Abstract
Background:
Whistle-blowing is an ethical activity that tries to end wrongdoing. Wrongdoing in healthcare varies from inappropriate behaviour to illegal action. Whistle-blowing can have negative consequences for the whistle-blower, often in the form of bullying or retribution. Despite the wrongdoing and negative tone of whistle-blowing, there is limited literature exploring them in healthcare.
Objective:
The aim was to describe possible wrongdoing in Finnish healthcare and to examine whistle-blowing processes described on the basis of the existing literature in healthcare as perceived by healthcare professionals.
Research design:
The study was a cross-sectional descriptive survey. The data were collected using the electronic questionnaire Whistle-blowing in Health Care and analysed statistically.
Participants and research context:
A total of 397 Finnish healthcare professionals participated, 278 of whom had either suspected or observed wrongdoing in healthcare, which established the data for this article.
Ethical considerations:
Ethical approval was obtained from the Ethics Committee of the University (20/2015). Permission to conduct the study was received according to the organisation’s policies.
Findings:
Wrongdoing occurs in healthcare, as 96% of the participants had suspected and 94% had observed wrongdoing. Regarding the frequency, wrongdoing was suspected (57%) and observed (52%) more than once a month. Organisation-related wrongdoing was the most common type of wrongdoing (suspected 70%, observed 66%). In total, two whistle-blowing processes were confirmed in healthcare: (1) from suspicion to consequences occurred to 27%, and (2) from observation to consequences occurred to 37% of the participants.
Discussion and conclusion:
Wrongdoing occurs in healthcare quite frequently. Whistle-blowing processes were described based on the existing literature, but two separate processes were confirmed by the empirical data. More research is needed on wrongdoing and whistle-blowing on it in healthcare.
Introduction
Whistle-blowing is an ethical activity aiming to stop wrongdoing, rooted in business 1 and virtue ethics. 2 Whistle-blowing has been traced in the literature in the organisational context to the early 1970s. 3 In the healthcare context, whistle-blowing has been studied for over 20 years. 4 As a symbolic term, whistle-blowing refers to sounding an alarm to bring attention to wrongdoing. 5
Wrongdoing in healthcare has been reported in several countries (e.g. Australia, the United Kingdom and the United States) during the past few decades. 6,7 In the United Kingdom, the Francis Report revealed a total system failure, with high mortality rates and appalling wrongdoing, between 2005 and 2008. 8 Recently, wrongdoing has been revealed especially concerning older people abuse, mistreatment and neglect. 8,9 Responses to wrongdoing include whistle-blowing policies, guidance from regulators and professional bodies 9,10 and legislation to protect the whistle-blowers. 11
Not much is known about wrongdoing and whistle-blowing in the Finnish healthcare context, even though whistle-blowing may well be a relevant factor in enhancing patient safety and well-being at work. This study aims to describe possible wrongdoing in Finnish healthcare and to examine whistle-blowing processes described on the basis of the existing literature in healthcare as perceived by healthcare professionals.
Background
Whistle-blowing on wrongdoing requires courage to act despite the possible personal or professional consequences. 12 It is associated with the values and norms of the individual, workplace or organisation 9 and requires moral integrity. 12,13 Moral integrity involves identifying not only the values and norms of the society and culture but also one’s own personal values and acting on them 14 to maintain one’s own ethical standards. 13 In addition, whistle-blowing can be considered as an act of advocacy, standing beside the patient 14 and being the patient’s advocate. 15,16 Whistle-blowing is defined here as a process where wrongdoing is suspected or observed in healthcare by a healthcare professional, a current or former member of an organisation, who blows the whistle to a party that can influence the wrongdoing.
