hub topic lead, Hugh Wilkins, explores attitudes towards and repercussions of whistleblowing, with emphasis on healthcare professionals who suffer retaliation after raising patient safety concerns. He draws attention to damaging discrepancies between written policy and actual procedure. Hugh urges all healthcare leaders to welcome the concerns that 'whistleblowers' raise in the public interest and respond positively to them, which would lead to substantial improvements in staff engagement, organisational culture, quality of care and patient safety.
*Whilst much of the information in this article is referenced and in the public domain it is not legal advice.
The word 'whistleblower' conjures up different emotional reactions in the minds of different people. Hero or villain? It probably depends on your perspective, which in turn may be shaped by your experience. In this article I hope to encourage reflection on terminology associated with the phenomenon of employer hostility towards healthcare staff who raise patient safety and related concerns while doing their job.
Reprisals against healthcare staff who raise patient safety concerns
Retaliation against whistleblowers is a problem in many industries. In this article I want to focus on healthcare staff whose careers suffer after raising concerns. In 2013, a report on a research project that studied the experiences of 1,000 employees who had sought advice from the UK whistleblowing charity Public Concern at Work (now Protect) found:
- Patient safety – an issue essentially confined to health and social care – is one of the top five concerns in this large sample of whistleblowers from many sectors (also including education, charities, local government, financial services and other industries). The other four of the top five issues reported in this study (ethical, financial malpractice, work safety and public safety concerns) are not industry specific.
- The study found that whistleblowers who had raised a patient safety concern were more likely to suffer formal reprisal than those who had spoken up about other matters. The most likely management reprisal against health sector whistleblowers was dismissal on their first attempt at speaking up, with the more senior the worker the higher the risk of dismissal.
These findings are truly disturbing from a patient safety perspective (not to mention other negative aspects of such retaliation).
Devastating consequences of negativity towards whistleblowers
I am ambivalent about the whistleblower term. I am aware of its pejorative connotation in the eyes of some and think that this hinders understanding and learning. Negative attitudes towards people who identify areas where healthcare improvements are needed can lead to failure to listen and respond properly to what they are saying – with devastating consequences for patients, staff and the organisation concerned.
Many NHS staff feel insecure about speaking up – even about unsafe clinical practice
Eight years after publication of the 'Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry', which documents abysmally poor response to numerous concerns raised by patients, families and staff, the recently published West Suffolk Review shows how poor the response can still be to NHS staff who speak up. The latest national staff survey results imply that about 330,00 workers (27.5% of the NHS England workforce of about 1.2 million people) would not feel secure raising concerns about unsafe clinical practice. Clearly this is wrong and underlines that there is still a long way to go before staff can be confident that it is safe for them to speak up about poor patient care.
Better understanding of how whistleblowers are perceived is needed
Whilst there are many facets to the complex issue of why some managers and leaders retaliate against staff who are simply doing their job in reporting problems, the way that whistleblowers are perceived within organisations and wider society is an important factor, which needs to be better understood if there is to be real progress in this area. Bias, conscious or unconscious, favourable or unfavourable, can cloud judgments in whistleblowing cases. Objectivity is required to recognise, and hopefully eliminate, any prejudice which may exist. This is important so that the concerns raised, the motivation of those who report them and organisational responses to such reports can each be assessed on their merits.
Prejudice against whistleblowers and hostility towards them is a patient safety issue
Referees in many sports carry a whistle which they can blow to call a halt and ensure fair play. The whistle blown by workers when speaking up is metaphorical rather than physical but raising a concern is analogous to referees blowing the whistle, in that both are attempts to rectify contravention of the rules. Illustrating the influence of bias, it is well known that football fans' opinions about the ref may be highly dependent on which team they support.
In a similar way, prejudicial bias against whistleblowers in general may carry over to workplace settings when organisations handle whistleblowing cases. All too often the organisational reflex is to focus attention onto the person who has spoken up, not on the concerns they have raised. Numerous cases and reports provide evidence of this being seriously detrimental to patients and staff – and to the organisations themselves. Hostility towards healthcare professionals who raise concerns is a patient safety issue.
