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Cassematis & Donkin, 2008). In this context, the human factor responses of managers to internal reporting is essential.
In light of the codified obligation that nurses have to‘ take appropriate action’ when patient safety and quality care are placed at risk, a critical investigation is required. Whistleblowing need never occur if those responsible for receiving and acting on patient safety reports adequately address them in a culture of transparency, trust and accountability. The way forward requires attention and research, not just on clinicians at the sharp end of patient care but also on the managers who receive reports of failure.
Schein’ s( 2016) key message to managers who receive reports of patient safety concern is“ to become more mindful of how they react to subordinate comments about safety or quality”. He acknowledges the failure of upward communication related to safety and quality concerns and challenges managers to be vulnerable and accept the fact that their subordinates will know and see systemic things that would improve quality and safety.
Schein also recommends learning to pay attention to“ weak signals” which are“ small problems that are detected, but are less likely to be reported or taken seriously”( p. 266). These weak signals often precede whistleblowing events in healthcare. He uses the example of tensions between surgeons and nurses as a weak signal that is often ignored.
In the Bundaberg case, it was tensions between a surgeon and senior nurses from perioperative, intensive care, infection control and renal that could have been conceived as weak signals.
In the Macarthur case, tensions between an anaesthetist and two senior clinical nurse specialists was a weak signal not recognised, and it set the path to the whistleblowing action( Cleary, 2014).
Dixon-Woods et al( 2014) recommended managers and leaders in healthcare actively seek out weaknesses in their organisations. Defined as“ problem sensing”, they suggest that this information come from not only the formal incident reporting systems, but also“ softer intelligence” such as listening to staff and patients as well as making informal, impromptu visits to the clinical areas.
Dixon-Woods et al recognised that all too often healthcare managers are preoccupied with compliance, external expectations and positive news.
These managers were labelled“ comfort seekers” who actively seek data that provide“ reassurance that all was well”( p. 111), instead of hearing or seeing the weak signals.
Negative feedback was avoided by comfort-seeking managers who distanced themselves from their frontline staff. When complaints, concerns or criticisms were raised, these were perceived as merely“ whining or disruptive behaviour”( p. 111).
When issues are reported, found or validated, it takes courage to upward report, effect action and bring to a close the offending practice or practices.
As speculated by Mannion and Davies( 2015), the“ more unpalatable the message” the less likelihood of action.
Vandekerckhove, Brown and Tsahuridu( 2014) believe future research to prevent whistleblowing should examine the variables that determine courage on the part of the recipient of the bad news – that is, the manager.
What influences some managers to demonstrate not only courage to hear what is being said, but to also take appropriate action and refrain from inappropriate behaviour? Behaviour such as retribution and increased surveillance on the bearer of the news.
Research on“ hearer courage” will promote a better understanding of the human factors involved in“ which managers have the courage to hear, under which circumstances”( p. 316) and for what wrongs.
Further work needs to be done to understand this complex phenomenon, for a failure to understand means more nurses and other health professionals having to blow the whistle. ■
Dr Sonja Cleary is associate dean, student experience, School of Health and Biomedical Sciences, RMIT University.
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