The whistle-blowing process will start from suspected or observed wrongdoing. 17 Suspicion of wrongdoing is the initial phase where one becomes suspicious of wrongdoing, 17 and it means not being sure whether wrongdoing is occurring or not, whereas an observation of wrongdoing means seeing wrongdoing with one’s own eyes and being sure that wrongdoing is occurring. 18
Wrongdoing occurs worldwide in healthcare. 7,19 However, studies in the Finnish healthcare context concerning wrongdoing were not identified. Wrongdoing occurs despite ethical guidelines, 20 patient safety guidance 21 and guidance for the professional duties 22 of healthcare professionals. It may be harmful to the patient, colleagues, healthcare organisation or society. 23 Wrongdoing can be classified into patient-related, healthcare professional–related and organisation-related wrongdoing (Table 3). The classification was adapted and modified for this study from the existing literature concerning ethical dilemmas. 24
Patient-related wrongdoing is targeted at patients. It may occur in the form of neglecting patient care or treating patients inappropriately. 6 Inadequate care is provided to patients. 25 Patients are left without assistance in feeding and toileting despite their requests. 7 Patients are left untreated allowing the progress of a deadly disease leading to increased mortality. Furthermore, inappropriate and unnecessary procedures are performed on healthy patients. 6 Patients’ rights are ignored and the privacy and dignity of the patients denied even when they are dying. 7 Physical violence towards patients occurs in the form of abusing 24 and beating patients. 26 Patients are also charged for supplies that are not used but discarded purposively. 17
Healthcare professional–related wrongdoing occurs first as workplace bullying. Healthcare as a public sector institution is recognised as a high-risk setting for workplace bullying. 27 Workplace bullying is well-documented worldwide and occurs in various forms involving managers and staff bullying each other or peers bullying peers. 28 Second, both alcohol and substance abuse seem to be a problem among healthcare professionals. 18,29 Workplace drug testing has been growing globally as a response to drug-related risks and safety at work. 29 Third, fraud or thefts occur, 25 and stealing from the workplace may occur, for example, stealing narcotics. 18
Organisation-related wrongdoing occurs in healthcare in the form of scarce human resources in relation to need of care, 25 incompetent personnel 6,7,17 and insufficient work equipment. 30 Shortage of staff resources 25 in workplaces has been described as leading to them being extremely understaffed, 17 and as staff have been cut, the number of patients has increased. 18 Unqualified and untrained staff have been used in healthcare. 6,7,17 In order to save money, insufficient equipment and the reuse of single-use products have been reported. 30
Wrongdoing was explored separately in terms of suspicions or observations. A qualitative study examining whistle-blowing processes in one particular hospital in Japan suggested that neither suspicion nor awareness of wrongdoing leads to a whistle-blowing act, but a firm conviction of wrongdoing does. 17 Another study from the United States presented that suspected wrongdoing was not reported because the respondent was not sure of the wrongdoing and did not want to make a false claim. 18 However, one study emphasised that concerns about quality of care should be raised in healthcare. 31 In addition, the Nursing and Midwifery Council (NMC) has produced guidance on openness and honesty in healthcare for healthcare professionals to raise concerns about safety and quality of care, even concerning near misses. 22 Therefore, it is justified to explore suspected and observed wrongdoing separately.
A whistle-blowing process will continue with a whistle-blowing act after suspected or observed wrongdoing. This whistle-blowing act can be either internal or external. Internal whistle-blowing means that the disclosure of wrongdoing is made to someone inside the organisation, and external whistle-blowing means the disclosure is made to someone outside the organisation. 32 Internal whistle-blowing acts may be addressed to superiors, 23 union or safety representatives or the health authorities. External whistle-blowing acts could be addressed to the media, regulatory bodies (e.g. police), health authorities, union representatives or ombudsmen. 25 In one study, 25 all the respondents (n = 30) had addressed a whistle-blowing act to management. In total, 18 had contacted the trade union, 17 health authorities and 13 the local or national media. 25 In another study, the respondents addressed whistle-blowing acts to the media. 17 Few studies suggest that in hypothetical wrongdoing situations, the whistle-blowing act will be addressed internally rather than externally. 32 –34
The whistle-blowing process then continues to the consequences of the whistle-blowing act. The consequences of the whistle-blowing act for the whistle-blower may be positive or negative. 2,16,26 A small amount of research deals with the positive consequences of whistle-blowing acts. Positive consequences occur in the form of being supported by colleagues, superiors, 26 trade unions or the public after blowing the whistle. Approval and respect are also received from outside the organisation. 35 Severe negative consequences affect whistle-blowers, 2,16 their family lives 25,36 and their working community. 2 The whistle-blower may also suffer from retribution in the form of workplace bullying 2,35,37 or discrimination in the form of isolation and ostracism. 2 The act of whistle-blowing can negatively affect the whistle-blower’s career: transfer to another working unit, 35 forced career change, 25 job loss 25,35 and other attempts to ruin their working career 35 have been reported as negative consequences.
