WHISTLEBLOWING: THE PATIENT OR THE CAREER?1

Whistleblowing: The Patient or the Paycheck?

Tracy Hill, BSN, RN

December 2, 2009

WHISTLEBLOWING: THE PATIENT OR THE PAYCHECK?1

Abstract

This paper encourages nurses to be courageous enough to blow the whistle on fraud, incompetent practitioners, and patient safety issues. Nearly two-thirds of nurses have raised concerns about patient safety with their employers but more than one in three say no action was taken as a result (Anonymous, 2009). Whistleblowing is an action talked about and heard about. A necessity exists for whistle-blowers in today’s healthcare environment; however, nurses should make more informed decisions about the issue of whether or not to actually blow the whistle. It is the moral obligation of nurses’ duty to report misconduct. Ramifications of whistle-blowing can include negative consequences, the main reasonnurses’ choose to remain silent and choose to collect their paycheck over advocating for patients and fellow nurses.

Key words: whistle-blowing, nursing, advocacy, ethics, patient safety, patient advocacy, workplace, healthcare, autonomy.

WHISTLEBLOWING: THE PATIENT OR THE PAYCHECK?1

Whistleblowing: The Patient or the Paycheck?

Introduction

“Ethics is an integral part of the foundation of nursing.”(American Nurses Association [ANA], 2001, p. 5).Nursing is about being an advocate for the patient and for the profession of nursing. The primary commitment for the nurse is the patient, not the organization. A patient is defined as the recipient of nursing and health care services, whether an individual, family, group or a community(ANA, 2001). The standard of conduct expected of a nurse prohibits any and all prejudicial actions, any form of harassment or threatening behavior, or disregard for the effect of one’s actions on others. Even with such high standards set for nurses, nurses are frequently put in situations of conflict arising from competing loyalties in the workplace, situations of conflicting expectations from patients and families, physicians and co-workers and in some cases, the health care organizations that employ them, as well as health providers and insurers.

Nurses strive to resolve conflict in the workplace and ensure patient safety by guarding the patient’s best interests while preserving their own professional integrity. Many nurses’ feel they’ve had tremendous support from their colleagues while discussing topics in private, but fewfeel openly supported by them. When done appropriately, reporting unethical, illegal, incompetent, or impaired practices presents substantial risks to the nurse. Whistle-blowing can sound simple and clear-cut, but in fact it is contradictory. When choosing to blow the whistle, nurses need to know what’s at risk, how to speak up, and what to say.

Definition

Whistleblowing is necessary today, in a healthcare environment weighed down with fraud, incompetent practitioners and patient safety issues. Nurses contemplate whether or not they are courageous enough to stand up for what is right. While there are numerous definitions of whistleblowing in healthcare literature, all point to the importance of advocacy and protecting someone who will likely be harmed. For this article, the author discusses the necessity that still exists for whistle-blowers in today’s healthcare environment, the moral obligations of nurses’ duty to report misconduct, the ramifications of whistle-blowing, including negative consequences, and the reasons nurses’ choose to remain silent and choose collecting their paycheck over advocating for patients and fellow nurses.

Few nurses are courageous enough to blow the whistle on fraud, incompetent practitioners, and patient safety issues. Whistle-blowing is an action talked about and heard about. Nearly two-thirds of nurses have raised concerns about patient safety with their employers but more than one in three say no action was taken as a result (Anonymous, 2009). Lachman (2008) defines whistleblowing as an attempt by a member or former member of an organization to issue a warning to the public about a serious wrongdoing or danger created or concealed by the organization.It is the act of going public and exposing a serious wrongdoing such as negligence or maltreatment that exists in the workplace. A whistleblower is “a person who informs on another or makes public disclosure of corruption or wrongdoing”(Whistleblower, 2009).McDonald and Ahern (2000) define the whistleblower 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”. Whistleblowers are often described as brave individuals who take a stand against the practices of an organization(Lachman, 2008).

Within the scope of nursing, whistleblowing is the action taken by a nurse who goes outside the organization for the public’s best interest when it is unresponsive to reporting the dangers through the organization’s proper channels (Lachman, p. 390). Lachman defines reporting as the action taken by the nurse within his or her organization, using the proper channels, to correct a dangerous situation. The reporting can be in the form of incident reports or through verbal reporting managers.

Examples of conflict in health care organizations include incentives and bonuses tied to financial targets and sanctions against speaking out such as refusal of a pay increase, failure to have access to a promotion, and exclusion from training programs (Goldman & Lewis, 2007). These create potential conflicts of interest between clinical practice and administration. It is imperative that nurses seek to ensure that employment arrangements are just, fair and do not create an unreasonable conflict between patient care and direct personal gain(ANA, 2001). Yet, “money talks”, and as a result, nurses remain silent in situations where whistle-blowing is necessary but could jeopardize salary or workplace security in today’s healthcare environment.

