Whistle-blowing, ethics and patient care:
some thoughts and lessons
Margaret Heywood, 58, a nurse at the Royal Sussex Hospital, Brighton, UK, was struck off by the Nursing and Midwifery Council for failing to ‘follow her obligations as a nurse.’ Concerned about the treatment of elderly patients, in July 2005, she filmed conditions in her hospital, undercover, for the BBC Panorama programme. (Reported by BBC News, 16 April 2009: http://news.bbc.co.uk/2/hi/uk_news/england/sussex/8002559.stm)
I am not in a position to comment on the detailed rights and wrongs of this case (though there seems to be strong evidence in favour of the nurse’s position), but the controversy raises issues which are important for all of us and for achieving the best possible healthcare.
Following discussion of this case, some specific lessons and recommendations appear at the end of the post.
If patients are being neglected, or abused or given less than satisfactory treatment, what should we do? Obviously the first stage is for staff to represent their views, ideally as a group, to local management, and to insist that they are taken seriously. Sadly, of course, in an institution where patients are badly treated, management itself is likely to be in collusion with the status quo (through laziness, blindness or financial priorities) and staff concerns may well be dismissed (as they seem to have been in the Sussex case).
When this happens there are three options for staff: put up with things as they are; resign; find some way of protesting and bringing the problems to wider attention, first to management, then beyond. In the last case, the risks are great, because, in spite of the rhetoric of openness and transparency, many managers and bureaucrats have a deeply-seated hostility to criticism and often react with oppressive and brutal measures.
The Chair of the Council which struck this nurse off, said, as reported by the BBC:
‘Although the conditions on the ward were dreadful, it was not necessary to breach [patient] confidentiality to seek to improve them by the method chosen…[the misconduct] was fundamentally incompatible with being a nurse.’
‘Dreadful conditions’? How can such a frightening situation have arisen? I do not know if any patient identities were revealed in the film, nor, if they were, whether the patients had given their consent (that would be important, certainly), but don’t ‘dreadful conditions’ demand dramatic remedies? And don’t the responsibilities of a nurse require them to take measures to bring such conditions to light and improve them?
What is fascinating about the Chair’s comment (amongst much else) is the comparative weighing of two ethical imperatives: patient confidentiality and patient safety and welfare. If we had to choose one above the other, which would it be? Can such a choice be made? Are there ways in which both principles could be respected while still finding a solution? (We do not know for certain whether patient confidentiality was actually breached in this case.)
Is ‘patient confidentiality’ being used as a manipulative moral flag or is it a genuine, fundamental concern of those who are hostile to the nurse’s revelations? Could breaches of confidentiality be justified in the face of real threats to patient welfare and safety? Where do you stand?
In the book, I write about the profound effects of the ethos of an organisation on the morale and effectiveness of HCPs. In this case we seem to have an organisation, within a much wider, supportive professional context, which is neglectful of many of the major priorities of staff and patient wellbeing and communication, and punishes those who criticise them.
In the BBC report, a Department of Health spokesman is quoted as saying:
‘Whistle-blowers already have full protection under the Public Interest Disclosure Act passed by this Government.
‘We expect any member of staff who reports concerns about the safety or quality of care to be listened to by their managers and action taken to address their concerns.’
Maybe I can guess your response to this, somewhat similar to my own: this is a communication so far from reality as to be laughable; in the real world, it’s just not like that. What happens when managers don’t listen?
This whole story is about how you can effectively communicate issues of major importance to those who may be able and willing to do something. Choosing to contact the media, even as a last resort, is a very powerful and effective course of action. But we also know that it is very dangerous, especially for individuals, in a world often more concerned with saving face than solving problems.
For the last word in this story, here’s what Joyce Robins, co-director of Patient Concern is reported as saying:
‘This just demonstrates the priorities of the regulators – rules come before patients every time. The message that goes out to nurses is: however badly you see patients treated, keep your [mouth] shut.’
What do you think about this and similar issues?
Lessons and recommendations
The penalties of not listening
People who are not listened to, or who feel they are not listened to, are likely to react badly in one way or another – from minor individual effects like transient irritation or resentment, through the entire spectrum, to massive, public effects like rebellion and revolution at the other extreme.
The act of not listening when someone else has something to say is potentially dangerous to all parties.
If we are not listening to our patients, we shall miss important information about their lives, feelings, health and everything else; we shall upset them, because they will know we are not taking them seriously, and their confidence and trust will be undermined, if not destroyed completely.
If managers do not pay careful attention to what their staff are saying, morale will be damaged and loyalty alienated.
The same dangers apply to teachers, parents, partners, friends, colleagues: if we don’t listen to others the chances are we’ll neglect, hurt, damage, frustrate, alienate them. The consequences can be serious.
People who are not listened to may simply end up carrying a burden of internal anger and frustration (which may damage their mental equilibrium); they may go off and complain and villify the cause of their frustration (in the case of patients or customers, damaging the reputation of an organisation); they may be prompted to go and take much more dramatic, possibly disproportionate action (media exposure and litigation being two of the nasty possibilities).
When we listen seriously to people, even when we do not wholly agree with them, or disagree completely, we take some of the steam out of their anger, frustration or distress: their case is being given a chance and that opens the doors to dialogue and negotiation. Such dialogue may not always end in agreement, but the case has been treated with respect and seriousness, and is far less likely to result in escalation of hostilities (though it may).
In the book, the section on complaints outlines the damaging results of not keeping an open ear for patient dissatisfaction, and not paying serious attention to it when it emerges. The same applies to the dissatisfaction of everyone: we must listen – and, where possible, concede the case or find a negotiated settlement.
Empathy
Stories like that of the nurse above suggest that empathy is often absent in responses to individuals and their concerns: what has brought this person to the point of such distress? What is it they are seeking (and the insight here could be positive or negative)? Is this a responsible, concerned professional, or a loose cannon out to cause trouble? What lies behind the strength of this feeling and is it something that should be taken seriously and investigated? What are the needs of this individual in terms of resolving the distress? How can we resolve the situation with least damage to all parties in terms of their needs, feelings and priorities?
When citizens take to the streets, it is often because they feel no-one is listening to their concerns, no-one is taking them seriously. Leaders who listen and have empathy are much less likely to have rioters besieging their cities than those who are actively attentive to their people. Healthcare is just as vulnerable to defective listening and absent empathy and no-one should be surprised that there are occasionally nasty conflicts which damage everyone in some way, when basic communication skills are often so sadly neglected.
Tags: complaints, confidentiality, duties of nurses, empathy, ethics, frustrated needs, hostile management, listening, organisational ethos, patient welfare, struck off, whistle-blowing
I must have missed that story when it happened in April. Very interesting post, thanks for sharing!