Online Journal of Issues in Nursing. Available at http://www.nursingworld.org/ojin/topic8/topic8_3.htm

Introduction

"It [whistleblowing] is a position no one should be in... It has consumed my life for two years."(Barry Adams, RN, whistleblower, 11/3/98)

Case Study

In 1996, Barry Adams, a registered nurse (RN) working on a sub-acute care unit in a New England hospital, blew the whistle on unsafe health care practices that he observed in his work setting. Adams became increasingly concerned about the quality, safety, and dignity of patient care as the hospital implemented staffing cuts and cost containment measures. He carefully documented unsafe practices and correlated these with inadequate staffing and a lack of adequate supervision of inexperienced nurses. There was an increased incidence of patient falls, instances where patients were left to lie in their own urine and feces, treatments not being completed, and serious medication errors. These incidents resulted from a substantial increase in the nurses’ patient assignments.

For three months Adams and other nurses followed precisely the process outlined by the organization to communicate concerns to hospital administrators. He soon realized that the administrators were not interested in using the information he provided to correct the situation; in fact, he was harshly criticized for collecting this information. He then decided to proceed with a variation of the traditional saying: "If it’s not documented, it’s not done" and, instead, adopted the approach: "If it’s not done, document it!" Also, at one point he refused to take narcotic orders from a technician working for a physician, citing that this was against the US Nurse Practice Act.

Adams was threatened with the loss of his job and, in spite of previous performance reviews that were excellent, he was eventually fired. He sued and won his case (his attorney was an RN). The hospital appealed and lost again. Five units of the hospital have since closed "for financial reasons."

Whistleblowing and the Whistleblower

In an ethically responsible Organisation whistleblowing should not have to occur because there would be internal procedures to address staff concerns. Whistleblowing is a moral action of last resort and that, under certain circumstances, it is not only appropriate, but necessary. According to Dougherty (1995), whistleblowing "refers to a warning issued by a member or former member of an organization to the public about a serious wrongdoing or danger created or concealed within the organization" (p. 2552). A genuine case of whistleblowing requires the whistleblower to have utilized, unsuccessfully, all appropriate channels within the organization to right a wrong. Some would disagree with our account. Nielsen (1997), for example, identified 12 ways that an individual could blow or threaten to blow the whistle, and he uses the term "whistleblowing" regardless of whether the revelation occurred internal or external to the organization. Our definition is in keeping with a study conducted by Sellin (1995) on patient advocacy within organizations that distinguished whistleblowing from reporting. According to Sellin, participants tended to view whistleblowing as an external action to an unresponsive organization and reporting "more as an internal process, done through organizational channels" (p. 23). Such was the situation with Barry Adams. He had unsuccessfully exhausted all the internal channels of communication regarding unsafe patient care and dangerously low staffing levels before "going public."

When all is said and done, the whistleblower must blow the whistle for the right moral reason and reasoning. It follows, therefore, that the whistleblower must be carefully scrutinized. What are the personal and the professional reputations of the whistleblower? What is the motive driving the whistleblower? Is it to benefit the client or the organization, or is it a need for attention or revenge? Is the whistleblower's cause seen as legitimate and significant by trustworthy colleagues and friends? Is the whistleblower aware of the potential consequences of blowing the whistle and still willing to accept responsibility for actions taken? In our case, Adams’ personal and professional reputation were above reproach (21 persons attested to his high integrity during the suit over his termination), and he blew the whistle out of a concern for patient safety and staffing inadequacies. He was aware of the consequences of his actions and willing to assume responsibility for them.

As Adams discovered, blowing the whistle can be a life-altering experience. The whistleblower who stops an unethical practice in their organization and gets rewarded for the behavior can feel a sense of deep accomplishment. The whistleblower who attempts to stop an unethical practice in their organization and gets punished for it may have to live through many experiences, including, as Barry Adams experienced, the loss of his job and court proceedings.

