Exploring the utility of internal whistleblowing in healthcare via agent-based models

Overcoming walls and voids: Responsive practices that enable frontline workers to feel heard

BACKGROUND

There is increasing recognition that beyond frontline workers' ability to speak up, their feeling heard is also vital, both for improving work processes and reducing burnout. However, little is known about the conditions under which frontline workers feel heard.

PURPOSE

This inductive qualitative study identifies barriers and facilitators to feeling heard among nurses in hospitals.

METHODOLOGY

We conducted in-depth semistructured interviews with registered nurses, nurse managers, and nurse practitioners across four hospitals ( N = 24) in a U.S. health system between July 2021 and March 2022. We coded with the aim of developing new theory, generating initial codes by studying fragments of data (lines and segments), examining and refining codes across transcripts, and finally engaging in focused coding across all data collected.

FINDINGS

Frontline nurses who spoke up confronted two types of challenges that prevented feeling heard: (a) walls, which describe organizational barriers that lead ideas to be rejected outright (e.g., empty solicitation), and (b) voids, which describe organizational gaps that lead ideas to be lost in the system (e.g., structural mazes). We identified categories of responsive practices that promoted feeling heard over walls (boundary framing, unscripting, priority enhancing) and voids (procedural transparency, identifying a navigator). These practices appeared more effective when conducted collectively over time.

CONCLUSION

Both walls and voids can prevent frontline workers from feeling heard, and these barriers may call for distinct managerial practices to address them. Future efforts to measure responsive practices and explore them in broader samples are needed.

PRACTICE IMPLICATIONS

Encouraging responsive practices may help ensure that frontline health care workers feel heard.

The Public's Self-Avoidance and Other-Reliance in the Reporting of Medical Insurance Fraud: A Cross-Sectional Survey in China

Purpose

To understand the public's self-willingness to report medical insurance fraud and their expectations on others, to provide a reference for the government to do a good job in medical insurance anti-fraud.

Methods

Data were obtained from a questionnaire survey of 846 respondents in China. Descriptive statistical analyses and multinomial logistic regression were used to analyze the different subjective attitudes of the public toward different subjects when faced with medical insurance fraud and the influencing factors.

Results

511 (60.40%) respondents were willing to report medical insurance fraud, while 739 (87.35%) respondents expected others to report it. 485 (57.33%) respondents were willing and expected others to report medical insurance fraud, followed by those who were not willing but expected others to report it (254, 30.02%). Compared to those who were unwilling to report themselves and did not want others to report, those who believe their reporting is useless (OR=3.13, 95% CI=1.15-8.33) and those who fear for their safety after reporting (OR=2.96, 95% CI=1.66-5.26) were more likely to expect others to report. Self-reporting willingness was stronger among the public who were satisfied with the government's protective measures for the safety of whistleblowers (OR=4.43, 95% CI=1.38-14.17). The public who believe that both themselves and others have responsibilities to report medical insurance fraud were willing to report and expect others to do the same.

Conclusion

The public had a "self-avoidance" and "other-reliance" mentality in medical insurance anti-fraud. The free-rider mentality, lack of empathy, concerns about own risk after reporting, and the interference of decentralized responsibility were important factors contributing to this public mentality. At this stage, the government should prevent the public's "collective indifference" in medical insurance anti-fraud efforts. Improving the safety and protection of whistleblowers and making everyone feel more responsible and valued may be effective incentives to enhance the public's willingness to report.

Intention of Staff and Students to Use Internal Whistleblowing to Report Sexual Violence: A Case Study of a Nigerian University

Sexual violence with its enormous negative consequences has become an epidemic most especially among the young populations. An effective danger-proof reporting system is necessary for curbing this menace including use of the internal whistleblowing mechanism. The study employed a concurrent (parallel) mixed method descriptive design for explaining the sexual violence experiences of university students, the intention of staff and students to blow the whistle, and their preferred whistleblowing strategies. A total of 167 students and 42 members of staff (69% males and 31% females, respectively) were randomly selected from four academic departments (50%) of a university of technology in Southwest Nigeria. An adapted questionnaire containing three vignettes on sexual violence and a focus group discussion guide were used for data collection. We discovered that 16.1% of the students reported to have experienced sexual harassment, 12.3% had attempted rape, and 2.6% had experienced rape. Tribe (Likelihood-Ratio, LR = 11.16; p = .004) and sex (χ² = 12.65; p = .001) were strongly associated with sexual violence experiences. Also, 50% staff and 47% students had high intention. Regression analysis showed that industrial and production engineering students will be 2.8 times more likely to have intention to internally blow the whistle more than other students (p = .03; 95% CI [1.1, 6.97]). Female staff had 5.73 odds of intention more than male staff (p = .05; [1.02, 32.1]). Also, we observed that senior staff will 31% less likely blow the whistle than the junior staff (Adjusted Odd Ratio, AOR = 0.04; [0.00, 0.98]; p = .05). In our qualitative findings, courage was mentioned as a factor necessary for blowing the whistle while anonymous reporting was emphasized for successful whistleblowing. However, the students preferred external whistleblowing. The study has implication for the establishment of sexual violence internal whistleblowing reporting system in higher education institutions.

