Author: Jackson, Debra; Peters, Kathleen; Andrew, Sharon; Edenborough, Michel; Halcomb, Elizabeth; Luck, Lauretta; Salamonson, Yenna; Weaver, Roslyn; Wilkes, Lesley
Date published: August 1, 2010
INTRODUCTION AND BACKGROUND
Whistleblowing occurs across health care sectors nationally and internationally, and whilst various definitions of whistleblowing exist, most incorporate the basic concept of promoting advocacy to prevent harm to individuals or groups (Bolsin, Faunce, & Oakley, 2005; Davis & Konishi, 2007). Furthermore, whistleblowing can involve the reporting of poor and unsafe work practices to both internal and external organisations (Ray, 2006). In previous nursing literature, whistleblowing has been more specifically defined as 'a nurse who identifies an incompetent, unethical or illegal situation in the workplace and reports it to someone who may have the power to stop the wrong' (Ahern & McDonald, 2002, p. 305). Whilst whistleblowing in the health care sector can be considered an honourable act (Lachman, 2008), it holds negative consequences for individuals involved (Firtko & Jackson, 2005; Ray, 2006). Despite these consequences, nurses continue to advocate for patient safety and, when their concerns are not addressed, blow the whistle in an attempt to enforce changes in practice (Myers, 2008). Although some difficulties experienced by those involved have been acknowledged, the impact that whistleblowing has on collegial relationships between nurses and other health care professionals remains largely unexplored.
Elsewhere we have argued that whistleblowing is a measure of last resort, and used when other means of drawing attention to issues fails (Jackson et al., 2010). For those who do speak out, 'backlash, backing off, backstabbing and isolation' may result (Attree, 2007, p. 397). In a study to explore perceptions of professional effects of whistleblowing in a sample of nurses, McDonald and Ahern (2000) confirmed previous findings (see Chafey, Rhea, Shannon, & Spencer, 1998; Dempster, 1997; Hunt, 1995; Mohr, 1996) that reporting misconduct often results in organisational reprisals and can negatively impact working relationships (Firtko & Jackson, 2005).
Any factor that negatively infl uences working relationships between nurses is a matter of concern. Effective professional relationships in nursing results in job satisfaction and decreased staff turnover (Duddle & Boughton, 2007), which benefits workforce recruitment and retention (Jackson, Mannix, & Daly, 2001). In contrast, ineffective relationships can lead to bullying or physical and psychological confl ict, in what has been termed lateral or horizontal violence (Duffy, 1995; Farrell, 2001), which has been found to be more distressing for nurses than aggression from other sources such as patients (Farrell, 1997).
The need for effective and strong professional relationships is not simply to engender work satisfaction among staff, but also to foster patient care (Mahlmeister, 2009). In fact, patient safety is dependent on health professional staff being able to speak up about any matters of concern and adopt an advocacy stance for patients (Firtko & Jackson, 2005). A workplace culture that views whistleblowing as 'telling tales' is not conducive to raising issues of patient safety (Harrison, 2003, p. 12).
The literature suggests that within healthcare organisations, whistleblowing is frequently perceived as a 'breach of loyalty and betrayal by those who conform' (Ahern & McDonald, 2002, p. 304), and as evidence of not being a team player (Faunce & Bolsin, 2004). This sense of betrayal can result in colleagues losing their trust in each other (Dunbar, Reddy, Beresford, Ramsey, & Lord, 2007), and Ahern and McDonald (2000) note a belief that the decision to take action could place whistleblowers in 'direct confl ict' with the rest of their colleagues (p. 314). However, given the fact that nurses are implicated in whistleblowing (Firtko & Jackson, 2005), there is little in the literature that explores the impact of whistleblowing on workplace relationships in nursing, and no literature could be found that includes the perspectives of the major stakeholders-whistleblowers, bystanders to whistleblowing events and subjects of whistleblowing complaints.
