Murray, John S. PhD, RN, CPNP, CS, FAAN
As difficult as it may be to accept, whistle-blowing in healthcare settings is increasingly becoming necessary in order to address unethical behaviors and ensure the delivery of safe patient care. Perioperative nurses working in a variety of settings from clinical practice, academia, research, to administration routinely face ethical challenges and aren't untouched by them.1,2 The following case study demonstrates whistle-blowing in practice.
Diane is an experienced perioperative advanced practice nurse who holds a dual faculty and clinical position at a prominent academic medical center. She has an outstanding performance record as a perioperative nurse and educator, and is held in extremely high regard by the entire medical staff. Over a period of several months, Diane recognized a trend of unethical behaviors in the workplace that greatly concerned her. A senior leader was wrongly manipulating student grades to improve pass rates, covering up student cheating, and inappropriately awarding scholarships to students despite documented academic deficiencies.
Concerned about the potential safety of patients in the clinical practice, Diane approached other faculty regarding her concerns. However, faculty and staff told her that they feared retaliation such as loss of benefits, promotions, and opportunities to compete for awards. They also feared losing their jobs if they reported the problems. Diane made the very difficult decision of informing her superiors despite the personal and professional risks involved. When they didn't take appropriate action, she requested and received help from her state nurses association.
In the past year, several prominent cases of healthcare whistle-blowing have been in the news. Most notable is the Winkler County nurses case in Texas, in which nurses Anne Mitchell and Vicki Galle reported a physician to the senior administrator for what they considered lapses in competence and judgment that jeopardized patient safety. When hospital administrators took no action, the nurses anonymously reported their concerns to the Texas Medical Board. As a result, Mitchell and Galle were fired by Winkler County Memorial Hospital, and were charged with a third-degree felony of misuse of official information for making the report. During the February 2010 criminal trial, Mitchell was found not guilty. The indictment against Galle was dismissed before the criminal trial commenced.3
Other noteworthy whistle-blower cases in 2010 include:
* A surgeon and former hospital executive at Rush University Medical Center, who charged orthopedic surgeons with overbooking OR schedules and letting residents complete procedures with little to no supervision (a violation of Medicare supervision requirements).4
* Cheryl Eckard, a former quality assurance manager for GlaxoSmithKline, who was awarded a whistle-blower settlement after exposing to the FDA that her employer was knowingly making and selling adulterated pharmaceuticals that could harm patients.5
An employee or former employee who brings forward serious wrongdoing in the workplace is a whistle-blower. The person typically first discloses the information to someone higher up in the organization—someone in a position to address the unethical behavior. If this doesn't result in action, the whistle-blower may go outside the organization for help. Oftentimes, going outside the organization places the well-being and safety of the whistle-blower and others in danger and may break laws or violate organization policies and procedures.6
From the standpoint of perioperative nursing, whistle-blowing occurs when a nurse recognizes a situa tion in the workplace that is unsafe and/or unethical and uses organizational channels to try to get the prob lem addressed and resolved. If the organization doesn't address the problem, the nurse may act in the public's best interest and go outside the workplace for help.1
Consequences of whistle-blowing
Deciding to expose wrongdoing and unsafe behaviors in the workplace isn't an easy thing to do. It requires moral courage the commitment to stand up for and act upon one's ethical beliefs, even when it means standing alone and facing adversity and personal risk.2,7,8 Unfortunately, whistle-blowers oftentimes face bullying, harassment, reprisal, demotions, and possibly loss of employment, even when organizations have processes in place to protect those who report unethical and unsafe actions. Despite these possible consequences, perioperative nurses have a responsibility, and sometimes a legal obligation, to report wrongdoing in the workplace.6 This applies to all settings where perioperative nurses practice, learn, teach, research, and lead.
What are your responsibilities?
