Canberra ACT: Australian National University E press.Do you have an idea for a story?
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