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Speaking the truth

The health service needs to support whistleblowing and encourage staff to speak out about poor care, write Alison Whyte and Adele Waters

The dictionary definition of a whistleblower is 'a person who informs on someone engaged in an illicit activity', unhelpfully reinforcing a widely held view that whistleblowers snitch on their colleagues.

While whistleblowers may report concerns that are in the public interest, their actions are not always supported by colleagues, employers and regulatory bodies. As a result, there are growing calls for the act of whistleblowing to be redefined as something positive.

Graham Pink and Karen Reismann

Graham Pink, a nurse who was sacked more than 20 years ago for speaking out against inadequate staffing levels at Stepping Hill Hospital, Stockport, says: 'Whistleblowing is an ugly term and, unfortunately, it is seen as a negative thing. I prefer to talk about "speaking the truth".'

Mental health nurse Karen Reissmann, sacked in 2007 for raising concerns about patient care, agrees. 'The word "whistleblowing" suggests you are criticising another person rather than speaking up for vulnerable people. Whistleblowing implies deliberate misbehaviour, but the problem may be unintentional or the result of policies that have a negative impact on patient care.'

Cathy James, chief executive of the whistleblowing charity Public Concern at Work (PCaW), says there is a perception that a whistleblower is a traitor who goes outside the organisation.

'But often problems are resolved before they get to that stage and these good outcomes are not acknowledged.'

Nurse Margaret Haywood was struck off the professional register by the Nursing and Midwifery Council (NMC) in 2009 after she exposed poor care at the Royal Sussex Hospital in Brighton. She has since been exonerated completely by the regulator.

Lead by example

She believes employers need to normalise whistleblowing and train ward staff in how to speak up. 'It does not need to be too formal, just "if you see anything you do not think is right, you need to do X",' she says. 'Managers need to lead by example.'

Like all the whistleblowers interviewed by Nursing Standard, Ms Haywood believes that line managers can be the main block to employees speaking out, and that organisations should offer a reporting line that could bypass them.

Nurses' rights to raise concerns are safeguarded under the Public Interest Disclosure Act 1998. This is popularly known as the whistleblowing law and it covers employees in the public and private sectors across England, Scotland and Wales. Equivalent provisions apply in Northern Ireland under the Public Interest Disclosure Order 1998.

The act provides protection for employees under a tiered disclosure regime, whereby they follow a recommended route, beginning with internal reporting. However, in practice, the act of telling an employer does not necessarily mean appropriate action will follow. PCaW advises staff who are unsure about whether, or how, to raise concerns. Between 2002 and 2010, a total of 13,406 people contacted its helpline for advice. More than a quarter worked in health and social care and, of these, around one third were nurses. Although most had already raised concerns, 40 per cent said their line managers failed to act on information they had provided.

"Whistleblowing is an ugly, negative term. I prefer to talk about 'speaking the truth'"
Graham Pink

Terry Bryan and Margaret Haywood

Terry Bryan, former charge nurse at Winterbourne View residential care home for people with learning disabilities near Bristol, faced similar problems when he tried to get the authorities to take his concerns seriously. He even contacted the Care Quality Commission before he went public.

The appalling treatment of vulnerable residents at the privately run home was eventually exposed by a BBC undercover investigation in May 2011.

He now believes employers must be accountable for the way they treat whistleblowers. 'The problem is that employers find other ways to get rid of whistleblowers,' he says.

'They record them as coming in to work late or having mental health problems. Previous whistleblowers at Winterbourne View were sacked.'

Employee concern about reprisals if they speak out is a significant barrier to greater openness. Last year, an RCN survey of 3,000 nurses found that 84 per cent would worry about victimisation, personal reprisals or a negative impact on their career if they were to blow the whistle.

Comparison of results from 2009 indicates this problem may be getting worse. More than one third of nurses had been 'discouraged' or directly told not to report concerns. Just 35 per cent - down from 46 per cent - felt confident that their employer would protect them if they did.

RCN head of policy Howard Catton says there can be a culture that dissuades, discourages and inhibits nurses from raising concerns. 'A line manager might say: "No one else has mentioned this" or "You know nothing will come of it." But what they should be saying is: "I am so glad you told me."

Culture change

'Every chief executive should say: "If you have a concern, please report it. We give you a guarantee that neither you nor your career will suffer any detriment." The fact that high-profile whistleblowers have either lost their jobs, had to move overseas or been dealt with harshly by their regulator sends a powerful message to nurses that will act as a deterrent to raising concerns.'