The whistle-blowing process was described on the basis of the existing literature (Figure 1). Whistle-blowing consists of three phases: (1) a suspicion or observation of wrongdoing, (2) a whistle-blowing act and (3) the consequences of the whistle-blowing act. The arrow in the background describes the direction in which the whistle-blowing process is proceeding. The process is considered from the perspective of the whistle-blower as the actor, the one who is making a disclosure of wrongdoing.
Whistle-blowing process described on the bases of the existing literature.
Empirical research on whistle-blowing in healthcare is narrow, even though interest in exploring whistle-blowing has been increasing in recent years. A limited number of studies were identified to have investigated whistle-blowing processes and only one in the healthcare context. Not much is known about wrongdoing in healthcare in many countries, including Finland.
Aim of the study
The aim of the study was to describe possible wrongdoing in Finnish healthcare and to examine whistle-blowing process described on the basis of the existing literature in healthcare as perceived by healthcare professionals. The ultimate goal was to describe the whistle-blowing process in healthcare for further research.
The following research tasks were set: To find out about possible wrongdoing in Finnish healthcare and the frequency of its possible occurrence. To find out if empirical data confirm the whistle-blowing process described on the basis of the existing literature. To find out what background variables are associated with possible whistle-blowing acts.
Methods
Study design
The study design was a descriptive, cross-sectional questionnaire survey.
Setting and participants
The study was conducted within a Finnish healthcare context, more specific in primary and specialised health and social care. Corresponding studies conducted in Finnish healthcare concerning whistle-blowing as such were not identified. Participants were healthcare professionals who were members of the trade union, The Union of Health and Social Care Professionals in Finland (Tehy). NQuery4 software was used to calculate the required sample size. The calculation was based on cross-tabulation of the variables in the instrument. With a 20% estimated response rate to Web-based questionnaires and the calculation with NQuery4, the estimated sample size was determined as being between 1290 and 1500 participants. Potential participants were recruited by sending an email, containing the questionnaire to 100,502 members of the trade union with valid email addresses in Tehy’s membership register. Altogether 1273 (= N) healthcare professionals opened the questionnaire and 397 (= n) returned the completed questionnaire, giving a response rate of 31%. The large number of healthcare professionals contacted was justified to receive a relatively good response rate despite the sensitive nature of the research topic.
Data collection
The data were collected using a questionnaire, Whistle-blowing in Health Care (WIHC) developed for this study. Data collection was carried out between 26 June 2015 and 17 July 2015 on the Internet using the Webropol questionnaire software. The Tehy trade union distributed an email to potential participants together with an invitation to participate and a link to the Webropol survey on 26 June 2015.
Instrument
The development of the WIHC questionnaire was based on deductive reasoning from the literature. 19 The questionnaire was pilot-tested by eight healthcare professionals, and some minor changes were made to the layouts.
The WIHC questionnaire had six parts, with a total of 41 questions; in this article, parts 1–4 are reported. The first part of the questionnaire (11 questions) included background factors: age, length of work experience, gender, education, occupation, management position, working shift, nature of the employment, working sector, working area and size of the working unit (Table 1). The second part comprised six questions on suspecting and observing wrongdoing in healthcare. The questions measured whether participants had suspected or observed wrongdoing, the frequency of their suspicions or observations (Table 2) and what wrongdoing occurred in healthcare (Table 3). The third part included three questions on the whistle-blowing act, whether healthcare professionals had blown the whistle on suspected or observed wrongdoing and to whom the whistle-blowing act was addressed internally or externally (Table 4). The fourth part comprised three questions concerning positive and negative consequences of the whistle-blowing act and whether the whistle-blowing act ended the wrongdoing (Table 5). The response formats varied from open-ended questions to closed questions with multiple choices.
