Speaking up in Health Care: The Canary in the Mine?

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham

“As the NHS increasingly seeks collaborations with other sectors as ways of responding to the challenges of an ageing population, external staff and other stakeholders are increasingly exposed to, and in a position to speak up about, poor quality care.”  

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When health care professionals see deficient or unsafe care it is important that they speak up so that care can be improved. Sometimes, speaking up is informal and managed within the care organisation. At other times, speaking out happens by alerting outside authorities (whistleblowing).

There is, however, compelling evidence from recent reports and official inquiries as well as data gathered over many years as part of the annual to suggest that, in many part of the NHS, staff may feel unable to speak up, and that even when they do voice concerns, their organisation may respond inappropriately.  

Against this background, our National Institute for Health Research funded study draws on a rich stream of theoretical research, empirical evidence, legal analysis and stakeholder work, with the aim of sharpening thinking around speaking up and whistleblowing in health care.

Raising concerns: a complex and contested issue

Individuals voicing concerns may be perceived as heroes by some but as villains by others.  This ambiguity is reflected in media portrayals of them either as ‘courageous employees’ who act at great personal cost or ‘disloyal malcontents’ who pursue their own interests regardless of the dysfunctional consequences for individuals and organisations.

Similarly, not all issues raised as concerns by frontline staff can neatly be categorised as either conducive or detrimental to safe and high-quality care.

Personal and cultural factors in raising concerns

There is mixed evidence on the role and impact of personal factors in raising concerns. For example, in terms of length and security of tenure, some studies have found that the more embedded and socialised into particular culture staff are, the less likely they are to spot poor practice and report it. Similarly, the evidence is mixed over whether health professionals who over time become more socialised and integrated members of the organisation are less likely (through desensitisation) or more likely (through better organisational knowledge and developed networks) to detect and report poor care. 

Silence or voice?

Policy prescriptions have tended to conceive the issue of raising concerns about unsafe or poor-quality care as a simple (individual) choice between deciding to speak up or remaining silent. Our research suggests that such simple dichotomies are unhelpful: for example, healthcare professionals may raise concerns internally within the organisation in more informal ways before (or instead of) voicing concerns through formal processes. Considering how to listen to, record and respond to this informal feedback is essential for any NHS organisation if they wish to learn from poor-quality care.

The ‘deaf effect’

Effective voicing of concerns is but the first stage in reshaping better safer healthcare: those with influence have to hear, and they have to act.  This is associated with the ‘deaf effect’, a concept that has been used in the management literature to describe the reluctance of senior managers to hear, accept and act on concerns by those raised by employees. 

 In some cases, it is clear that senior managers seek to ostracise individuals by undermining their concerns. In extreme cases, healthcare professionals have been disciplined, suspended or reported for misconduct to professional bodies on pretexts derived from a very partisan reading of events. In an intensely hierarchical organisation such as the NHS, entrenched status and power differences between professional groups can harm the development of open reporting cultures. Any attempt to address speaking up in the NHS must deal with the challenging organisational dynamic of resistance to bad news.

Whistleblowing or bell ringing?

Whistleblowing usually describes staff members raising concerns to those who can take action. However, ‘bell-ringing’: the reporting of care failings by those other than employees (for example, relatives, or professionals from other agencies, such as social workers) is potentially a more significant issue for healthcare than for any other sector. As the NHS increasingly seeks collaborations with other sectors  as ways of responding to the challenges of an ageing population, external staff and other stakeholders are increasingly exposed to, and in a position to speak up about, poor quality care. 

All quiet on the frontline?

Frontline staff are often best placed to identify substandard care and alert colleagues and managers if patients are at risk - they are the ‘canaries in the mine.’ Yet staff are often fearful of raising legitimate concerns and have sometimes been bullied and victimised for doing so.  Managers on their part need to redouble efforts to create the right organisational environments where frontline voices can be aired and responded to appropriately. Finding ways to encourage this will be a key challenge for management education and leadership training.