Even if one does not lose one’s position, Hunt (1995a, pp. 155-158) describes other troubling experiences such as broken promises to do something about the unethical practice, isolation and humiliation, formation of an "anti-you" group, organizational stonewalling, questioning of one’s mental health, unusually close observations of what one does and says, vindictive tactics to make one’s work more difficult or insignificant, talk about so-called generous severance packages, assassination of one’s character, disciplinary hearings before one has had a chance to address one’s concerns, and possible suspension. Adams experienced virtually all of the preceding tactics. Not noted by Hunt, but most tragic of all, are those persons who commit suicide because they tried to do what was morally right but could not survive the harassment and threats to their selves. The preceding tactics and situations are the result of an organization that has profoundly lost its moral compass and has been ethically tainted to its core.

What makes whistleblowing so difficult for all persons involved is the clash of values inherent in most cases of whistleblowing. This clash of values may take many forms, for example, loyalty to clients or to one’s own integrity versus loyalty to the organization. But what is meant by personal integrity and by loyalty? By personal integrity is meant that one is consistently true to one's moral ideals and value system and is able to demonstrate this consistency in how one lives their daily life. By loyalty is meant that one is steadfast in allegiance to others and does not desert or betray others in their time of need. Loyalty also suggests other virtues such as mutual respect, promise keeping, and ability to keep confidences. In addition, one must remember that at times loyalty can be blind or misplaced and, thus, ceases to be a virtue because harm, rather than good, can come from it (Silva & Synder, 1992). In Adams’ case, he placed loyalty to safe patient care and his role as patient advocate over the profit motive of the hospital.

Whistleblowing should not be a capricious matter; a person's or an organization's life or death may result from it. Thus, strong moral justification must exist for blowing the whistle and, ideally, the whistleblower should have an established reputation for high integrity lest his or her personal characteristics detract from the issues. The following are considered some necessary conditions that should be established before one undertakes blowing the whistle and Adams met all of them:

1. The reason the whistleblower is blowing the whistle is because they see a grave injustice or wrongdoing occurring in their organization that has not been resolved despite using all appropriate channels within the organization;
2. The whistleblower morally justifies their course of action by appeals to ethical theories, principles, or other components of ethics, as well as relevant facts;
3. The whistleblower thoroughly investigates the situation and is confident that the facts are as they understand them;
4. The whistleblower understands that their primary loyalty is to client(s) unless other compelling moral reasons override this loyalty;
5. The whistleblower ascertains that blowing the whistle most likely will cause more good than harm to client(s); that is, clients will not be retaliated against because of the whistleblowing; and
6. The whistleblower understands the seriousness of their actions and is ready to assume responsibility for them.

We agree with Hunt (1995b) that whistleblowing represents a "multi-layered breakdown in accountability" (p. xvii). Since the common welfare of citizens, particularly in matters of health, is a goal of the health care professions, whistleblowing affects health care institutions, corporations, providers, and clients profoundly. At the core of the whistleblowing issue lies accountability--public and private organizational accountability, health care professional organizational accountability, health care worker accountability, and consumer/client accountability.

As reflected in the Adams case study, if nurses adhere strictly to the Code’s directives they are often called upon to make personal and professional sacrifices, including loss of employment. The Code calls for nurses to be accountable professionals, yet fails to acknowledge that, in reality, nurses have little power within the health care system. As Barry Adams noted, "Why should nurses have to choose between carrying out the behaviors called for in the [ANA] Code (trying to ensure safe, quality, and dignified care for their patients) and providing for their families?"

Whistleblowing and Organizational Ethics

James Rest (1986) proposes a four-step model for individual ethical decision making that must:

1. recognize a moral issue;
2. make a moral judgment;
3. resolve to place moral concerns ahead of other concerns; and
4. act on the moral concern.

Agents faced with a moral dilemma have the greatest difficulty with the third step of Rest’s model. The difficulty comes, in part, from the recognition that agents who "blow the whistle" almost always suffer negative consequences (Seeger, 1997). For this reason, many workers are reluctant to report what they know, especially if the person about whom they would report is a supervisor or someone perceived to have greater standing in what is almost always a hierarchical structure (Walsh-Bowers, Rossiter, & Prilleltensky, 1996). Even when negative consequences are not anticipated, moral agency in organizations can be difficult because some "settings do not encourage understanding and acting upon ethical issues as social and organizational in nature" (Walsh-Bowers, et. al., 1996, p. 332).