Background variables of the participants n = 278.
Occurrence of wrongdoing in healthcare, n = 278.
Occurring wrongdoing in healthcare as suspicions or observations, n = 278.
Internal and external whistle-blowing acts, on suspected (n = 107) and observed (n = 147) wrongdoing.
AVI: Regional State Administrative Agencies; Valvira: National Supervisory Authority for Welfare and Health.
Consequences of whistle-blowing act to whistle-blower on suspected (n = 107) and observed (n = 147) wrongdoing.
Ethical considerations
Ethical approval for this study was obtained from the Ethics Committee of the University (20/2015). Written permission to conduct the pilot study and use Tehy’s membership register in recruiting potential participants were obtained according to the organisation’s policies. This study was conducted according to good scientific standards by following the responsible conduct of research guidelines. 38 All potential participants received detailed information about the study, its objectives and methods. The voluntariness of participation and the right to withdraw at any time without consequences were assured. Confidentiality and anonymity were guaranteed, as the data were collected without individual identifiers. The potential participants were also informed about an opportunity to obtain additional background information from the researcher via email. The returned questionnaire was considered to be consent to participate.
Data analysis
The analysis of the data was statistical. Descriptive statistics (frequencies, percentages, mean values and standard deviation) were used to describe relevant variables. Pearson’s chi-square test was used to calculate associations between the background variables and whistle-blowing acts on suspected or observed wrongdoing. Statistical significance was considered to be present when the p-value was less than 0.05 (two tailed). Sum scores were formed by calculating the values from patient-, healthcare professional- and organisation-related wrongdoing, internal and external whistle-blowing acts and positive and negative consequences. Data were analysed using SPSS Version 22 for Windows (IBM, Chicago, IL).
Findings
Participants
A total of 397 healthcare professionals responded to the questionnaire and the majority of them (70%, n = 278) had either suspected or observed wrongdoing in healthcare. Suspicions and observations of wrongdoing established the data of 278 participants for this article. Most of the participants were female (95%), their mean age was 47 years and their mean length of work experience was 20 years. Over half of the participants (54%) had a vocational school degree as their highest educational level and more than half were registered nurses (57%). Nearly half of the participants (45%) were working in small units with fewer than 20 employees. The majority of the participants (82%) were staff, half were working on the dayshift (50%) and the majority in a permanent position (80%). In addition, a majority were working in the public sector (82%) and either in primary (38%) or specialised healthcare (41%; Table 1).
Wrongdoing in Finnish healthcare
Wrongdoing is seen as occurring in healthcare in terms of both suspicions and observations. All the participants had suspected (96%) or observed (94%) wrongdoing. Wrongdoing occurred more often than once a month with regard to both suspicions (57%) and observations (52%). A minority had suspected (15%) or observed (17%) wrongdoing less than once a year (Table 2).
Patient-related wrongdoing was the least occurring type of wrongdoing in healthcare; however, over half of the participants had still suspected or observed patient-related wrongdoing. The most common was inappropriate treatment of the patient and neglecting patient care and the least common physical violence towards the patient and stealing their property (Table 3).
Healthcare professional–related wrongdoing was the second most common wrongdoing in healthcare. Here, workplace bullying was most commonly suspected and observed by nearly half of the participants. The least common wrongdoing was stealing property from the workplace (Table 3).
Organisation-related wrongdoing was the most commonly occurring wrongdoing in healthcare. Here, scarcity of human resources in relation to the need of care was the most common wrongdoing. Insufficient work equipment was the least common wrongdoing. Other wrongdoing included data protection offences and discrimination by superiors or colleagues (Table 3).
