Nurses and whistleblowing: the ethical issues

The principle of double effect and external whistleblowing in nursing

Nurses are generally expected to raise concerns when a harm or wrongdoing is committed against patients. Should their concerns not be adequately addressed, then nurses may take the decision to engage in external whistleblowing. Given that it could have a negative effect on the health care organization or service, nurses may question whether they should engage in external whistleblowing. Consequently, is there an ethical criterion to discern whether the negative effect on the health care organization or service is ethically permissible? This paper argues for the suitability of the Principle of Double Effect as an ethical criterion. The position of this paper is that external whistleblowing by a nurse when understood as an advocacy act with two effects (i.e. the effect of defending a patient and the further negative effect on the health care organization or service) can be ethically permissible through meeting the conditions of the Principle of Double Effect.

What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff

The importance of trainee medical staff in alerting Trusts to patient safety risks and low-quality care was established by the Francis Report, yet many remain hesitant about speaking up. Known barriers include lack of feedback, sceptical attitudes to the likelihood of change and fear of consequences. The author explores other factors including moral orientation in the workplace, role modelling by senior clinicians, discontinuity, 'normalisation of deviance', human reactions to burnout/moral injury, loyalty and the spectrum of motivation. The issues of absent feedback and fear are discussed in detail. Challenges met by those receiving reports are also described, such as how to collate soft intelligence, putting concerns into context (the 'bigger picture') and stewardship of resources. Initiatives to encourage reporting of trainees' concerns such as speak up guardians, 'Speak Up for Safety' campaign and simulation training are described. A proposal to embed proactive intelligence-gathering arrangements is presented.

Improving health care quality: the implementation of whistleblowing

Purpose

In line with the current literature, the purpose of this paper is to contribute to a better understanding of whistleblowing procedures and their influence on overall organisational quality. To this end, institutional, organisational, and cultural barriers to whistleblowing implementation have been investigated.

Design/methodology/approach

A qualitative analysis based on three explorative case studies investigates and compares different whistleblowing practices implemented in health care organisations, operating within the Italian National Health Service (INHS).

Findings

INHS organisations have implemented whistleblowing procedures in different ways, despite the fact that the procedures are laid down by law. These differences are mainly due to cultural, administrative, organisational, and process barriers, which have a deep impact on whistleblowing integration in managerial practices and their influence on the overall quality of health processes and services.

Research limitations/implications

This research paper was limited by the analysis of three Italian public health care organisations, which did not allow the generalisability of findings. Therefore, the study offers interesting insights on the way effective whistleblowing systems should be implemented in order to support managers to improve organisation’s management and service quality.

Originality/value

The paper represents one of the first attempts to structurally analyse the practice of whistleblowing in an Italian healthcare system. Therefore the study has mainly focussed not only on the analysis of whistleblowing practices, but also on their impacts on the improvement of organisational processes’ quality and, subsequently, on social well-being.

Whistleblowing and Boundary Violations: exposing a colleague in the forensic milieu

The purpose of this article is to examine the phenomenon of whistleblowing as it relates to a reconstructed case study of an erotic boundary violation that emerged from a clinical situation in forensic psychiatric nursing practice. The unique features of this case are illustrated with the help of a model for decision making. Although the ramifications of exposing a colleague are many, it is argued that, in this particular case, it was morally and ethically the right thing to do.

Will nurses be enabled to speak up when things go wrong?

Professor Alan Glasper of the University of Southampton discusses the Government's efforts to provide support for whistleblowers who wish to escalate healthcare concerns in institutions in England.

Reporting misconduct of a coworker to protect a patient: a comparison between experienced nurses and nursing students

Purpose. Whistleblowing is the reporting of illegal, immoral, or illegitimate practices to persons or organizations that may affect the action. The current study compares experienced nurses to nursing students regarding their willingness to blow the whistle to protect a patient's interests. Methods. 165 participants were divided into two groups: 82 undergraduate nursing students and 83 experienced nurses. Participants responded to two vignettes that described a colleague's and a manager's misconduct at work. Results. The nursing students perceived the severity of the misconduct significantly lower compared to the experienced nurses. The nursing students also ranked the internal and external whistleblowing indices higher than the nurses, but the differences did not reach statistical significance. For each of the examined internal and external indices, professional experience was found to be significant in multivariate regression analyses. Conclusions. Even though nursing students perceived the severity of the misconduct significantly lower than the experienced nurses, the students demonstrated a greater readiness to blow the whistle, both internally and externally. Recommendations for handling comparable situations are offered.