Perhaps, as Silva (1998) observes in the lead article of this issue, this is the reason that HCOs have paid insufficient attention to the organizational dimension of ethical issues. While biomedical issues have been a focus of attention for more than 30 years, institutions have exhibited behavior that Silva calls "the cart before the horse" and "the Band-Aid" phenomena. That is, HCOs have tried to solve very difficult moral problems, such as those relating to end of life issues or to distributive justice, before thinking through the moral basis for their actions ("cart before the horse") and by trying to locate responsibility for moral decisions only in a committee or consultant ("the Band-Aid").

The "ethical climate" (Victor & Cullen, 1997) of an organization is the prevailing perception of the organization as reflected in the organization’s practices and procedures. Because whistleblowing results from a failure of organizational ethics, it is imperative for Organisations to establish their ethical climates by identifying common values and beliefs so that both employees and clients are able to recognize the organization’s core values and to hold the organization accountable for them. In large, complex settings, however, the individuals employed by Organisations will hold a variety of moral perspectives, generally reflective of the pluralistic society the Organisation serves. And whistleblowing results, in part, from a tension of values. Part of that tension may stem from the diversity of moral beliefs held by the staff. For example, while all employees may agree with a hospital’s stated value that individuals be treated with dignity, some employees may believe that a policy that allows a surrogate decision maker to remove nutrition and hydration from a person in a persistent vegetative state is inconsistent with that core value. Further, as Liedtka (1991) points out,

the differing educational and socialization experiences of staff, coupled with the fact that the primary focus of management has tended to rest on the health of the organization, rather than the individual patient, suggests that the potential for the development of differing value systems between staff is high. (p. 15)

In the presence of multiple value systems, the occasions for disagreement and misinterpretation are multiplied. Thus, it is the Organisation’s responsibility to articulate the organization’s ethical climate distinct from the individual beliefs held by staff members. In addition, it is important to establish forums and procedures through which individual members of the organization may challenge, in a constructive way, institutional values and decisions made by other members of the organization.

Robert Potter (1996) defines organizational ethics as "the intentional use of values to guide the decisions of a system" (p. 4). One approach to enhance an organization’s efforts is for the organization to develop its own code of conduct. They also must outline specific procedures for how a reported concern will be addressed. There is no point for nurses to report concerns if nothing is done with the information.

However, an institution’s culture is more than an articulated mission statement. During the Tylenol contamination incident, there was no doubt within the company about what action Johnson & Johnson would undertake. Despite the fact that a recall of the product cost millions of dollars, the corporate culture put doing the right thing above earning profits unethically. This priority of doing right over earning profits unethically was well known to all the employees of Johnson & Johnson. As Sims (1994) states, "the culture not only places constraints upon activities of the organization and its members (cultural prohibitions), it also prescribes what the organization and its members must do (cultural imperatives). In short, the culture guides the activities of the organization and its members" (p. 27). A telling observation by Jackall (1988) is that unethical behavior in modern corporations is traceable more to bureaucratic structures than to individual moral deficiencies.

Since the decision making process in HCOs is increasingly in the hands of non-clinicians, an ethical culture which preserves the priority of patient health over organizational health may be more difficult to find. As Silva (1998) has noted, an HCO must undertake a deliberate process to build an ethics infrastructure. According to Potter (1996), one way to achieve this infrastructure is through the evolution of clinical ethics to organizational ethics. He states, "we will have to learn how to integrate clinical and corporate aspects of bioethics. We must learn how to maintain our skills of analysis of the patient/provider relationship and, at the same time, account for the patient/system relationship" (p. 7). While matters of billing and admission policy are certainly part of this integration, they are only a small part of the ethical climate of an organizational culture. In fact, if an HCO’s organizational culture were as well known to its staff as Johnson & Johnson’s ethics was known to its employees, statements of principle governing billing and admissions would not be necessary except as information for patients. The importance of an articulated organizational ethics is captured by the analogy which identifies the ethical climate of an organization with the character of an individual and the organizational ethics processes within an organization with the conscience of an individual (Spencer, Mills, Rorty, & Werhane, forthcoming 1999).