Whistle-blowing processes in healthcare
There are two whistle-blowing processes in healthcare: (1) from suspicion to consequences (SUSP), and (2) from observation to consequences (OBSE). Both of these processes consist of three phases. The SUSP process begins with (1) suspicion of wrongdoing (Table 2), followed by (2) a whistle-blowing act on those suspicions (Table 4) and (3) consequences of the whistle-blowing act (Table 5, Figure 2). The SUSP whistle-blowing process had occurred to 27% of the 278 participants. The OBSE whistle-blowing process starts from (1) an observation of wrongdoing (Table 2), (2) a whistle-blowing act on those observations (Table 4) and (3) consequences of the whistle-blowing act (Table 5, Figure 2). The OBSE whistle-blowing process had occurred to 37% of the 278 participants.
Whistle-blowing process based on the empirical data, whistle-blowing process from suspicion to consequences (SUSP) and whistle-blowing process from observation to consequences (OBSE).
Whistle-blowing process from SUSP
Of the participants, 266 had suspected wrongdoing in healthcare and less than half of them (40% or 107) had blown the whistle on their suspicions of wrongdoing (Figure 2). The whistle-blowing act was done internally or externally. The majority of the 107 whistle-blowers had blown the whistle internally (97%) to their closest manager (76%). Internally, the whistle was blown least to the workplace union representative (10%). External whistle-blowing acts were mostly addressed to union representatives (12%) and least to the media or the Parliamentary Ombudsman (1%; Table 4). Half (50%) of the whistle-blowers stated that blowing the whistle on their suspicions did not end the wrongdoing (Figure 2).
Well, over half of the 107 whistle-blowers (70%) experienced consequences after blowing the whistle on their suspicions of wrongdoing; out of these, 39% were positive (Figure 2). Positive consequences were mostly in the form of private thanks (Table 5). In total, 46% suffered from negative consequences (Figure 2), such as bullying, discrimination, job loss or criticism (Table 5). In total, 15% (n = 16) had experienced both positive and negative consequences.
Whistle-blowing process from OBSE
Of the participants, 262 had observed wrongdoing in healthcare, and out of them, 147 (56%) had blown the whistle (Figure 2). The majority (94%) of the 147 whistle-blowers had blown the whistle internally, and the whistle-blowing act was addressed mainly to their closest manager (76%). In total, 29% had blown the whistle externally. External whistle-blowing acts were addressed mostly (15%) to the union representative, least to the Parliamentary Ombudsman (1%; Table 4). Half (50%) of the whistle-blowers stated that their whistle-blowing act did not end the wrongdoing (Figure 2).
Well, over half of the 147 whistle-blowers (69%) experienced consequences after blowing the whistle on the observed wrongdoing; of these, 42% were positive (Figure 2). Positive consequences were received mostly in the form of private thanks (Table 5). In total, 43% suffered from negative consequences (Figure 2), such as being fired from work or criticism of the whistle-blowing act (Table 5). In total, 16% (n = 23) had received both positive and negative consequences after blowing the whistle on their observations of wrongdoing.
Background variables associated with whistle-blowing acts
There were three background variables associated with whistle-blowing acts: length of working experience, gender and working in a management position. In terms of length of working experience, an important period is 10 years of practice: participants with <10 years had blown the whistle less on observed wrongdoing than those with >10 years (p-value = 0.009). Female participants had blown the whistle more on suspected wrongdoing than male (p-value = 0.017). Participants working in management positions had blown the whistle on suspected wrongdoing more than participants not working in management positions (p-value = 0.046; Table 6).
Association of background variables with whistle-blowing act on occurring wrongdoing.
*Pearson chi-square.
