Whistleblowing and patient safety

Hey there, time traveller!
This article was published 02/12/2023 (691 days ago), so information in it may no longer be current.

Whistleblowing in government is usually assumed to involve the disclosure of illegal, corrupt, or unethical conduct. The activity becomes more complicated and ambiguous when used in relation to the health-care sector, where matters of life and death are involved. Providing safe, quality care is the central purpose of all parts of the sprawling health-care system.

Above all else health professionals are expected to do no harm.

I came back to this topic after reading Carol Youngson’s book Take Your Baby and Run (Great Plains Press 2023), which provides a moving, personal, and informative account of the tragic deaths of 12 infants in the pediatric cardiac surgery program at the Health Sciences Centre in 1994.

Youngson led a group of nurses who sounded the alarm about the mistakes being made by a new surgeon. Their concerns were initially dismissed as ill-informed and unduly emotional.

Eventually the surgery program was closed, and a five-year long inquest led by then-Justice Murray Sinclair produced an impressive, lengthy report with many far-reaching recommendations. In 2000, the health minister appointed a committee (I was chair) to review the Sinclair report. One of the Sinclair recommendations, which the Thomas committee did not endorse, was the immediate adoption of a whistleblower protection law for the health sector.

Back then, few such laws existed and the early experience with them was disappointing in terms of both encouraging individuals to complain about perceived wrongdoing and protecting them against reprisals. Instead of immediate adoption of a law, the Thomas report recommended as an initial step the creation of safe channels of communication within health-care institutions and declared institutional commitments of no reprisals for good faith disclosures. A review of experience after five years could lead, if required, to the adoption of a whistleblower protection law.

Most jurisdictions have since developed elaborate regimes of laws, regulations, structures, procedures, and reporting requirements intended to allow for safe whistleblowing across the public sector, including the health system. Manitoba adopted the Public Interest Disclosure Protection Act (PDA) in 2007, which has been amended several times but it still requires strengthening to provide greater encouragement and support to potential whistleblowers (a subject for another occasion).

For laws to work as intended in health care, they must be supported by professional codes of conduct, committed leadership within the various health professions and institutions, ongoing education and training, and perhaps most importantly, supportive cultures and interpersonal climates within organizations that allow for questioning and dissent as legitimate activities.

Too often, the issue of raising concerns about the safety and quality of care is presented in dichotomous terms of silence versus blowing the whistle. Careful studies indicate that this simplistic dichotomy ignores the role of low-profile strategies and informal channels of communication used to raise concerns about poor standards of care. In some situations, these approaches have proven to be more effective than formal whistleblowing.

For most employees blowing the whistle is, for several possible reasons, the last resort. This has led to a recent emphasis within health systems on routines and cultures of “speaking up” rather than utilizing complicated, disruptive formal complaint regimes.

“Speaking Up” programs can help with the so-called “deaf effect,” a phrase which describes the reluctance of managers to hear and act on challenging concerns from beneath them within the organization.

Whistleblowers need courage to come forward, but in some situations, it also takes courage for managers to act on those concerns based on the anticipation that senior authorities above them within the health system will not welcome and may resist bad news coming from the front lines.

Whistleblower protection laws typically apply only to present and former employees of health institutions. External complaints from patients, relatives, non-health professionals (e.g., social workers), contractors and the media are not legally whistleblowing. It might be assumed that outsiders are freer to speak up, yet they may also feel constrained.

For example, during the pandemic long term care facilities banned some visitors who raised concerns about care. As the health-care system comes to rely increasingly on private organizations to deliver services, governments need to amend the PDA to provide incentives and protections for employees of those organizations who witness serious problems.

A short article cannot fully convey the complexity of whistleblowing and how it is influenced by numerous factors, including other laws. For example, in 2006, Manitoba was the second Canadian province to adopt mandatory reporting of critical incidents, a law which is meant to support a culture of no-blame, learning, and disclosure to patients and families when something goes seriously wrong.

In surveys of public trust in various occupations, nurses are almost always at the top, which reflects the fact that advocacy for patients is central to the professional culture of nursing.

Facing serious concerns about the quality of care, not all nurses will take the risks associated with formal whistleblowing, but nearly all will heed the voice of their professional conscience and speak up.

Paul G. Thomas is professor emeritus of Political Studies at the University of Manitoba. He was the founding board chair of the Manitoba Institute for Patient Safety from 2004 to 2008.