Read the full report. Mannion R, Blenkinsopp J, Powell M, McHale J, Millar R, Snowden N & Davies H.  Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. Health Serv Deliv Res 2018;6(30)

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    I tested positive for HSV-2 few months ago. At first, yes, I was devastated thinking I have an incurable STD for life. After doing hours of research I quickly realized genital herpes is a filthy parasite that just likes to hide in your body. Yes, there’s no “medical cure” but that doesn’t mean your body can’t get rid of it. I literally flush it out of my system with the help of Dr. Aza natural herbal medication which I ordered after doing some research. And now I’m HSV-2 Negative, I never believed it until my doctor finally gave me the test results and behold I was HSV free. I’m so glad that I found you Dr. Aza. Thanks so much for your goodness I’m grateful. You can also get your help from him through his Whats App Contact for fast communication  (+1(315) 795 1518 )  OR  Email: drazaherbalcenter@gmail.com   . ..

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    76. At 4:10PM on 13 May 2022, kline wrote

    I’m here to testify about the great work Dr OMOBUAN did for me. I have been suffering from (HERPES) disease for the past 5 years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctor, few weeks ago i came across a testimony of one lady on the internet testifying about a Man called Dr Smith on how he cured her from HIV Virus. And she also gave the email address of this man and advise anybody to contact Dr OMOBUAN for help for any kind of sickness that he would be of help, so I emailed him on ( christianomobuan4825@gmail.com ) telling him about my (HERPES Virus) he told me not to worry that i was going to be cured!! Well i never believed it,, well after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me as Dr OMOBUAN assured me that i will be cured,after some time i went to my doctor to confirmed if i have be finally healed behold it was TRUE, So friends my advise is if you have such sickness or any other at all you can contact Dr OMOBUAN via email. { christianomobuan4825@gmail.com } or whatsapp him on(+2348140903559 ) DR OMOBUAN CAN AS WELL CURE THE FOLLOWING DISEASE:- HIV/AIDS HERPES CANCER ALS hpv eye problem etc.

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    77. At 11:18PM on 13 May 2022, Jane Smith wrote

    I was told there is no Herpes Simplex Virus cure except treatment to control it. I totally lost hope, my life was embarrassing to have this Herpes Virus and the doctor said Herpes has no cure until I met Dr Kachi who helped me in my life. I have been infected with Herpes Virus since 2014, i went to many hospitals for a cure but there was no solution, so I was thinking how can I get a solution that my body can be Okay, Until this faithful day as I was browsing on internet I saw testimony on how Dr Kachi helped people in curing Herpes Disease, quickly I copied his Email and ordered his herbal treatment, behold Before 2weeks i noticed the blisters were gone, I got 100% cured. Now I'm so excited to share this testimony to every article living with Herpes Virus there is possible natural treatment to eliminate this virus Email: drkachispellcast@gmail.com or WhatsApp number: +1 (570) 775-3362 Dr Kachi website: https://drkachispellcast.wixsite.com/my-site

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    80. At 7:22AM on 16 May 2022, jesae molisa wrote

    Am testifying of the miraculous work of a great traditional doctor called Dr Maggi. I have been suffering from herpes since last 2 years with my Husband but today I am happy that am cured from it with the herbal medicine made by Dr Maggi the great healer, I was browsing the Internet searching for help when I came across a testimony shared by someone on how Dr Maggi cure her from Herpes Disease. I quickly contacted him to get the cure and today I am now free from the Virus,drmaggiherbalhome@gmail.com you can also call or whatsApp him on +1(917) 979-6387

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    82. At 4:41PM on 16 May 2022, James Long wrote