Discussion
This study produced information on the frequency and forms of wrongdoing and on whistle-blowing processes in healthcare, based on the existing literature, from the perspective of healthcare professionals. The results indicate that healthcare professionals face a variety of severe wrongdoing, as is also seen in the previous findings of international studies. 4,6,7 In addition, wrongdoing such as malpractice and poor care in health services has been mentioned increasingly in news headlines and reports. There are also a growing number of recommendations and guidelines for raising concerns about the quality of care and safety of patients. In this area, the professional codes for healthcare workers suggest that any concerns about the well-being of patients should be raised immediately. 39
Suspected and observed wrongdoings were examined separately here. Previous studies present that merely a suspicion of wrongdoing does not necessarily lead to whistle-blowing. 17,18 However, guidelines and laws discuss suspected wrongdoing. 11,40 For further research, it is crucial to understand whether there is a difference in healthcare professionals’ action if wrongdoing is suspected or observed and whether observing wrongdoing is more powerful in leading to whistle-blowing than suspecting.
In total, two whistle-blowing processes in healthcare were confirmed with empirical data. Based on the starting point of the process, the first process (SUSP) begins with a suspicion and the second process (OBSE) with an observation. However, different results were found, with one study suggesting that neither observation nor suspicion lead to whistle-blowing, but firm conviction does. 17 Inconsistent results were also presented in a study in another context than healthcare, suggesting that whistle-blowing is a two-stage process including pre- and post-reporting phases. 41
Wrongdoing is suspected and observed quite often. Only a few previous studies have separated suspicions from observations of wrongdoing. 17,18 However, one study explored raising concerns about poor care quality, which indicates not only observed wrongdoing but also matters that are worrying healthcare professionals. 31 Although this study found that wrongdoing is suspected and observed often in healthcare, one study reported in contrast that healthcare professionals had observed poor care more rarely, 1–5 times during 6 months. 37 Almost all the participants had observed wrongdoing, as supported by previous research. 15
Patient- and healthcare professional–related wrongdoing violates human rights and dignity. Research on wrongdoing such as older people abuse, neglect of patient care 8 and workplace bullying has increased during recent years. 42 Workplace bullying is a global and worrying phenomenon with severe consequences. Furthermore, workplace bullying increases staff turnover and sick leave of healthcare professionals and decreases job satisfaction, increasing the costs of healthcare. 42 The results of this study show that nearly half of the healthcare professionals had suspected or observed workplace bullying in healthcare: this is more than the amount of between 18% and 31% of nurses as having been the targets of bullying presented in previous studies. 42
Having scarce human resources is a common wrongdoing in healthcare. Compatible findings were made in a study suggesting that personnel shortage is a quite common wrongdoing. 25 According to the World Health Organization, the global deficit in healthcare professionals was 7.2 million in 2014 and is estimated to increase to 12.9 million by 2035. 43 However, despite the shortage of healthcare professionals, this study considered shortage as an organisation-related wrongdoing of not hiring enough competent personnel.
Suspected or observed wrongdoing does not necessarily lead to a whistle-blowing act, and it is rare if the wrongdoing is suspected. One explanation for the reluctance to blow the whistle might be lack of courage and fear of the possible negative consequences for oneself. 14 Contradicting findings have been reported in studies where nearly all participants had blown the whistle on wrongdoing. 13,15 The findings in this study pointed out that whistle-blowing acts were mostly addressed internally to the closest manager rather than externally, as can be seen also in hypothetical wrongdoing situations. 32 –34 Considerably few of the participants had addressed the whistle-blowing act externally to the health authorities, even though they are the supervisors of healthcare services. Contradicting findings were presented when over half of the participants in a study had blown the whistle to the health authorities. 25
The consequences of the whistle-blowing act were both positive and negative. Positive responses to whistle-blowing acts were mainly private thanks. One study 15 suggested that very few received a positive response, which was less than in this study. In this study, an almost similar number suffered from negative and received positive consequences. However, in previous studies, negative consequences were experienced more often than positive ones. 25,37 Whistle-blowing acts rarely ended wrongdoing. The reason for this may be that the whistle-blowing act was inefficient when addressed mainly to the closest manager. The closest manager could be unaware of how to handle the situation and put an end to the wrongdoing. In addition, the closest manager could be involved in the wrongdoing or protect the wrongdoer. 2 Workplace culture or climate could also impact whistle-blowing. Therefore, it is important to create ethically safe and supportive workplace culture with jointly agreed protocol to handle possible wrongdoings in healthcare context.