Stages of whistleblowing
There are substantially different interpretations of what constitutes 'whistleblowing' and what a 'whistleblower' is, which colour perceptions as to whether whistleblowers are seen in a positive or negative light. In this respect, it is important to distinguish between:
- internal reporting within an organisation;
- external reporting to a person or body, such as an MP or regulator;
- public disclosure, e.g. via social media, mainstream media or writing a book.
In my experience, healthcare professionals who inadvertently joined the community of harmed whistleblowers invariably started their journey by internal reporting. In all innocence they reported patient safety and related concerns through appropriate internal channels.
In so doing they were doing their job, in line with their professional codes of conduct. They surely had a right to expect a professional response (in line with organisational policy, though they may not have consulted the whistleblowing policy at that stage - they probably did not then see themselves as whistleblowers). I think it needs to be stressed that they were simply doing their job and were probably unprepared for the hostility with which their concerns were received by their employers.
Whistleblowing is usually a process, rarely a single event. In healthcare organisations, internal reporting typically involves a succession of reports, to higher and higher levels in the local organisational hierarchy if the whistleblower believes that the issue has not been properly addressed. In such cases, in line with NHS whistleblowing policy, they may escalate matters by external reporting to a 'prescribed person'.[7, 8] Increasing numbers of harmed whistleblowers, having exhausted internal reporting and perhaps also external reporting stages, put their stories into the public domain. I do not know of any healthcare professional who has made a public disclosure without having first gone through at least the internal reporting stage. I think this is often overlooked, but is very important in understanding the realities of whistleblowing, particularly in the healthcare context.
Whistleblowers – heroes or villains?
As suggested above, perception of whistleblowers is an important aspect of how they are treated. Perceptions about them generally fall into one of two groups. On the one hand, it seems to be increasingly recognised that they are a force for good in society. On the other hand, there are those who still regard whistleblowers in a very poor light. This simple binary model is complicated by virtue-signalling from some who profess support for whistleblowers in concept, whilst in real life being instrumental in detrimental action taken against them.
Context and motivation are important. There is a world of difference between people speaking up in good faith in the public interest (e.g. healthcare professionals seeking to improve patient safety) and individuals claiming whistleblower status for other reasons. These groups deserve to be regarded and treated differently.
I am of course not suggesting that healthcare professionals raising concerns about patient care are the only whistleblowers acting in the public interest. Nor am I suggesting that all whistleblowers are subjected to retaliation. Many people in all walks of life raise concerns every day and are thanked by organisations who recognise and welcome the opportunity to make improvements. But far too often this this does not happen, with organisations reacting with inappropriate and sometimes brutal aggression against the whistleblower, distracting attention away from the concerns themselves.
The attached document, which can can be downloaded by clicking below, contains a number of definitions that have been proposed for whistleblowing and whistleblower. It also contains other alternative terms sometimes used instead of whistleblower, whistleblowing and concern.
Acting in the public's interest
I have explored the lexicon of whistleblowing (see attachment above), with a particular focus on healthcare professionals raising concerns about patient safety in the course of doing their job. I highlight that whistleblowing can be a very loaded term, evoking bias and adversely affecting attitudes towards whistleblowers.[24-26] However, 'whistleblowing' and 'whistleblower' have the merit of being single words, which can be beneficial in concise communication.
United Nations guidance on good practice in the protection of reporting persons states that:
"A public awareness campaign is one way to promote cultural perceptions of whistleblowers as people acting for the public good and out of loyalty to their organization, profession and to society, rather than as traitors or informers."
Greater awareness that whistleblowers acting in the public interest are doing so out of loyalty to their organisation, profession and society is certainly needed.
Those judging the actions of staff who raise valid concerns about patient safety should reflect on whether or not they are acting in the public interest (a rhetorical question, surely). They should also reflect on the fact that healthcare staff who speak up are probably acting in accordance with organisational policies and, where relevant, professional codes of conduct.
Discordance between policy and practice
A message on the Gov.uk website ends with the exhortation "don't ever stop speaking truth unto power". However, speaking up is just part of what needs to happen. Those in power need to listen to what staff are telling them, however uncomfortable that may be. Problems arise if organisational power dynamics prevent concerns being heard by leaders.