Labor unions in medicine: the intersection of patient advocacy and self-advocacy

BACKGROUND

Labor unions have been a weak force in the medical marketplace.

OBJECTIVES

To briefly review the history of physicians' and nurses' labor unions, explore the ethics of unions in medicine, and offer a solution that simultaneously serves patients and professionals.

RESEARCH DESIGN

A selective review of the literature.

RESULTS

Labor unions of medical professionals pose an ethical quandary, that is a tension between selfless patient advocacy versus self-advocacy. The primary role of labor unions has been to extract from management benefits for employees. The threat of work actions is the primary tool that labor unions can apply to encourage management to negotiate mutually acceptable conditions of employment. Work actions-namely slow-downs and strikes-may harm patients and may therefore run afoul of professionals' primary duty to the primacy of patients' welfare. An alternative model is offered wherein medical unions align self-centered and patient-centered interests and leverage the Public Good, in the form of public opinion, to encourage good-faith bargaining with management.

CONCLUSIONS

As medicine becomes increasingly corporatized, physicians will join nurses in "at-will employment" arrangements whereby self-advocacy and patient advocacy may be impacted. Although labor unions have been a means of counterbalancing unchecked discretion of corporate management, conventional labor unions may run afoul of medical ethical principles. Reconsideration and innovation, to address this ethical dilemma, could provide a solution that aligns both clinicians' and patients' welfare.

Nursing students' willingness to blow the whistle

BACKGROUND AND PURPOSE

Whistleblowing in the nursing profession is a complex dilemma. If nurses decide to do nothing to stop a colleague's or management's harmful conduct, they may be violating their basic professional commitment to promote and protect patients' health. Whistleblowing is also complex given that the act might have negative consequences for the whistleblower as well as the wrong doer. This study aims to answer three questions, and suggests some lines for further research on this topic as well as ways for integrating it in the nursing curriculum: Are nursing students willing to take action to stop misconduct in order to protect a patient's interest? Are they willing to report the misconduct to authorities within an organization and/or outside of it? Are they willing to report a colleague's wrongdoing as well as that of a manager?

SUBJECT AND METHODS

Eighty two nursing students in Israel were presented with a questionnaire containing two vignettes, and required to make a decision that involved whistleblowing. One vignette described a case of misconduct of a colleague, and the other a misconduct of a manager.

RESULTS

The findings indicate that the students considered acts that are detrimental to the patient to be very serious. The participants gave high and similar scores to their own willingness to take action to change the situation for both vignettes. The score of the internal index was found to be significantly higher than the external index.

DISCUSSION

The participants' desire to correct a colleague's or superior's misconduct was coupled with a progressive retraction as the circle of disclosure widened. The retraction may reflect the respondents' concerns that external exposure could have negative consequences for the wrong-doer, the healthcare organization and/or the individuals who receive its services.

The Process of Whistleblowing in a Japanese Psychiatric Hospital

This study aims to unveil the process of whistleblowing. Two nursing staff members who worked in a psychiatric hospital convicted of large-scale wrongdoing were interviewed. Data were analyzed using a modified grounded theory approach. Analysis of the interviews demonstrated that they did not decide to whistleblow when they were suspicious or had an awareness of wrongdoing. They continued to work, driven by appreciation, affection, and a sense of duty. Their decision to whistleblow was ultimately motivated by firm conviction. Shortly after whistleblowing, wavering emotions were observed, consisting of a guilty conscience, fear of retribution, and pride, which subsequently transformed to stable emotions containing a sense of relief and regret for delayed action. It is necessary for nurses to recognize that their professional responsibility is primarily to patients, not to organizations. Nurses should also have professional judgment about appropriate allegiance and actions.

Blowing the whistle on healthcare fraud: should I?

PURPOSE

The purpose of this article is to explore some of the factors involved when a nurse practitioner (NP) is confronted with a healthcare fraud situation. Ethical concepts and decision-making strategies are provided, as well as practical legal considerations.

DATA SOURCES

Government Internet Web sites; healthcare management, ethics, and nursing journals.

CONCLUSIONS

There are many forms of healthcare fraud. Healthcare fraud saps financial resources from the healthcare system and from individuals. The decision to blow the whistle on a colleague or organization is not an easy one and has potential for great discomfort. There are ethical decision-making strategies and practical considerations for the process of whistle-blowing should it become necessary.

IMPLICATIONS FOR PRACTICE

NPs may be confronted daily with billing and reimbursement issues. Being prepared to recognize healthcare fraud and knowing the ramifications of whistle-blowing are important tools to have in one's practice repertoire.