Whistle-blowing acts on suspected or observed wrongdoing seem to be associated with three background variables: length of work experience, gender and management position. Participants working in management positions were more likely to blow the whistle than those not working in management positions. This is compatible with previous research where associations between whistle-blowing and background variables were examined, and nurse managers were more likely to blow the whistle on wrongdoing than staff nurses. 37
Strengths and limitations
There are some strengths and limitations in this study. The first limitation has to do with the instrument. We could not find any existing instrument, and therefore, the WIHC instrument was developed and pilot-tested for this study. Its development was based on deductive reasoning and the construct of the instrument was based on the theoretically developed whistle-blowing process, which was a strength. The second limitation was that the response format in the questionnaire varied, although this was justified to obtain the information needed to describe potential wrongdoing and whistle-blowing processes in healthcare. The third limitation was that empirical research on whistle-blowing is narrow, but corresponding findings have been reported in international studies that were also discovered in this study. Use of the NQuery4 software to calculate the required sample size was a strength. Wrongdoing is a sensitive research topic, and anonymity was guaranteed by collecting the data with the help of the trade union, Tehy: this supported the reliability of the study. The representativeness of the participants improved external validity in this study. Half of the participants were registered nurses, and majority were female, which corresponds with the figures for Tehy members. 44
The fourth limitation of this study had to do with suspicions and observations of wrongdoing. Due to differences in the questionnaire, it was not possible to analyse the associations between the phases of the whistle-blowing process. The sample was national, and participants were healthcare professionals and members of the trade union. However, 90% of the working healthcare professionals in Finland are members of the trade union. 44 The sample size was smaller than was estimated with the NQuery4 software, and the response rate was quite low. Participants’ understanding of the difference between suspected and observed wrongdoing might have also been a limitation.
Implications
This study has implications for practice, education and further research. The results, the descriptions of whistle-blowing processes, can be used to enhance whistle-blowing on wrongdoing and to intervene in wrongdoing. The results help to enhance ethical quality and safety for patients, healthcare professionals and organisations. Developing ethical curricula for healthcare professionals and increasing ethical discussion in workplaces might decrease wrongdoing, increase whistle-blowing and decrease the negative consequences of whistle-blowing. In addition, simulation education could be an effective way to practise action in potential wrongdoing and whistle-blowing situations.
Future research is needed to gain a deeper understanding of the whistle-blowing phenomenon, to decrease wrongdoing and to increase appropriate whistle-blowing. Effective interventions are needed, for example, to teach nurse managers how to effectively handle whistle-blowing acts to stop wrongdoing or group interventions for healthcare professionals on how to enhance openness in the workplace and lower the barriers to raising concerns of wrongdoing. Associations between the phases of the whistle-blowing process described and confirmed here could be examined. In addition, other potential processes associated with and other options for blowing or not blowing the whistle on wrongdoing could be explored. To study cultural differences concerning wrongdoing and whistle-blowing, an international comparative study could be initiated.
Conclusion
Based on the results of this study, wrongdoing occurs frequently in Finnish healthcare but has been stated to be an international characteristic of healthcare. 6 –9 In total, two separate whistle-blowing processes, SUSP and OBSE, were confirmed. It is crucial to understand that suspicion of wrongdoing sometimes leads to different actions than does observation. Suspecting or observing wrongdoing does not necessarily lead to whistle-blowing, and whistle-blowing turns out to be an ineffective way to stop wrongdoing. The results of this study show that whistle-blowing is a multidimensional phenomenon that requires more research in the future. However, learning from these whistle-blowing processes helps to develop the ethical quality of care and organisations.
Footnotes
Acknowledgements
We kindly thank all the participants and the authorities that made this study possible.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical approval
Ethical approval was obtained from the Ethics Committee of the University of Turku (20/2015).
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.