Experts want to see more done to ensure that employers meet their responsibilities in supporting those who speak out. According to Ms James, this responsibility does not simply end with putting a whistleblowing policy in place.

'People will not trust policies unless they see them working. Organisations must live and breathe the policies, review them regularly, target them carefully and build up a track record,' she says.

In addition, managers need more training on handling concerns, giving feedback to staff, ensuring whistleblowers are not victimised and approaching the relevant authorities.

Brighton and Sussex University Hospitals NHS Trust, where Margaret Haywood worked as an undercover nurse for the BBC's Panorama programme, has since tried to create a more open culture. It has introduced a new role of patient safety ombudsman, which PCaW would like to see more healthcare organisations offer.

Delilah Hesling, a nurse by background who took up the post five years ago, believes it has been an important step in addressing the anti-whistleblowing culture in the NHS. 'We need to reassure staff that it is okay to speak out, that it is necessary and may even be career enhancing,' she says.

The trust boasts a zero-tolerance approach to negative staff attitudes and has set up a 'caring café' where Ms Hesling meets patients and relatives over coffee. She tracks trends in the reporting of grievances and ensures that individuals who raise concerns get a letter congratulating them for advocating for patients. Such employees are now seen as future leaders, rather than troublemakers, she says.

There is growing pressure for this kind of patient advocacy to become a professional obligation or duty. Last year, at a meeting organised in the run-up to the launch of our Care campaign, nurses and policy experts agreed that whistleblowing should become a professional expectation, and should even become a mandatory part of staff appraisals.

The health select committee has examined this and in July 2011 its chair, Stephen Dorrell, took a stronger line, calling for nurses, midwives and doctors who failed to report poor care or abuse to be struck off their professional registers.

While PCaW opposes a mandatory duty to blow the whistle - fearing it would backfire and lead to a culture of silence - Mr Catton disagrees. 'We have to be firm about this. There is no wiggle room. The duty to raise concerns is already enshrined in the NMC code of conduct. You have an absolute responsibility to speak out about poor standards of care.'

Moral duty

The fear of negative consequences is a substantial deterrent to all nurses weighing up whether or not to speak out. However, they will have to balance this against a professional and moral duty to do the right thing.

Encouragingly, there are signs that there may be systemic support in place for nurses - and others in the health service - to do just that. In January, health secretary Andrew Lansley pledged to protect whistleblowers and launched a free whistleblowing helpline for health and social care staff (see sources of help). That month, NHS chief executive David Nicholson told NHS trusts that they must allow employees to make protected disclosures and warned that they should not use confidentiality clauses in employment agreements.

Revisions to the NHS constitution, expected shortly, are also likely to bring strengthened protection for NHS workers who blow the whistle.

The changes will make it clear that all NHS workers have a duty to report bad practice and mistreatment of patients. It will include a pledge that the NHS will support staff and investigate their concerns, and that staff will be able to speak to an independent party. In addition, in a move that could lead to organisational cultures becoming more open, the Council for Healthcare Regulatory Excellence is consulting on new standards for NHS executives and board members. Proposals include a requirement for executives to raise concerns should their organisations or colleagues be engaged in harmful behaviour.

Competition

Ms Reissmann is concerned that increased competition within the health service will make it harder to flag up poor standards of care in future.

'If you sit in any hospital canteen, you hear terrible tales about what goes on, but you cannot talk about them in public. There is a conflict of interest between giving the best standard of care and protecting the reputation of an organisation that has to look good to win a contract.'

Yet, despite the challenges involved in doing the right thing when faced with patient suffering, speaking up is the only option. As Mr Bryan says: 'Some things have improved, but abuses are still happening in large institutions. I want to believe that there will be change. If you know what you are seeing is wrong, have the courage of your convictions'.

Feature | Nursing Standard | April 18 | vol 26 no 33 2012

The RCN Publishing Company is a wholly owned subsidiary of the Royal College of Nursing, the world's largest organisation for nurses. RCN Publishing produces one weekly, eight monthly and two quarterly nursing publications. Nursing Standard, the flagship journal, is the UK's biggest selling weekly for nursing. It is produced by RCN Publishing Company along with a suite of specialist nursing journals - Cancer Nursing Practice, Mental Health Practice, Learning Disability Practice, Nursing Children and Young People, Nursing Management, Emergency Nurse, Nursing Older People, Nurse Researcher and Primary Health Care. RCN Publishing Company also produce the RCN Bulletin, a major source of up-to-the-minute information for RCN members in all specialities, grades and working environments. With the latest nurse vacancies from trusts nationwide, it has become the most cost-effective nurse recruitment magazine available.