Aim of the study
This paper is drawn from a larger study that sought to investigate the effect of whistleblowing in the health sector from the perspective of whistleblowers, bystanders, and subjects of whistleblowing complaints. Elsewhere we have presented participant views of some of the contextual issues affecting nurse whistleblowing as experienced by whistleblowers themselves (Jackson et al., 2010). In this current paper, we present and describe the effects of the whistleblowing episode on the workplace relationships of the nurses involved, from the perspectives of whistleblowers, bystanders to whistleblowing events and subjects of whistleblowing complaints.
Qualitative narrative inquiry was used to gather experiential accounts of whistleblowing, as either a whistleblower (W), the subject of a whistleblowing complaint (S) or as a bystander to a whistleblowing incident (B). The participant stories are embedded in the context of nursing, and therefore provide insights into the complexities, meanings, conventions and dominant beliefs surrounding whistleblowing within the nursing culture.
Recruitment and participants
The study was advertised in the local media, professional journals and magazines. Potential participants - nurses with direct experience of whistleblowing - were invited to contact the research team, upon which they were mailed a plain language statement explaining the aim of the study, the details of their involvement, and an informed consent form. Additional information was provided on request, ensuring voluntary informed consent. Recruitment continued until data saturation was reached.
Our non-randomised convenience sampling strategy resulted in the recruitment of 18 eligible participants: 11 whistleblowers, 4 bystanders, and 3 subjects of whistleblowing complaints. One participant (pseudonym Anna) identified as both subject and bystander to separate whistleblowing events. Participants had been working in nursing for 2-40 years, had various qualifications, and were employed as enrolled nurses, registered nurses, clinical nurse specialists, and nurse managers. They were drawn from a number of general and speciality areas, including medical/surgical, aged care, operating theatre, mental health, coronary care, midwifery, emergency, intensive care and community nursing. In keeping with gender representation in nursing, 17 of the participants were women. All participants had direct experience of whistleblowing, either as a whistleblower (W), subject of a whistleblowing complaint (S), or as a bystander to a whistleblowing event (B).
Data were collected via face-to-face and telephone semi-structured interview. A mutually convenient time and place was organised to conduct the interview by an experienced and skilled narrative researcher, further facilitating the collection of subjectively constructed participant narratives (Chase, 2005; Duffy, 2007). All interviews were digitally recorded and transcribed verbatim.
Whistleblowing, and the associated social stigma, can be a highly emotive misunderstood phenomenon, with the potential to be sensationalised. At every stage of the project the research team sensitively and morally engaged with the participants, their stories and the representations of the whistleblowing narratives, enacting the ethical principle of justice (Carter, 2008). Confidentiality and anonymity were also of particular relevance for this study (Holloway & Freshwater, 2007a). Interviews were conducted in the researcher's office, an office on a university campus, or by telephone. No interviews were conducted within any participant workplace. All participants were de-identified by the interviewer following the interview process. Pseudonyms were used from this point onwards.
Cognisant of the potential emotional distress that may be experienced by participants, as well as their vulnerability, all participants were given the name and details of a free, independent counselling service. The counsellor's details were also available on the plain language statement. The interviewing researcher was supported by the research team through regular informal debriefing.
Narratives were analysed to discover the personal knowledge(s) of whistleblowing reconstituted within social constructions, language, and the culture of nursing (Holloway & Freshwater, 2007b). Data were thematically analysed by experienced researchers. Each interview was read, and re-read by two members of the research team: the principal researcher and the interviewing researcher. Data were sorted into meaningful codes (Lee & Fielding, 2004). This iterative data analysis process continued until mutual agreement was reached, and meaningful stories of whistleblowing within the social conventions of nursing were presented.
Rigour was exemplified by interviewer expertise and thematic analysis of the verbatim narratives as well as the selection criteria. Interviewer expertise ensured that a trusting, open relationship was developed during the interview. Therefore, the results re-present the narratives and voice of the participants. This supports transferability and credibility of the results. Finally, the selection criteria made certain the participants had direct experience of the phenomenon of interest, adding to authenticity and confirmability (Polit & Beck, 2008).
