Speaking Up in Health Care: The Canary in the Mine?
By Professor Russell Mannion (Professor of Health Systems in the Health Services Management Centre)
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 NHS National Staff Survey (NSS) 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. Some of the key findings are summarised below.
Raising concerns: a complex and contested issue
Individuals voicing concerns may be perceived as heroes by some (for championing patients’ interests and for promoting better care) but as villains by others (for denigrating services, and damaging organisational reputations). 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. Moreover, not all issues raised as concerns by frontline staff can neatly be categorised as either conducive or inimical to safe and high-quality care and it would be naïve to assume that all those voicing concerns are necessarily motivated entirely by genuine concerns about patient care: some may be motivated in addition by work grievances or personality clashes.
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 more embedded and socialised into particular culture staff are, the less likely they are to spot poor practice and report it (perhaps because of personal and social links with colleagues). 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. The NHS is one of the most culturally and ethnically diverse organisations in the world, and so there is a pressing need to explore how cultural differences in values, beliefs and attitudes towards speaking up and whistleblowing affect the willingness of staff to raise concerns, and also the willingness of managers and organisations to respond.
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 determining to remain silent. Yet 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. Other informal strategies may include the use of humour or sarcasm to signal discontent or the use of ‘off-the-record’ discussions with managers and employees.
Hearing and acting
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 serve to attenuate 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, especially by those in positions of power who may already be vested in narratives of success.
Whistleblowing or bell ringing?
As conceived in both the academic literature as well as in wider public understanding, whistleblowing usually describes internal organisational members raising concerns to those who can effect action. However, ‘bell-ringing or outsider whistleblowing is also a possibility: the reporting of care failings by those other than employees (for example, relatives, or professionals from other agencies, such as social workers). Potentially, this is a more significant issue for healthcare than for any other sector. As the NHS becomes increasingly diverse in terms of collaboration with other sectors (and as social media and information sharing technologies become ever more developed), external staff and other stakeholders are increasingly exposed to, and in a position to speak up about, poor quality care.
Better use of existing data
In the NHS there is often considerable ambiguity and rival interpretations around whether a particular situation is a safety problem or just acceptable variation in level of service. The volume of data now collected by the NHS, and the increasingly sophisticated ways in which it can be analysed, is such that it ought not only to be possible to reduce this ambiguity, but also reduce the need for whistleblowing – potential problems may be detectable as trends in the data, making the service less reliant upon staff bringing it to management’s attention. In particular, the annual national NHS Staff Survey (NSS) collects data on staff perceptions in relation to whistleblowing and organisational responses when concerns are raised – these could be exploited to look at trends over time, across services and staff groups to highlight potential system and organisational weaknesses.
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 - metaphorically 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.