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.

Why Not Blow the Whistle on Health Care Insurance Fraud? Evidence from Jiangsu Province, China

Purpose

To identify the factors that influence whistleblowing behavior as it relates to health care insurance fraud in Jiangsu Province, China.

Methods

To construct a factor model and formulate research hypotheses using the Motivation–Opportunity–Ability framework. We designed a questionnaire containing 24 items and distributed it on-site to 2081 respondents in Jiangsu Province, China. Afterward, we applied structural equation modeling to validate the research hypotheses.

Results

Policy awareness negatively contributes to whistleblowing behavior, risk perception does not reduce the incentive to blow the whistle, and an inability to recognize fraud is another critical barrier to converting whistleblowing intentions into behavior.

Conclusion

Practices that are likely to promote citizen whistleblowing on insurance fraud may focus on the constraints identified by the comprehensive Motivation–Opportunity–Ability framework.

Speaking-up for patient safety: A scoping narrative review of international literature and lessons for radiography in Ghana and other resource-constrained settings

OBJECTIVES

Employees 'speaking-up', or raising concerns about unsafe practices, has gained traction across healthcare, however, the topic has not been widely discussed within radiography generally or within resource-constrained healthcare settings. A systematic scoping narrative review identified the experiences of radiographers in speaking-up about safety concerns, which was extended to healthcare professionals more broadly. The scope of the review was further extended to cover speaking-up in non-healthcare resource-constrained settings in Africa.

KEY FINDINGS

Sixty-three studies were included in the review. The majority originated from westernised and/or higher resource health systems, with a dearth of literature from Africa and other resource-constrained settings. Several studies identified barriers and enablers confronting healthcare workers wishing to speak-up. While 'speaking-up' as a concept has gained international interest, most studies are, however, focussed on nursing and medical practice contexts, overlooking other healthcare professions, including radiography. The findings are synthesised into a series of key lessons for healthcare and radiography practitioners in Ghana and other resource-constrained settings.

CONCLUSION

The topic has been largely overlooked by policy makers, both within healthcare generally and specifically within radiography in Ghana. This is particularly concerning given the many complexities and risks inherent to radiography. A radiography and a healthcare workforce lacking in voice is poorly positioned to improve workers' safety and patient safety. More generally, promoting speaking up could enhance Ghana's ambitions to deliver a high-quality health care system and Universal Health Coverage (UHC) in the future.

IMPLICATIONS FOR PRACTICE

National and regional policy makers need to implement speaking-up processes and procedures reflecting the lessons of the literature review, such as ensuring no detriment as result of speaking-up and making staff feel that their concerns are not futile. Speaking-up processes should be implemented by individual organisations, alongside staff training and monitoring.

Whistle-blowers - morally courageous actors in health care?

Background

Moral courage means courage to act according to individual’s own ethical values and principles despite the risk of negative consequences for them. Research about the moral courage of whistle-blowers in health care is scarce, although whistleblowing involves a significant risk for the whistle-blower.

Objective

To analyse the moral courage of potential whistle-blowers and its association with their background variables in health care.

Research design

Was a descriptive-correlational study using a questionnaire, containing Nurses Moral Courage Scale^©, a video vignette of the wrongdoing situation with an open question about the vignette, and several background variables. Data were analysed statistically and inductive content analysis was used for the narratives.

Participants and research context

Nurses as healthcare professionals (including registered nurses, public health nurses, midwives, and nurse paramedics) were recruited from the membership register of the Nurses’ Association via email in 2019. A total of 454 nurses responded. The research context was simulated using a vignette.

Ethical considerations

Good scientific inquiry guidelines were followed. Permission to use the Nurses’ Moral Courage Scale^© was obtained from the copyright holder. The ethical approval and permission to conduct the study were obtained from the participating university and the Nurses’ Association.

Findings

The mean value of potential whistle-blowers’ moral courage on a Visual Analogue Scale (0–10) was 8.55 and the mean score was 4.34 on a 5-point Likert scale. Potential whistle-blowers’ moral courage was associated with their socio-demographics, education, work, personality and social responsibility related background variables.

Discussion and conclusion

In health care, potential whistle-blowers seem to be quite morally courageous actors. The results offer opportunities for developing interventions, practices and education to support and encourage healthcare professionals in their whistleblowing. Research is needed for developing a theoretical construction to eventually increase whistleblowing and decrease and prevent wrongdoing.