Whistleblowing resulted in hostility in the workplace. Analysis of the data revealed that whistleblowing had a profound and overwhelmingly negative effect on working relationships. For these participants, the loss of collegial relationships was by far the most distressing aspect of their experience. For many participants, workplace relationships were damaged seemingly beyond repair. Findings have been clustered into four themes:
1. Leaving and returning to work: The staff don't like you;
2. Spoiled collegial relationships: Barriers between me and my colleagues;
3. Bullying and excluding: They've just closed ranks; and
4. Damaged interprofessional relationships: I did lose trust in doctors after that.
Leaving and returning to work: The staff don't like you
Several participants had left their usual work areas or taken periods of leave immediately following the whistleblowing event. In some cases this was imposed, in that participants were strongly encouraged to remove themselves from the site of the complaint. When Diana was informed she was the subject of a whistleblowing complaint, she was asked to either take immediate leave or go to work elsewhere.
I said I will not. I'm not standing down, I'm not leaving. I haven't done anything wrong, like I was adamant. Anyway, the union organiser said we need to go outside and have a chat, so we went outside and had a chat and she said look I think for your own safety, you should at least just go to work elsewhere while the investigation happens ... So I agreed to go. So we went back in and she (manager) said okay and this is effective immediately. You must get your things and leave. I was devastated. (Diana - S)
Diana had no opportunity to farewell or offer any explanation to her colleagues, and she believes the fact that she was immediately asked to leave the premises created an impression of guilt, though she vigorously refuted all of the accusations against her. Similarly Anna recalled being physically escorted off the premises. She had a deep and life long attachment to her place of employment, and was distraught by this.
I was humiliated and I was taken out by some poor little guy who worked in HR [Human Resources Department] and because the head of HR had instructed him to do it. He knew it was wrong, and I took all my anger out on him, which is really bad. And I just said go away. I can walk myself, but he had to walk with me. You know, I was born in that hospital. I had all my children in that hospital. And to be led off the premises was just horrific ... (Anna - S/W)
Commonly, the reason participants were asked to take a period of absence was to allow for inquiries or investigations to be undertaken. However, the return to the workplace was not smooth, as even after a period of leave, matters were often not clarified or resolved, and hostility had not diminished.
When I came back it was okay for a while but then I started getting nervous because there was still quite a lot of hostility at work ... I felt like sinking into the ground. I felt so bad. I felt so bad. I really did. It was horrible and I kept on saying [to myself ] it's not your fault, you didn't, you know. I know I blurted something out but I didn't cause this. (Moira - W)
In Rita's case the absence from her work environment continued for a number of years. However, her return to her original working area was still difficult. Despite staff changes and the number of years that had elapsed since she left, hostility and mistrust towards her was still evident.
Finally, the secondment was coming to an end and ... another new DON [Director of Nursing] had arrived since then who knew nothing about all this [the whistleblowing events]. He just said 'Your secondment's nearly up. You'll be coming back, but we've got a problem - the staff don't like you'. (Rita - S)
Spoiled collegial relationships: Barriers between me and my colleagues
Overwhelmingly, participants disclosed that the whistleblowing event had a serious deleterious effect on collegial relationships. This caused participants much distress, and they contemplated the reasons for this at length. Rosie felt that it was due to a general misunderstanding on the part of colleagues about why people became whistleblowers.
They don't seem to think that patient safety comes into it. I don't know. It's just an attitude, they don't seem to think, they seem to think you're a whistleblower just to get somebody into trouble. (Rosie - W)
Previously comfortable and uncomplicated relationships - even those that had been established over many years - were spoiled and damaged as a result of the whistleblowing episode.
The camaraderie-ship that we'd had over the years had gone. I felt like I was treated with suspicion, like they were watching their backs, as if they thought that I was going to, you know, say something about them. (Jenny - W)
Though she was later fully exonerated, Carolyn had been the subject of very public and serious whistleblowing complaints. The public nature of these allegations affected every aspect of Carolyn's life, and her relationships with her colleagues were altered.
It created barriers between me and my colleagues and it also created a barrier between me and the staff on whom I had relied and in whom I had great faith. (Carolyn - S)
Moira had raised her concerns about an inappropriate relationship between a doctor and patient. Although Moira believed that the impropriety was common knowledge amongst the staff, she was the one who blew the whistle on the situation. This action had immediate consequences for her.
