If whistleblowing is the answer,ask a better question

There is a romanticism at the heart of processes meant to put an end to unacceptable practices going unchecked in the NHS and wider healthcare sector. Those in senior managerial positions, often distant from the direct work of providing treatment and care to patients, demand that everyone has an unquestionable duty to speak up, to tell ‘the truth’ – an advocacy that co-exists with faith in the power of formal organisational procedures, focused on individual courage and with limited attention to relational context.

Workplace ‘truth’ – what passes for common sense custom and practice – is treated unproblematically, sitting apart from all forms of social power and ideology. Both, however, are actively involved in creating what is treated as true in a world where Government Ministers instruct their staff to ‘sweat the data until it gives me what I want’. ¹

Managerial distance is further sustained by the disconnect between the organisational reporting metrics and lived experience of healthcare professionals – highlighted by the late Professor Hopwood, ² who describes how the managerial discourse fuels this divide through its naïve understanding of how truth gets created in the NHS, particularly with its denial of deep-seated professional loyalties trumping institutional ones.

This perspective is sustained by the bias of positional power, where those of high rank are least aware of how their personal experiences of truth-telling are eased by their professional and social authority – what Fuchs et al. refer to as ‘advantage blindness’. ³ In the latest cycle of the Reitz et al. research into ‘speaking truth to power’, ⁴ rank and hierarchy continue to matter contradicting the persistent belief in the reality of the flat organisation. ⁵ The more people experience themselves to be senior, the more they feel free to speak up – and think (wrongly) that others do as well.

There is a double bind locking senior people out of awareness of the world of others – if they do ask more junior people how they feel about speaking up, then the junior person will give the answer they think this person wants to hear. Foucault offers a more structural explanation, framing truth and power in the social sphere as an intertwined co-creation, ⁶ rather than separate realities – a framing that people brought up within the positivist epistemological tradition of the natural sciences often find hard to engage with! ⁷

At the level of day-to-day practice, two very human, and ordinary, features dominated the rationale for keeping silent – the fear of being perceived negatively by others and the fear of upsetting others. People at work want to retain their membership of the groups they belong to and fear actions which will result in their exclusion. This need to belong is often overlooked by people who advocate heroic individualism as the solution to taken-for-granted group habits.

The experience of many whistleblowers, when seen as an isolated activity, is a grim reminder of the social and professional costs that this absence of attention to relational context results in. A whistleblower recently spoke of colleagues literally turning their backs on them whenever they walked into a room. To step outside of a group results in patterns of behaviour that are brutal in terms of their effectiveness in reinforcing a sense of isolation and exclusion, and beyond the reach of a rationalism which ignores social and relational realities. Meanwhile, those who are desperate to be heard, despite of or because of their social isolation, become harder to hear. They become more strident and so less attractive to those of higher status, who carry with them an expectation of coolness in being presented with data.

In the Reitz and Higgins ⁸ study, a TRUTH mnemonic is presented, which provides a framework to explore how people do and don’t silence themselves and others. A principle of the mnemonic is that speaking up and silencing ourselves and others are relational acts. Meaning is created in the context of mutual connection – not as an individual experience, connecting to Fletcher’s ⁹ notion of growth in connection.

The TRUTH mnemonic

T stands for Trust – Our capacity to trust in the value of our own opinion and that of others. There is a clear discrepancy between these two perspectives, with people persistently trusting their own opinion more than they do others – usually by a factor of around one-third, although this can go up to a matter of two or three times in some groups. There is also a confirmatory bias as to whose opinions are trusted and listened to – we are drawn to those voices that sound like ours and fit with our world view.

This over-valuing of our own opinion, especially when in positions of perceived relative power, helps create and sustain silencing cultures where more junior people are invited into undervaluing their experience. The importance of valuing the experience of junior others is explored in Tjan, ¹⁰ who finds rich data are to be found in their day-to-day work.

R is for Risk – To speak up is rarely a neutral act, for whistleblowers it can be life- and career-defining. More broadly, the Reitz et al. survey ⁴ reports that of 1752 respondents, 17% responded they expected to be punished for reporting malpractice. While people often catastrophise about the consequences of speaking up, over-heated internal narratives can create a sense of personal fear – which is easily amplified by a wider, anxiety provoking context. This provocative context, and its underlying assumptions, is explored by Cole and Higgins. ¹¹

This sense of systemic and personal risk is further amplified by the lack of felt psychological safety, a vital ingredient of organisational transparency as identified by Edmondson. ¹² Psychological safety is undermined by the addiction to organisational restructuring that has bedevilled the NHS throughout its life, which undermines personal connections and incurs a relational cost discounted by its advocates.

Trust and Risk shape whether an individual is willing to make a move to speak up – or hear news that may unsettle the status quo.

The last parts of the mnemonic concern the execution of speaking and listening. There is the amount of Understanding of the political landscape, the agendas in play. Much of the management discourse emphasises common purpose and shared values, when in practice there is always a rich mish-mash of differences about where priorities lie. Even if the patient experience was genuinely at the heart of healthcare delivery (and Ingerslev ¹³ suggests it is not), different professional disciplines see patients differently and are confused by the complexity of the system they are part of. In a healthcare group in South London, staff were bemused about where authority lay, even when it came to something as basic as sorting out an overflowing toilet (which developed into a flood requiring the Fire Brigade to be called out).

T is for the Titles that we put on ourselves and others and have put on us. This is a fact of social life and riddled with conscious and unconscious biases. Within the NHS there are myriad titles which people deploy that create and sustain certain patterns of advantage when it comes to who is expected to speak up and who is expected to wait their turn. Alongside these public titles, gender, accent, height, ethnicity and age all play their part, however much their influence is outlawed. The snowy white peaks of NHS senior leadership remain in place creating a particular silencing shadow. Working with the reality of titles and labels is a much healthier starting point than denying their existence, which is how Kegan and Lahey’s ¹⁴ cultures of ‘fake-believe’ take hold.

Lastly comes the How to, the basic need for the right words to be said and heard, at the right time and in the right place. In the work of the NHS London Leadership Academy, what has become apparent is how the conceptual framing of what creates a speak up culture needs to be combined with the techniques and skills professional voice coaching can make available. Speaking up is an embodied activity and there are ways in which the human voice can be deployed to better effect. Chaskalson and Reitz ¹⁵ also document the importance of mindfulness to support this.

Moving on from whistleblowing: some concluding remarks

Whistleblowing is a high-stakes activity, which rarely ends well for an individual. Its framing as a solitary activity ignores the social and relational consequences, pitting the lone individual against the weight of multiple professional bodies and relentless procedural scrutiny. As explored by Reitz and Higgins ¹⁶ this imbalance of risk and reward skews the pitch in favour of those invested in the status quo and those who believe in what is being formally reported. This presents a major challenge if whistleblowing is to be freed from its stuck narrative as a controversial and negative act – and instead becomes experienced as normal and expected.

In Reitz et al.’s ⁴ findings, there is little chance of reward for people who speak up about significant malpractice – only 21% of respondents believed this was likely. This illustrates a disconnect with organisational mechanisms which otherwise assume people only respond to extrinsic gain for doing the right thing.

Workplaces are riddled with power and hierarchy that cannot be disappeared – and relying on whistleblowing is a sign of conversational pattern where people have lost the capacity to speak truth to power on a day-to-day basis.