    Am so glad expressing my profound gratitude to a man that is so concerned about other people's well being. I was suffering from (HERPES SIMPLEX VIRUS TYPE II) The doctors kept telling me that there is no cure but i believe that there is cure somewhere and they dont want people to get cured. I tried searching online if i could see anything that will help me and I saw alot of comments on YouTube on how Dr Omosun help to cure herpes with herbs and i also saw so many comments about him on many web pages on how he had helped and cured so many people suffering from HERPES 1$2, HPV, CANCER, HIV/AIDS, COLD SORE. So i contacted him through his email and i shared my problems with him and he sent me the herbs through UPS and gave me instructions on how to be using it. It took me two weeks to finish the herbs and after i finish using it, he told me to go for a medical test, behold the result was negative, now am HERPES VIRUS free. I just want to use this platform to thank Dr. Omosun for curing me from that horrible disease and also for exposing his herbal cure to the world at large, please you can as well contact Dr Omosun on his email,website or WhatsApp below

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    83. At 4:52AM on 17 May 2022, James Long wrote

    Am so glad expressing my profound gratitude to a man that is so concerned about other people's well being. I was suffering from (HERPES SIMPLEX VIRUS TYPE II) The doctors kept telling me that there is no cure but i believe that there is cure somewhere and they dont want people to get cured. I tried searching online if i could see anything that will help me and I saw alot of comments on YouTube on how Dr Omosun help to cure herpes with herbs and i also saw so many comments about him on many web pages on how he had helped and cured so many people suffering from HERPES 1$2, HPV, CANCER, HIV/AIDS, COLD SORE. So i contacted him through his email and i shared my problems with him and he sent me the herbs through UPS and gave me instructions on how to be using it. It took me two weeks to finish the herbs and after i finish using it, he told me to go for a medical test, behold the result was negative, now am HERPES VIRUS free. I just want to use this platform to thank Dr. Omosun for curing me from that horrible disease and also for exposing his herbal cure to the world at large, please you can as well contact Dr Omosun on his email,website or WhatsApp below

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    WhatsApp +2349023705898

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    84. At 5:53AM on 19 May 2022, Woźniak Krystyna wrote

    Hello my name is Krystyna, I want to thank Dr. Jatto for bringing back my life. I was cured from genital herpes 2 with the herbal medicine Dr. Jatto sent it to me. I got to know about Dr. Jatto through a friend that was also cured from Diabetes after taking Dr. Jatto herbal medicine. Dr. Jatto herbal medicine works very fast without any side effects. I recommend Dr. Jatto to everyone suffering from genital herpes or any type of disease, His medicine will cure you 100% completely. You can contact him through His WhatsApp Number:+2348156965480 or email address: drjattolovespelltemple01@gmail.com or his Website: https://drjattolovespellte0.wixsite.com/my-jattosite

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    85. At 6:02AM on 19 May 2022, Woźniak Krystyna wrote

    Hello my name is Krystyna, I want to thank Dr. Jatto for bringing back my life. I was cured from genital herpes 2 with the herbal medicine Dr. Jatto sent it to me. I got to know about Dr. Jatto through a friend that was also cured from Diabetes after taking Dr. Jatto herbal medicine. Dr. Jatto herbal medicine works very fast without any side effects. I recommend Dr. Jatto to everyone suffering from genital herpes or any type of disease, His medicine will cure you 100% completely. You can contact him through His WhatsApp Number:+2348156965480 or email address: drjattolovespelltemple01@gmail.com or his Website: https://drjattolovespellte0.wixsite.com/my-jattosite

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    How I Got My Ex Husband Back...........

    After a year of Broken marriage, my lover left me with one kid, I felt like ending it all, i almost committed suicide because he left us with nothing, i was emotionally down all this while. Thanks to a spell caster called Dr kuta which i met online who brought my Lover back to me. On one faithful day, as I was browsing through the internet, I came across several of testimonies about Dr kuta Some people testified that he brought their Ex lover back, some testified that he restores womb,cure cancer,and other sickness, you can contact him on his page at his page https://www.facebook.com/Lovespellandvoodoolovespell Dr-kuta powerful-love-spell... or his WhatsApp----:+2349150310901

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