It was just me against them sort of thing even though there were a few silent supporters that really wouldn't say an awful lot, that had no power anyway. I was at the bottom of the heap waiting to be kicked ... Look one girl, she couldn't even talk to me ... One guy was rude. He'd make sarcastic remarks and stuff like that. ... I remember just feeling hurt by remarks that he made and they just were really off the cuff things. He never used to do it beforehand [before the whistleblowing]. We used to get on okay and then it was like he just couldn't stand me. It was like I was just sort of like this dirty, trashy person. (Moira - W)
Irene was in a rather different situation to other participants, in that she retained the very strong support of her NUM and some close colleagues throughout her experience. This helped balance the lack of support Irene sometimes felt from other colleagues.
Sometimes I felt like I was supported by other staff members. Other times they'd go, you should leave the poor guy [subject] alone. Felt sorry for him or whatever. At some stage, yes my NUM went away and my best friend went away. So two of my main support people had gone away and I found those few weeks really hard when there wasn't that support. (Irene - W)
Bullying and excluding: They've just closed ranks
The relationships between participants and their colleagues deteriorated to the point that participants regularly experienced episodes of bullying and exclusion in the workplace. On some occasions, the bullying actions were was subtle, while on other occasions, bullying was more overt. Participants reported ostracism, marginalisation and open hostility associated with whistleblowing, and this was sustained over periods of time.
It was really tough even forcing myself to go to work. Half of the staff were silently supportive. The other half of the staff were actually hostile towards me. It was really horrible going to work. You didn't know what was going to happen because some colleagues were really angry with you. They started ignoring you, withholding information, you didn't know whether sometimes you'd be set up with clients or whatever. It was just really difficult to know. (Moira - W)
Participants reported being excluded and isolated within the workplace. Mary's relationships with her colleagues had resulted in her being excluded from most interactions with other nurses. This sense of professional isolation served to create a sense of aloneness for Mary as she went about her duties.
After what had happened I just felt so alone really in my practice with patients, with my nursing care. (Mary - W)
These experiences of bullying and exclusion were made worse by the fact that many people were involved. These were not cases of one or two colleagues participating in hostile acts against participants-it was widespread and involved collusion and complicity between numbers of people.
There was a whole lot of other staff involved and they all sort of colluded and everything. It became, where people said, we don't want her in our ward, she's a trouble-maker. (Evelyn - W)
Participants felt they were excluded by their colleagues, and talked about. Newer staff were warned about them, and there was a sense they were somehow dangerous to be involved with, and so they felt colleagues avoided working with them. Evelyn reported working in a context of being constantly talked about and actively confronted on occasion.
I do know that pretty horrible things have been said about me behind my back ... and one nurse actually came up and - young nurse - and she said I'm really afraid of working with you and so is everybody else because we know that you're a 'dobber'. Oh my god. I said well do you intend abusing a patient tonight? She said no and I said well then we're okay. I said I just don't like bullies and I don't like people who abuse patients, so if you're not one of them then what are you worrying about? (Evelyn - W)
The impact of this damaged workplace was felt not only by the whistleblowers themselves, but also by others in the workplace who witnessed the hostility on a daily basis.
I just see her [whistleblower] and how she's treated, people not talking to her, people treating her so - but she's, she just thinks oh well, whereas I couldn't do that, I couldn't do that. (Jessie - B)
Difficulties were compounded by a sense that even senior staff, to whom one might go in the event of workplace difficulties, were also involved in some cases. Refl ecting on the actions of her NUM, Karen said:
She treated me like dirt. She couldn't speak to me. I found out subsequently that she was canvassing people to find dirt on me and commit it to writing to discredit me. ... they've just closed ranks and I'm persona non grata. (Karen - W)
In Valerie's situation, the hostility from her manager was not as overt as being openly ignored, but took the form of more subtle actions, such as through rostering practices.