Evidence suggests that discrepancies between policy and practice in responses to healthcare staff who speak up exist in many healthcare organisations.[1,4,7,14,22-24,29]
Organisational leaders should be alert to the possibility of conscious or unconscious bias prejudicing the handling of whistleblowing cases. They should exert due diligence in ensuring that policies that allow personnel to raise concerns freely without fear of retaliation are not only created but, crucially, are also implemented. There is compelling evidence of discordance between policy and practice in this respect.[1-3,7,14-18,22,29]
In considering whether or not reports of wrongdoing, breaches, violations or poor practice are in the public interest, it may be helpful to start by considering whether or not the concern relates to any of the following: criminal offence; failure to comply with a legal obligation; miscarriage of justice; danger to health or safety; environmental damage; cover up.[15,16] Did the so-called 'whistleblower' report their concerns internally at the outset, in line with organisational policies? If so, how can reprisals against them be defensible in an organisation seeking to support its workforce in delivering compassionate care?
I suspect that careful analysis of the concerns raised by most healthcare professionals whose careers have been wrecked after speaking up would show that they meet the criteria for being both qualifying disclosures and protected disclosures.[15-18] Should they be seen as troublemakers? Of course not.
Healthcare professionals have a professional duty to raise patient safety and related concerns if they are aware of poor practice. It is totally wrong for any worker to be at risk of retaliation from their employers for doing their job. Protection of healthcare staff who speak up is a patient safety issue.
This article is not legal advice. However, it contains information in the public domain about legislation,[15-17] authoritative guidance,[8,13] and policy.[7,23] Until there is a substantial change of culture within the NHS, UK healthcare professionals must decide for themselves how to balance risks of speaking up about poor practice and risks of keeping silent – and how they can best do this to protect patients and themselves.
I have focused on healthcare professionals who have suffered detriment after identifying areas for improvement in healthcare provision. The Freedom To Speak Up review confirmed the existence of serious problems in this area in the NHS. It is clear from the most recent Annual Report from the National Guardian's Office, NHS staff survey results, and the latest in a series of reports of retaliation against whistleblowers that many staff are still, with good reason, far from confident that they will be safe if they speak up about poor patient care.
My aim in writing this article is to improve understanding of what motivates healthcare staff to speak up and the risks they run in doing so. I have emphasised the crucial public interest aspect of whistleblowing and drawn attention to the need for whistleblowers acting in the public interest to be recognised as loyal members of the team, not regarded as troublemakers. I hope it contributes to learning and the culture change in this area that is widely acknowledged as being needed. I would be delighted if it supports rehabilitation of the reputation and career of anybody who has experienced reprisals after raising concerns in the public interest. They should be thanked, not vilified.
Critical thinking, good analytical skills and wisdom are needed in judging the extent to which organisational policies supporting the rights and responsibilities of personnel to raise safety concerns are borne out in practice. Whistleblower voices need to be heard and welcomed. If all healthcare leaders were to respond positively to employees who, in good faith, raise genuine concerns, and not tolerate harassment, intimidation, retaliation or discrimination for raising concerns, I have no doubt that this would lead to substantial improvements in staff engagement, organisational culture, quality of care and patient safety.
