Healthcare staff struggled to speak out long before COVID-19. They need help to do so now

While healthcare workers fight on behalf of us all against COVID-19, they can still risk their jobs for blowing the whistle on dangerous practices and wrongdoing. In fact whistleblowing and the global crisis caused by COVID-19 are closely intertwined.

We first learned about the outbreak of the pandemic and its seriousness through disclosure by Dr Li Wenliang, who has since fallen victim to COVID-19 and who was questioned and admonished by the Chinese police in early January when he circulated a colleague’s report on what proved to be the new coronavirus. Other doctors around the world have also been silenced for speaking out in an attempt to protect lives. A Washington State doctor was moved from his job in the emergency room at PeaceHealth St Joseph Medical Centre at the end of March for disclosing the lack of protective measures for staff and patients at the hospital. He had spoken to newspaper journalists, and on social media posts, pleading that he and his colleagues were being left exposed and vulnerable to COVID-19. In Pakistan doctors were detained by the police for protesting publicly against the lack of PPE for front line healthcare workers.

And in the UK, 10,000 NHS staff felt desperate enough in April to sign a letter to the Prime Minister demanding better personal protection. In May we learned that healthcare staff were being threatened with losing their jobs for speaking publicly about the crisis that lack of protection was creating.

This is not new in the NHS, where drawing attention to wrongdoing and risks has long been a problem, forcing staff to become whistleblowers, often at high personal cost to themselves. Whistleblowing is prevalent but difficult in the health sector, because of hierarchical structures, reinforced by constant pressure to save money due to chronic underfunding, leading to organizational defensiveness and blindspots.

The ‘deaf effect’

Hospital-based healthcare is typically hierarchical. What MIT Professor Edgar Schein describes as ‘professional distance’ keeps leaders apart from those lower down the hierarchy. This separation is a feature of day-to-day operations and enables the coordination of complex activities. Critically, however, it works against managers being open to challenge from staff lower down.

Senior leaders are often seen as unapproachable. Nurses rarely criticize senior doctors’ decisions, even those that are potentially dangerous. This set-up can give rise to a ‘deaf effect’, which also happens when a healthcare manager ‘does not hear, ignores or overrules a report of bad news to continue a failing course of action’, in the face of a crisis. Successive surveys of healthcare staff show that people do not speak out in this sector because they believe nothing will be done and their attempt will be futile. The arrival of COVID-19 has done little to change this culture.

Defensive managers

Healthcare managers can act defensively in times of crisis. Health is unusual. It is among the sectors most scrutinized by the media. The public tends to be intolerant of mistakes, despite the fact that healthcare is inherently complex and errors are a fact of life. Crises frequently result in the search of an individual to blame and punish.

Because scandals are so public, and because health is traditionally highly political, managers tend to be rewarded for success stories but punished when problems emerge and reach the public domain. It is almost impossible to manage effectively with this kind of political and organizational pressure. There is a strong temptation for managers to suppress problems at the early stage with the hope of moving to a new role before things get out of hand.

When people are preoccupied with external expectations to deliver good news, a style of management known as ‘comfort seeking’ can emerge in response to serious problems. Managers respond to critical situations by attempting to control the narrative, limiting their sources of information when investigating, focusing on data that reassures, and even altering messages coming from clinicians. They work hard to maintain an image of rationality and control in times of crisis — often because this is what the public demands. People who speak out threaten this image. Negative messages from frontline staff are ignored. Staff who report problems are seen as obstacles to be removed rather than a valuable source of insight. It is thus no surprise that fear of reprisal is one of the top reasons given by healthcare staff for not speaking out; people are afraid of being seen as troublemakers.

Short term staff

Healthcare staffing arrangements can discourage speaking out. The people who are most likely to disclose poor or unsafe care include clinical staff who are in relatively secure management roles, according to the research. They are typically senior, more experienced, and enjoy employment protection.

But this kind of employee is becoming less common. Changes to healthcare since the 1980s have seen an increase in the use of agency workers and staff on short-term contracts in place of permanent employees. These workers are more likely to remain silent if they encounter wrongdoing. Junior doctors, students, and trainees depend on references and approval from their line managers for future job security. They often lack the confidence that comes with experience in a particular setting, necessary for deciding whether to speak out about wrongdoing. Nursing home staff and home carers are often in an equally precarious employment position.

All these kinds of staff are in the front line of the struggle against COVID-19. They will hesitate to speak out and they need help to do so, from those with more security and authority.

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Given that the culture and structure of large healthcare organizations works against the ability of staff to speak out, how do they typically respond to crises? Research suggests that to deal with extreme incidents of poor care, instead of speaking out through formal channels both nurses and doctors often act independently. People tend to devise smaller workarounds rather than making formal complaints. This strategy helps clinicians deal with isolated incidents. But COVID-19 is not an isolated incident, and the serious issues that healthcare staff face cannot always be ‘worked around’.

We know from staff at whistleblower helplines that healthcare is the sector from which they get most calls. But it can be extremely difficult for healthcare staff to effectively report problems. UK whistleblowers are ostensibly protected from retaliation under the 1998 Public Interest Disclosure Act. Time and again, this legislation has proved ineffective for addressing reprisals against whistleblowers, including in healthcare. The Francis Inquiry report into failings at Mid Staffordshire NHS Foundation Trust was published in 2013, pointing to the importance of supporting and protecting whistleblowers. Changes were introduced to enable safe disclosures by NHS staff. But the plight of workers during COVID-19 suggests that the systems in place to support them ─ both organizational and legal ─ are not working as intended.

Healthcare whistleblowers need help to speak out, now more than ever now, when timely disclosures can help prevent major disasters. Building transparent and fit-for-purpose channels for disclosing and preventing wrongdoing is key for achieving this. Senior healthcare managers, politicians, and unions must also fight hard to be the voices of frontline healthcare staff who struggle to draw attention to serious issues they encounter at work.