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Mannion R, Blenkinsopp J, Powell M, et al. Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. Southampton (UK): NIHR Journals Library; 2018 Aug. (Health Services and Delivery Research, No. 6.30.)
Any study intending to explore whistleblowing in the NHS requires an understanding of the conceptual underpinnings of whistleblowing and the key theoretical and methodological debates within whistleblowing research. This chapter, therefore, begins the process of unpacking what is meant by whistleblowing and introduces some of the sources of the ideas, conceptual underpinnings and different approaches to understanding whistleblowing and related terms such as ‘speaking up’. The material draws on the systematic literature review detailed in Chapter 3 (see that chapter for an account of the methods by which the literature was uncovered and collated), as well as from the accumulated expertise of the research team and from discussions with leading researchers in the field.
The chapter is structured as follows. We begin by outlining how whistleblowing has developed as a distinctive field of enquiry, and explore how whistleblowing and related concepts such as speaking up have been defined in the literature. We then review the main theoretical perspectives on whistleblowing that have been seen in the literature, and examine emerging perspectives that have the potential to develop our understanding further. We then rehearse the key methodological challenges involved in whistleblowing research, before drawing out some of the implications of these for more thorough NHS-specific research.
Whistleblowing was first brought to wide public awareness in the 1970s, and has become progressively more high profile. The release of the Pentagon Papers in 1971 was not the first example of whistleblowing, but it was arguably the first to be widely known. There are three competing explanations for the origins of the term ‘whistleblowing’, and these provide useful insights into the tensions and ambiguities that still surround the practice. The most frequently encountered explanation is that it comes from an analogy with police officers blowing a whistle, to attract the attention of an individual to whom the officer wished to speak, or to bring other officers in the vicinity to the scene (in the days before mobile communications). Another suggested analogy is with the use of a whistle by referees in sport to call a halt to a game after a foul has been committed.
A third, perhaps less likely, but nonetheless intriguing, explanation, is that the term derives from 19th century US legislation that required train drivers to sound a whistle when they approached crossings. Failure to do so could lead to fines, and, moreover, citizens calling attention to these failures could receive payment for doing so. Indeed, in the US legal system it remains the case that those blowing the whistle on financial irregularities can sometimes stand to gain personally from the reporting of such wrongdoing. This articulation of whistleblowing speaks to the still-current concern that whistleblowers might be motivated by personal gain. Taken together, then, these putative etymologies describe whistleblowing variously as an act of calling for help, crying foul or informing the authorities (perhaps) for personal gain.
The academic interest in whistleblowing followed its greater public profile, with a handful of seminal articles published between 1983 and 1985 proving influential (see Chapter 3, Literature review methods). From the outset, whistleblowing research was inherently multidisciplinary, with scholars from law, management, public administration, sociology and psychology all interested in the phenomenon. An unusual feature of the whistleblowing field is the relative lack of definitional debates. Over 30 years ago, Near and Miceli 12 defined whistleblowing as ‘the disclosure by organization members (former or current) of illegal, immoral, or illegitimate practices under the control of their employers, to persons or organizations that may be able to effect action’. This definition quickly gained almost universal acceptance and application, and remains the standard definition. The surprising lack of debates on definition among whistleblowing researchers stands in stark contrast to debates within wider society concerning the purpose and value of whistleblowing, the motivation of whistleblowers and the circumstances under which they should receive legal protection for their actions. The last issue is key: prospective whistleblowers are likely to be less concerned about how academics define whistleblowing, and more concerned about how the law defines it and whether or not they can expect protection under the law for their actions. 13
The debate continues as countries around the world consider enacting whistleblowing protection legislation or revising existing laws.
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 definition 12 incorporates behaviour that most employees or citizens would be unlikely to label whistleblowing. Park et 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 1 details how the Park et al. 14 typology might translate into a health-care context.
Types of whistleblowing (from Park et al.)
Notwithstanding the Park et 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 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 Kelly 17 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 in Chapter 3 that the relevant literature within health care tends to emphasise voice behaviours rather than formal whistleblowing.
Francis 11 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. Alford 18 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 up 2 , 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 Francis 11 and Kelly and Jones 19 observe, in many scandals staff had voiced their concerns; the problem was getting someone to listen.
This is consistent with the ‘deaf effect’, a term originally coined by Keil and Robey 23 to describe the reluctance of senior managers to hear, accept and act on challenging observations from lower down the organisation. Vandekerckhove et 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, Vandekerckhove et 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 (see Chapter 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 Inquiry 11 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.