- Vandekerckhove W, West C. Public Concern at Work / University of Greenwich. Whistleblowing: the inside story - a study of the experiences of 1,000 whistleblowers, 2013. https://gala.gre.ac.uk/id/eprint/10296/
- Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry
- Outram C.West Suffolk Review, December 2021. https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/12/west-suffolk-review-081221.pdf
- NHS Staff Survey 2020 National results briefing (March 2021) p.35 q17b. https://www.nhsstaffsurveys.com/static/afb76a44d16ee5bbc764b6382efa1dc8/ST20-national-briefing-doc.pdf
- Full Fact (2017). How many NHS employees are there? https://fullfact.org/health/how-many-nhs-employees-are-there/
- Vandekerckhove W and Phillips A. Whistleblowing as a protracted process: A study of UK whistleblower journeys. Journal of Business Ethics Issue 1 2019; 159(2):1-19. https://www.springerprofessional.de/en/whistleblowing-as-a-protracted-process-a-study-of-uk-whistleblow/15192750
- NHS England and Improvement (2016). Freedom to speak up: raising concerns (whistleblowing) policy for the NHS. https://www.england.nhs.uk/wp-content/uploads/2021/03/freedom-to-speak-up-raising-concerns-policy-for-the-nhs-april-19.pdf
- Department for Business, Energy and Industrial Strategy. Whistleblowing: list of prescribed people and bodies. https://www.gov.uk/government/publications/blowing-the-whistle-list-of-prescribed-people-and-bodies--2/whistleblowing-list-of-prescribed-people-and-bodies
- Rodulson V, Marshall R, Bleakly A. Whistleblowing in medicine and in Homer's Iliad. Medical Humanities 2015;41:95-101. https://mh.bmj.com/content/41/2/95
- Nader R, Petkas P, Blackwell K. Whistle Blowing: the Report of the Conference on Professional Responsibility held in Washington DC, September 1972. ISBN-10: 0670762253. https://searchworks.stanford.edu/view/685302
- Miceli M, Near J. Characteristics of Organizational Climate and Perceived Wrongdoing Associated with Whistle-Blowing Decisions. Personnel Psychology, 1985; 38(3), 525-544. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1744-6570.1985.tb00558.x
- International Standards Organization (2021). Whistleblowing management systems - Guidelines: ISO 37002:2021. https://www.iso.org/standard/65035.html
- Gov.uk website. Whistleblowing for employees. https://www.gov.uk/whistleblowing
- Robert Francis QC. Report of the 'Freedom to speak up' review, 2015. http://freedomtospeakup.org.uk/
- Employment Rights Act 1996. https://www.legislation.gov.uk/ukpga/1996/18/contents
- Public Interest Disclosure Act 1998. https://www.legislation.gov.uk/ukpga/1998/23/contents
- Enterprise and Regulatory Reform Act 2013. https://www.legislation.gov.uk/ukpga/2013/24/contents
- Sprack J. Blackstone's Employment Tribunal Handbook 2014-2015. https://global.oup.com/academic/product/blackstones-employment-tribunals-handbook-2014-15-9780198719427?cc=gb&lang=en&
- Directive (EU) 2019/1937 of the European Parliament and of the Council of 23 October 2019 on the protection of persons who report breaches of Union law. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32019L1937
- National Guardian's Office. What is speaking up? https://nationalguardian.org.uk/speaking-up/what-is-speaking-up/
- National Guardian's Office. Listen Up training for all managers launched (2021). https://nationalguardian.org.uk/2021/01/26/listen-up-training/
- National Guardian's Office Annual Report 2020 pp 5, 17. https://nationalguardian.org.uk/wp-content/uploads/2021/04/NGO_AR_2020_Digital.pdf (published March 2021)
- NHS England (2017). External Whistleblowing Policy. https://www.england.nhs.uk/wp-content/uploads/2016/09/external-whistleblowing-policy-v4.pdf (accessed 29.12.21)
- United Nations Office on Drugs and Crime (UNODC, 2021). Speak up for health! Guidelines to enable whistle-blower protection in the health-care sector. https://www.unodc.org/documents/corruption/Publications/2021/Speak_up_for_Health_-_Guidelines_to_Enable_Whistle-Blower_Protection_in_the_Health-Care_Sector_EN.pdf
- Roget's 21st Century Thesaurus, third edition. Whistleblower synonyms. https://www.thesaurus.com/browse/whistleblower
- UNODC (2013). An Anti-Corruption Ethics and Compliance Programme for Business: A practical guide. https://www.unodc.org/documents/corruption/Publications/2013/13-84498_Ebook.pdf
- UNODC (2015). United Nations Convention against Corruption: Resource guide on good practices in the protection of reporting persons. https://www.unodc.org/documents/corruption/Publications/2015/15-04741_Person_Guide_eBook.pdf
- Gov.uk website (2014). Speak truth unto power. https://www.gov.uk/government/news/speak-truth-unto-power (accessed 1.1.22)
- Reitz M, Higgins J. Speaking truth to power: why leaders cannot hear what they need to hear. BMJ Leader 2021;5:270–273. https://bmjleader.bmj.com/content/5/4/270
- International Atomic Energy Agency (IAEA, 2020). A Harmonized Safety Culture Model. https:/www.iaea.org/sites/default/files/20/05/harmonization_05_05_2020-final_002.pdf
About the Author
Hugh is Patient Safety Learning's hub topic leader for whistleblowing.