Ethics

Besides direct advocacy for a patient, many nurses are committed to improving the practice of nursing and maintaining the integrity of the healthcare profession. The framework for nurses to use in ethical analysis and decision-making is The ANA’s Code of Ethics for Nurses (2001). It states “Nurses are leaders and vigilant advocates for the delivery of dignified and humane care(ANA, 2001, p. 8). Provision 3 in the ANA Code of Ethics for Nurses (2001) directly addresses whistle-blowing in principle. Provision 3 states that there should be “established processes for reporting and handling of incompetent, unethical, illegal, or impaired practice within the employment setting so that such reporting can go through official channels, thereby reducing the risk of reprisal against the reporting nurse”(ANA, 2001, p. 14). In an ethically responsible healthcare organization, whistleblowing would not be necessary because there would be internal procedures in place to accommodate staff concerns.

Ethical codes of conduct bind nurses to the role of patient advocacy and require them to safeguard patients from harm. The act of beneficence means that nurses are in the position to benefit someone else or to bring about good to others.Taking steps to prevent harm, remove harm when it is being inflicted, and bring about positive good are all acts of beneficence (Purtilo, 2005).Reporting illegal activities requires the integrity found in professional character and turning a blind eye to practices that compromise integrity,breaches the ANA Code of Ethics for Nurses, and supports the virtues of honesty and courage.

Kantian (duty), virtue, and utilitarian ethical principles and theories justify whistleblowing. Kant’s interpretation of the principle of autonomy emphasized the role of being in control of making one’s own choices in accord with a moral standard that could be willed valid for everyone (Purtilo, 2005).Virtue theory requires an individual to show integrity and courage. “Moral courage is a virtue that, when cultivated, will prod one to the right action, even in the face of fear or other difficulties” (Purtilo, 2005, p. 333). Utilitarianism (consequentialism) provides the most powerful justification for whistleblowing, maximizing the human benefit and minimizing the harm, which is morally required for the greatest good of society (Lachman, 2008).The ANA reinforces virtue and Kantian (duty) when addressing autonomy, or self-determination; Provision 1 of the ANA Code of Ethics for Nurses states that “Patients have the moral and legal right to determine what will be done with their own person…The provision of advice and support from knowledgeable nurses and other health professionals…Patients should be involved in planning their own care to the extent they are able and choose to participate”(ANA, 2001, p. 8).Virtues such as mutual respect, promise keeping, and ability to keep confidences are found in loyalty. Loyalty to an organization is usually expected and valued. Feelings of loyalty to organization, self, career, profession, or principle enter into the evaluation of consequences from whistleblowing. In addition, loyalty can be blind or misplaced and, thus, ceases to be a virtue because harm, rather than good, can come from it (Fletcher, Sorrell, & Silva, 1998).

Nurses are expected to safeguard patients from incompetent, unethical or illegal practices as mandated in ethical codes of conduct that require nurses to act as patient advocates; however, it is not a realistic description of the practice setting. “The reality is that hospital power structures limit the moral authority of nurses and require obedience and loyalty to group norms that are often in conflict with patient advocacy issues” (McDonald & Ahern, 2000, p. 320).

Whistleblowers attempt to apply ethical principles in the face of many obstacles. Nurses need to be prepared to stand up for their patients. The nurse’s first consideration must be the interests and safety of patients. Many times it is the failure of managers and employers to encourage honest and open discussion, allowing injustices to go unreported, not the individual nurses acting in their own interest that deters nurses from reporting. Lachman (2008)suggests that whistleblowing results from a failure of the ethical climate of the organization to address accountability for the safety and welfare of the patients.

Review of Literature

In depth information on whistleblowing as it relates to nurses and patient advocacy in the workplace is extensively discussed in nursing and medical literature. McDonald and Ahern (2000) used a descriptive survey design to examine the professional effect of reporting misconduct (whistle-blowing) versus not reporting misconduct (non-whistleblowing). Ninety-five anonymous respondents were included in their study from a random sample of nurses from the Nurses Board of Western Australia register. Lynn’s (1986) content validity index (CVI) was used by a panel of three experts who were asked to assess the validity of the instrument. The three nurses had knowledge of stress-induced illness and had experienced an ethical dilemma in their own practice. The sample included 250 general nurses and 250 mental health nurses, with a final number of 95 participants, a return rate of 20%. Seventy were self-identified whistleblowers, and 25 were self-identified non-whistleblowers. The majority of whistleblowers (71%) and non-whistleblowers (96%) worked in public hospitals, and most whistleblowers (70%) and non-whistleblowers (84%) were employed as staff nurses. Results indicated that there were severe professional reprisals when the nurse reported misconduct, but there were few professional consequences when the nurse remained silent. Their findings suggest that when nurses identified and reported misconduct in the workplace, they experienced serious professional consequences.

