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Who's going to speak up for Irish healthcare staff?
Author: Professor Kate Kenny, Whitaker Institute
Opinion: frontline staff are doing incredible work right now, but is our health service capable of listening to whistleblowers when serious concerns are raised?
Dr Ming Lin was getting ready for his shift in the emergency room at PeaceHealth St Joseph Medical Center in Washington State when he got a message to say he had been fired. Since the arrival of Covid-19, Dr Lin had become well-known for speaking out about the lack of protective measures at the hospital. He had talked to journalists and posted on social media, pleading on behalf of colleagues and patients. And then, he was sacked.
As the crisis develops, we continue to hear about healthcare staff being silenced for voicing concerns about safety. Doctors in China, India, the US and the UK are among those who have been punished for speaking out. This silencing leaves hospitals vulnerable to the dreaded surge that threatens ICU units as the virus spreads.
But what about Ireland? Healthcare staff are doing incredible work on behalf of us all, but is our health service capable of listening when employees and managers raise serious concerns? Every sector has distinct features that enable or constrain speaking out. As research shows, healthcare is not always a welcoming place for whistleblowers.
From RTÉ Radio 1's Drivetime, Kate Kenny discusses the reasons why people blow the whistle in the workplace
The authority gradient
Enabling staff to raise informal concerns is the core of a healthy organisation. But as in many large bureaucracies, a steep "authority gradient" between lower-level healthcare staff and their line managers can cause difficulty. In clinical practice for example, nurses feel unable to criticise doctors' decisions, even those that are potentially dangerous. Skillful managers work hard to overcome this hierarchical distance. They demonstrate openness to listening and spend time with staff to signal approachability. But workload pressures related to Covid-19 can make this impossible, and close down avenues for informally raising concerns.
Threat of retaliation
In Ireland, retaliation for speaking out about wrongdoing is not the norm. Four out of every five people who say they have reported concerns encountered no problems. Even so, this leaves one in five people experiencing retaliation for disclosing and healthcare appears particularly problematic. Health workers are among the largest group of callers to Transparency International Ireland's Speak Up helpline with over a third of all whistleblowing complaints from this sector.
What are they phoning about? In almost half the cases, it is whistleblower retaliation. The reported treatment of HSE whistleblowers in the "Grace" abuse case - including threats and attempts to discredit them - has received scathing criticism. Recent accounts of staff in HSE-funded services being ignored or belittled for speaking out left their colleagues "feeling fearful of bringing up concerns" to their bosses. Whistleblower retaliation may not be the norm, but it discourages others from coming forward when it does occur.
From RTÉ Radio 1's News At One in 2017, Aoife Hegarty of RTÉ's investigations unit explains the story of Grace
Cover-ups and whistleblowers
International research tells us that healthcare organisations have a poor record when it comes to listening to and supporting whistleblowers. When a potential scandal emerges, pressure from the media and politicians can be intense. Health is emotive; we all know someone who needs the services of the system and the general public is intolerant of mistakes in this sector.
This intolerance is often unfair: health is incredibly complex and errors are a fact of life. This constant demand for good news stories, or for a person to blame when something goes wrong, puts managers in an impossible position. Fearful of admitting mistakes, the temptation to cover them up is strong. With this comes a silencing of any whistleblowers involved. Healthcare crises exacerbate this problem.
Job security and speaking out
When asked about barriers to raising concerns, almost half of Irish employees list fears of losing their job or damaging future career prospects. Staff in the HSE and related services who are on short-term contracts are therefore in a particularly weak position when it comes to speaking out. Agency workers, student nurses and junior doctors are loath to jeopardise their reputation and find themselves excluded from future work. Covid-19 has increased the numbers of such people on the front line. People in precarious employment are, for example, among the most vulnerable staff in care homes. How likely is it that this group will disclose the ways they and their charges are being left behind?
From RTÉ News' Pandemic podcast, Colm Ó Mongáin and RTÉ Health Correspondent Fergal Bowers discuss the situation in nursing homes
The legal position
So if healthcare workers persist in raising a serious issue despite all of us, they are protected by law, right? Technically, yes. Ireland's whistleblower law, the Protected Disclosures Act, is well-known and covers most healthcare workers since 2014. But the situation is confusing for employees in practise, with HSE guidance also referring to older legislation setting a much higher bar for legal protection if someone speaks out. This includes a requirement to show a "good faith" motivation. Famously difficult to prove and often used to discredit genuine whistleblowers in court, good faith motivations were omitted from the Protected Disclosures Act. Overall a confusion about policies leads to a lack of confidence in the law, and a reluctance to speak out in healthcare.
We need whistleblowers now more than ever
These issues are not unique to Ireland and healthcare is one of the most difficult sectors worldwide in which to voice serious concerns. But Covid-19 did not encounter an Irish healthcare service in good shape. Successive crises in waiting lists and hospital overcrowding point to a pressurised system. Against this backdrop, we now see rapid redeployment of staff and resources to deal with the virus and dramatic changes in an already-struggling sector.
Robust oversight has never been more critical. According to the OECD and European Commission, whistleblower support is vital for accountability. Transparency International Ireland have introduced welcome guidelines on raising concerns related to Covid-19, both for employers and workers, but more is needed.
Senior healthcare managers, politicians, and union representatives must act as voices of frontline staff who witness serious wrongdoing. Irish healthcare workers and managers need support when raising genuine concerns to protect themselves, their patients and the rest of the country. We owe it to them for all they are doing on our behalf.