Central to whistleblowing research has been the idea of wrongdoing, a catch-all term that includes everything from persistent acts of minor incivility to multibillion-pound corruption. Within any given organisation, there are various types of wrongdoing on which an individual might feel it necessary to blow the whistle. The focus of the present project is on issues pertaining to the quality and safety of patient care, but it is worth examining the ways in which perceptions of the nature of the wrongdoing might affect whistleblowing. The bulk of whistleblowing research has been concerned with pecuniary wrongdoing such as fraud and corruption, in which there is, in principle, a final legal judgement to be obtained as to whether or not wrongdoing has occurred. In contrast, issues around safety and quality can be much more ambiguous, a point illustrated by two cases that form part of NHS folklore on whistleblowing: the ‘Graham Pink case’ 27 and Bristol Royal Infirmary. 5
The Graham Pink case is generally remembered as an archetypal whistleblowing narrative. Pink (a nurse) raised concerns with the hospital’s management about dangerously low staffing levels; management would not listen and did not act, so Pink ‘blew the whistle’ and was eventually removed from his post for his trouble. Vinten 28 suggests a somewhat different interpretation, arguing that there was ample evidence that management took Pink’s concerns seriously and investigated, but found staffing levels to be appropriate. Pink’s colleagues on the unit agreed with the management’s assessment, but were unable to get this message across to the Royal College of Nursing, who found Pink’s account more compelling against a backdrop of concerns about government policy in the NHS. The Pink case revolved around an issue – staffing levels – about which there was (and is) considerable scope for experienced practitioners to reach very different views. Although there will be a level of staffing that everyone would agree is unsafe, it has proved difficult to develop an evidence-based metric to calculate minimum safe staffing levels and appropriate skill mix. 29
The tragic events surrounding infant heart surgery at Bristol Royal Infirmary might appear to be more amenable to an evidence-based analysis, given that the extensive use of clinical audit data allows comparisons of performance over time and between units. Yet, as Weick and Sutcliffe 30 observe, even with such extensive data there is still a need for organisations to make sense of the data, and all sense-making is intentional and social. There was clearly a desire at Bristol Royal Infirmary to believe that the unit was performing acceptably, and management and senior clinicians interpreted the data in terms of a learning curve. They focused on evidence that the unit was improving, and overlooked evidence that it was still underperforming relative to comparable units and that it was improving only slowly.
As the analysis of public inquiries shows (see Chapter 4), issues that appear unambiguous after the event may have seemed open to interpretation of the event at the time. This creates a challenge for policy-makers: we are generally dealing not with malevolent individuals or corrupt systems, but with individuals and systems that are failing in some way, and resistant to hearing the messages about that failure. As the whole premise of whistleblowing is ‘wrongdoing’, and wrongdoing appears a moral appellation, people are reluctant to use the term and recipients are reluctant to hear it. This underlines the importance of developing a greater understanding of hearer courage, particularly in a NHS context.
The inherent ambiguity of many of the situations complained about at the heart of whistleblowing in the NHS draws further attention to the importance of definitional issues. Brown et al. 31 suggest that wrongdoing be defined as ‘when a person or organisation does things that are unlawful, unjust, dangerous or dishonest enough to harm the interests of individuals, the organisation or wider society’. This definition is both more precise and more encompassing than the traditional ‘illegal, immoral or illegitimate practices’, 20 and would certainly cover actions/omissions that could have a negative impact on care quality and safety.
Taking this further, Skivenes and Trygstad 32 suggest that there are six ‘intrinsic dimensions’ that affect individuals’ assessment ‘of an alleged act or practice of wrongdoing and the degree of importance (or seriousness) of an act of wrongdoing’ (p. 97). These dimensions are (1) whether the perception of wrongdoing is subject or objective, (2) whether it relates to values (such as dignity) or facts (such as clinical outcomes), (3) the frequency of the wrongdoing (e.g. a rare occurrence or an ongoing problem), (4) whether or not the wrongdoing was intentional, (5) whether or not there is a public interest dimension and (6) the persons/groups affected (e.g. are they vulnerable?). In a NHS context, the final two dimensions are arguably ‘fixed’; the activities of the service always have a public interest dimension, and patients are by definition vulnerable persons even if they would not in the normal course of life be viewed in those terms. It is therefore only the first four dimensions that influence whether or not a situation is assessed as wrongdoing, and, if so, how serious it is (Figure 1; Table 2 provides some simple vignettes that illustrate the opposite ends of these dimensions).
Dimensions for assessing wrongdoing (adapted from Skivenes and Trygstad, p. 97).