Then my manager started ... rostering me the days I couldn't work. So then you know I started having to take sick days, I tried to swap shifts. It was just impossible. (Valerie - W)
Amy had become a whistleblower quite unintentionally. As an enrolled nurse, she felt she was being asked to work outside her competency by taking on very advanced clinical skills that she felt ill-prepared for. In order to better clarify her position in relation to performing these advanced skills, she had contacted state nurse registering authorities. This action ultimately resulted in serious confl ict with her NUM and generated an avalanche of negative experiences for Amy, in which she felt she was being bullied. She took some leave and on her return:
I went back to work and after that, you know, she [NUM] passively bullied me. She excluded me from things. One day she came out with everyone's pay sheet and handed everyone's out but mine, you know just stupid crap and then she wouldn't talk to me. (Amy - W)
Damaged inter-professional relationships: I did lose trust in doctors after that
Where the whistleblowing nurses had raised concerns about the practice or behaviour of a medical practitioner, there was a breakdown in trust that made it difficult to work well together. Participants reported breakdowns in interprofessional relationships between them and the medical officers they needed to be able to work with.
I thought that they [medical staff ] thought, like, they didn't - they didn't trust me, or they didn't believe what I had said ... And I did lose trust in doctors after that too. I just felt - just lost confidence in them, because I didn't feel I had the support. (Jenny - W)
Mary had raised concerns about the practice of a particular medical officer, and this had resulted in extensive negative publicity.
Continuing to work along side the doctor was just really, really, really bad and it got worse to a point where I thought he really wasn't treating me as a professional. It got really, really awful and there was just nothing I could do about it. (Mary - W)
Mary's distress was so great that her difficulties also extended to dealing with other medical offi- cers. After the doctor who was the subject of the whistleblowing complaint was stood down pending investigations, a replacement medical officer was appointed.
We got a new doctor, I was having a lot of problems even just communicating to him because I was anxious around him ... where I had to ring him on a night duty about a patient. I was worried, he just said look, your nursing is - it was really bad and that I had to change my ways and I can't just ring him up ... I didn't think there was a lot wrong with my nursing practice but there was in my professional relationship with the doctor, because it had actually, I'd become really anxious around him and really, really nervous. So I suppose that really was bad that I had got to a point where it affected me professionally as well. (Mary - W)
For Moira, the ramifications of whistleblowing about an inappropriate doctor/patient relationship, meant working in an environment that had become hostile. Moira felt she might be somehow deliberately sabotaged by either the doctor concerned, or other medical staff sympathetic to the doctor.
It did seem to be that a few of the staff would play games and they were really angry. They wanted to pay me back and at the time I thought they'd do something and maybe put me in a situation that was dangerous or not tell me something about the client so I'd make a mistake with something ... it was strong in me at the time that I thought I have to watch my back, I have to be continually alert if somebody, one of [the doctor's] friends, or [the doctor] sets me up somehow so that there's a mistake at work and it'll be a serious mistake for me. (Moira - W)
The inter-professional difficulties caused by whistleblowing extended beyond the actual people who were directly involved, and also infl uenced the relationships between the two groups generally.
The allegations that the hospital was clearing beds by not appropriately treating patients and really. ... It's a dreadful thing to say about people and for them to have to defend. I think that particular allegation has set back the relationships between nursing and medicine at that hospital a lot. (Carolyn - S)
This perceived loss of previously successful relationships was felt keenly by participants, and was also a source of distress and concern for bystanders. As a bystander, John perceived that the whole of the nursing staff at his hospital were made to pay for the whistleblowing of a small group of nurses.
Because in that work environment, there's - it used to be. It's not so much now. I think this has also helped erode it. But there was that real - you know, nurses were really valued by the medical staff, and that sort of thing. The whistleblowing helped erode that. Yeah. Sort of like that betrayal of trust, I suppose. (John - B)
The major finding that emerges from this study is that the whistleblowers and subjects of whistleblowing experienced retribution in the form of hostility from other staff, bullying, and a loss of trust from co-workers. The bystanders in this study affirm the perceptions of whistleblowers and subjects of exclusion and poor treatment. These findings support Attree's (2007) study that identified factors infl uencing nurses raising concerns about practice, and in which retribution was clearly a feared outcome. However, the study by Attree (2007) was not based on lived experience, but rather speculations of possible outcomes (similarly, McDonald & Ahern, 2000, 2002).