As Spencer et al. (1999) point out, effective organizational ethics encompasses diverse ethical perspectives, including business, professional, and clinical imperatives, each of which maintains its traditional stance. To this we would add that the HCO must articulate and disseminate those values which will be predominant so that ambiguities about priorities will be eliminated (Sims, 1994). For example, an HCO might pronounce that meeting patient needs comes before unethical profits. An HCO with an articulated ethical climate and published procedures for resolving ethical disputes can minimize the need for whistleblowing (Bok, 1980).

Summary Recommendations

Matters of interpretation and concrete steps that organizations can take to ensure an ethical environment that goes beyond mere compliance (Giblin & Meaney, 1998). James Rest (1986) proposes a four-step model for individual ethical decision making; the individual must:

1. recognize a moral issue;
2. make a moral judgment;
3. resolve to place moral concerns ahead of other concerns; and
4. act on the moral concern.

These recommendations will never entirely eliminate the need for whistleblowing. There will always be some organizations that are concerned only with mere compliance and, therefore, lack the will to establish an ethical climate such as we have envisioned.

The Authors

James J. Fletcher received his BA from Iona College, his MA from Marquette University, and his PhD from Indiana University. He is an Associate Professor of Philosophy in the Department of Philosophy and Religious Studies at George Mason University, Fairfax, Virginia. He has been a member of the George Mason faculty since 1972 serving in a variety of teaching and administrative capacities, including 15 years in the Office of the Provost. He teaches courses in ethics, bioethics and philosophy of technology. His current research interests in the area of bioethics include organizational ethics for health care providers and end of life issues. In addition, he has written and presented extensively on higher education issues relating to faculty roles and rewards. He is the Ethics Collaborator in the Office of Health Care Ethics in the College of Nursing and Health Science. He also serves as a community member of the Prince William Health Systems Bioethics Committee for which he provides consultancies and educational programming.

Jeanne Sorrell, PhD, RN is an Associate Professor in the College of Nursing and Health Science at George Mason University. Dr. Sorrell currently serves as Coordinator of the PhD in Nursing program and Coordinator of Special Projects for the Office of Health Care Ethics. She teaches courses in research and writing, as well as courses in the Advanced Clinical Nursing and graduate Nursing Education Certificate programs in the College. She has published articles on a variety of topics related to writing, education, and research and is currently coordinating the production of a videotape on Ethics of the Care of Persons with Alzheimer’s Disease. Dr. Sorrell’s interest in the ethics of dementia is also reflected in a current funded research project: Ethical Concerns in the Diagnosis and Treatment of Dementia: Stories of Persons with Alzheimer’s Disease and their Families.

Dr. Silva received her BSN and MS from the Ohio State University, her PhD from the University of Maryland, and her post doctorate in health care ethics from Georgetown University. She is a Professor and Director of the Office of Health Care Ethics, Center for Health Policy and Ethics, College of Nursing and Health Science, George Mason University, Fairfax, Virginia (http://www.gmu.edu/departments/chp/ethics.htm). She currently teaches a doctoral course on "Ethics in Health Care Administration" and is engaged in scholarship and research related to health care ethics. Dr. Silva serves on the ANA Code of Ethics Project Task Force to revise the 1985 ANA Code for Nurses with Interpretive Statements. She is also a member of the American Academy of Nursing Expert Panel on Ethics.

ACKNOWLEDGEMENT

The authors wish to extend their appreciation to Barry Adams, RN, BSN for his generosity and forthrightness in sharing first hand the details of his whistleblowing experience. The case presented here is with the permission of Mr. Adams.

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