Fletcher, Sorrell, & Silva (1998) in an article about whistleblowing as a failure of organizational ethics, suggest that the expectation inherent in professional codes of conduct may put unreasonable burdens on nurses if there are not effective support networks within the organization.They further suggest that at the core of the whistleblowing issue is public, private, professional, worker, and consumer and client health care accountability. The authors suggest that unappreciated consequences associated with whistleblowing or reporting wrongdoings have become a deterrent. Exposing unethical, incompetent and illegal practices is necessary, but whistleblowers fear of termination of employment may win out.

Vere-Jones (2007) investigates the improvements in the protection afforded to whistleblowers wherein legislation was designed to help encourage people to raise concerns about malpractice in the workplace. The author discusses legislation that provides protection for whistleblowers from dismissal and victimization (The False Claims Act). The author suggests nurses are now more likely to raise concerns because they do not want to be the person who said nothing or who helped cover up a scandal. The author also suggests that whistleblowers must separate fact from opinion before raising any concerns, as whistleblowers are witnesses, not judges(Vere-Jones).

Lachman (2008) discusses the steps whistleblowers should consider before deciding to blow the whistle. First, the potential whistleblower identifies the threat of harm, reports it clearly to the immediate supervisor, and concludes that the supervisor will do nothing about it. Next, the potential whistleblower exhausts other internal procedures within the organization such as the reporting channels required, without putting themselves or others in danger or risking their safety. The potential whistleblower has or has accessible, evidence that would convince a reasonable, impartial observer that his or her view of the threat is correct, and last, has good reason to believe that revealing the threat will hopefully prevent the harm at reasonable cost (Lachman, 2008).

Barriers to Whistleblowing

Many nurses enter the profession of nursing because of the diversity and flexibility of the medical field. However, the longer the nurse works in the same specialty, the less likely they are to move to a new specialty area, especially when that is weighed alongside the issue of whether or not to be a whistleblower.Nursing is a job, whose members take pride in their profession, based on strong ethics as described in codes of conduct and health care mandates. Professional and ethical concerns can be eroded and overridden by employment necessities and can lead to ethical distress. It is the failure of organizational ethics, in part, that leads nurses to whistleblowing. Unfortunately, some nurses resort to coming to work to collect their paycheck, and nothing more, after failed attempts at properly reporting misconduct internally, and unaware of the negative consequences they would face.Bound by theirprofessional obligations, many nurses feel that important safety issues brought to their employers’attention that they felt was important were ignored; the end result of reporting was that they were labeled a troublemaker. Nurses cite many reasons for choosing to remain silent, including: fear of retribution, emotional turmoil, fear of losing their job and lack of knowledge about whistleblowing (Kao, 2001).Additional reasons nurses cite for remaining silent include: employment constraints, the desire to work close to home, loss of bonuses and promotions, and hostile work environments.

Barriers to reporting up the chain of command include: animmediate threat to the safety or health of patients, the direct supervisor being the source of the problem, fear of retaliation, and blindness to the danger by the next level of the chain of command. Loyalty to the organization or naiveté on how healthcare organizations function are also challenges the whistleblower faces when attempting to resolve internal ethical concerns(Lachman, 2008).

Nurses have not been educationally prepared for the ethical distress caused by hostile work environments or the personal and professional risks involved in whistleblowing when discussing patient advocacy, nurse autonomy, or the Code of Ethics for Nurses. Nursing educators need to be proactive and adopt curriculum that includes information on the predictable reprisals that will occur if nurses choose to blow the whistle on misconduct. Nurses, including new graduates and seasoned experts, need to know the risks of reporting wrongdoing in the practice setting. Nurses should be encouraged to speak up and reminded of the ethical codes of conduct that bind them to safeguard patients from harm

Consequences of Whistleblowing

Nurses who blow the whistle almost always have negative consequences, in part because organizations do not like members who report events that reflect negatively on the organization (McDonald & Ahern, 2000).Whistleblowing is personally and professionally risky and creates considerable moral distress as nurses weigh the consequences of their actions against the duties of the profession.Negative consequences suffered by whistle-blowers can include: 1) broken promises to fix the problem, 2) disillusionment, 3) isolation, 4) humiliation, 5) formation of an “anti-you” group, 6) negative reactions from co-workers, 7) questioning of the whistle-blower’s mental health, 8) losing one’s job and, in the extreme 9) legal retaliation. Vindictive tactics can make the individual’s work more difficult and insignificant and may include: assassination of character, formal reprimand, and extensive court proceedings. Examples of negative responses may include, but are not limited to: “Is everything ok? Are you feeling alright”; “No one asked you to speak for them”; “You have not been elected spokesman by your co-workers”; “Your opinion is not the same as everyone else’s”; “You are an outlier from your peers”; “You just think you are better than everyone else”; “Your peers think you aren’t pulling your weight”. The preceding examples of a hostile work environment can beperceived as an organization that has profoundly lost its moral compass and has been ethically tainted to its core.