In this study, ostracism and bullying became the dominant behaviours in the workplace to control and intimidate whistleblowers and subjects of whistleblowing complaints. As indicated in previous studies, bullying can take many forms (Hutchinson, Vickers, Jackson, & Wilkes, 2005, 2006a, 2006b). It can involve individuals, or networks of bullies, and can infl uence the ways work is organised (Hutchinson et al., 2005, 2006a, 2006b). These strategies were evident in the present study, through rostering practises, exclusionary behaviour and allocating the nurses back to units where the manager knew they were 'not wanted'. It was also manifest in the way other staff colluded to bully the whistleblower. These examples confirm the ways management and colleagues can facilitate conditions to make the whistleblowers fear for their existence at work and wonder why they reported the incident in the first place (Kingston, Evans, Smith, & Berry, 2004). The findings from this study reaffirmed the manner in which colleagues and managers can respond to whistleblowers' actions (Dempster, 1997; McDonald & Ahern, 2002).
Health professionals have an obligation to promote a change in organisational climates and the need for this is affirmed in this study. There is a need for a working culture that supports the investigation of errors and wrongdoing (Attree, 2007; Faugier & Woolnough, 2002; Kingston et al., 2004). Nurses involved in whistleblowing have an ethical dilemma. They must decide whether they should report bad practice in accordance with their professional code of practice/codes of professional ethics (Johnstone & Kanitsaki, 2006), or maintain the safety and well-being of themselves and their families by not putting their employment in jeopardy. The findings of this study reinforce that whistleblowers need to seriously consider this dilemma if they are going to proceed and report poor practices or wrongdoing in health care.
Faunce and Bolsin (2004) argue that whistleblowers will not have institutional support until there is more academic legitimacy to the case for whistleblowing. Whistleblowing in nursing has largely escaped academic scrutiny, instead being framed more in industrial or legislative terms. Though in some parts of the world there are current legislative measures in place to protect whistleblowers against civil or criminal action (Department of Parliamentary Services, 2005; Kingston et al., 2004), the findings of this study suggest that the very real danger to whistleblowers is the hostile workplace culture and collegial mistrust (Jackson, 2008) that can develop subsequent to a whistleblowing event. The need to protect whistleblowers from reprisal is acknowledged (Department of Parliamentary Services, 2005), however the problems associated with ensuring ongoing safety of whistleblowers in real terms is not adequately addressed. Furthermore, there is little acknowledgement of the needs of subjects of whistleblowing complaints, or bystanders, who can also be traumatised by the events.
Strengths and limitations
It is unclear whether the sample used in this study is representative of the experiences of all nurses directly involved in whistleblowing incidents. Individuals may have been more likely to participate in this investigation if they felt a need to expose their experiences of unjust treatment. Furthermore, recruitment into the study was through a large industrial nursing organisation, meaning that nurses not in this organisation may not have had the opportunity to participate. However, this paper adds a vital element to the literature-that is, a perspective on how workplace relationships may be affected by whistleblowing, from the perspective of the major stakeholders, whistleblowers, bystanders to whistleblowing events and subjects of whistleblowing complaints.
Internationally, the health system is under considerable pressure and it is not likely that whistleblowing events will diminish in the future. Whistleblowers can lose their employment, be bullied and unsupported by management and colleagues, and have their collegial relationships destroyed. Given the importance of workplace relationships and collegial trust in nursing, it is clearly damaging to have seriously fractured relationships in the workplace. Nursing and health care organisations are challenged to work to develop supportive cultures of trust that will enable nurses and other health care professionals to safely raise legitimate concerns about patient care and safety.
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Received 31 October 2009 Accepted 04 March 2010
DEBRA JACKSON, KATHLEEN PETERS, SHARON ANDREW, MICHEL EDENBOROUGH, ELIZABETH HALCOMB, LAURETTA LUCK, YENNA SALAMONSON, ROSLYN WEAVER AND LESLEY WILKES
Family and Community Health Research Group (FaCH), University of Western Sydney, Sydney, NSW, Australia