State boards of nursing mandate that nurses practice in a safe and ethical manner. Professional organizations establish the standards and guidelines of recommen ded practice that nurses need to follow. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements contains a common, shared set of ethical principles to guide nurses' professional behavior. For example, nurses should report unethical and unsafe behaviors in the healthcare workplace, first through appropriate channels within the organization and, if needed, to outside agencies such as state nurses associations and professional nursing organizations.2,6,9–11
The code requires nurses, as patient advocates, to protect the rights and safety of patients who are judged to be in jeopardy. Nurse-whistle-blowers have an essential responsibility to the patient's well-being and should always protect the patient from unsafe and unethical healthcare providers.12 The same code also calls for professional organizations to support and assist nurses who report unethical behavior and protect those who voice these concerns. Perioperative nurses must make every effort to uphold the values of one of nursing's most important foundation documents.2,10,11
Under state Nurse Practice Acts, and the state and federal examples below, perioperative nurses also have a legal obligation to report conduct that's incompetent, unethical, and illegal. This obligation is established in state and federal statutes and regulations, as well as healthcare organizations' and professional organizations' policies and procedures. A widely recognized example is a nurse's duty to report child and elder abuse. Another exemplar is the responsibility, mandated by state laws, to report suspicious deaths. At the federal level, legislation such as the Safe Medical Devices Act mandates the reporting of medical instruments, apparatus, or other articles thought to have caused or contributed to the serious illness, injury, or death of a patient.12 An example for perioperative nurses is the practice standard set by the Association of periOperative Registered Nurses to report adverse events related to warming devices meant to protect patients from unplanned perioperative hypothermia.13
The ST factor
The role of the surgical technologist (ST) is a subject of much discussion in the perioperative community because the ST scope of practice isn't well-defined and varies according to institutional policies. The ST plays a critical role in healthcare, contributes greatly to the safety of patients, and has helped significantly to address widespread surgical personnel shortage. Concern surfaces when perioperative nurses perceive STs aren't working within their scope of practice. The Association of Surgical Technologists website (http://ast.org) has information on the job description of association-approved STs, and all members of the surgical team should be familiar with the roles and responsibilities of STs within their respective organization.
Because all team members must work together to create and sustain a culture of safety for patients, perioperative nurses need to speak up when the health and safety of patients is at risk or a member of the team is deemed to be practicing in an unsafe, incompetent, or unethical manner.14,15
If you're about to blow the whistle, first familiarize yourself with the internal and external resources that will guide, support, and protect you when you report unethical and unsafe practices. The most important first step is to follow the healthcare organization's chain of command and to report only factual information about the event. Documentation of specifics is critical. Maintain a paper trail including dates, times, locations, and outcomes. Make copies and keep them in a secure location. Reach out for help as needed—all healthcare organizations have a responsibility to protect workers who report concerns.
The processes for perioperative nurses to report unethical and unsafe behaviors should be readily available within the organization. When possible, seeking legal advice from within the organization or the outside may be helpful.7,16,17 Remember that ethics committees provide a valuable forum for addressing questionable behaviors.6,11
Whistle-blower protection laws are meant to prevent employers from retaliating against employees (including nurses) who uncover unsafe behaviors in the workplace. Retaliation may include, but isn't limi ted to, suspension, demotion, harassment, bullying, or dismissal. Learn about the federal and state whistle-blower protections: the ones for healthcare emplo yees vary from state to state, and not all states have safeguards.18 State nurses associations, state attorneys general, and members of Congress can also assist with questions and clarification on existing protections.7
Much more work needs to be done to improve whistle-blower protections for all nurses. In 2006, the Federal Nurses Association, a constituent member of the ANA, worked with U.S. Rep. Ed Markey (D-Mass.) to advance legislation providing whistle-blower protections for nurses in the uniformed services.17 Although the federal measure hasn't passed, the ANA also is working to advance state whistle-blower protection laws for nurses.18
Deciding to blow the whistle on unethical and unsafe behaviors that jeopardize patients and staff is never easy, yet it's every perioperative nurse's responsibility. Policies and procedures also must be enforced to ensure that perioperative nurses feel safe to report offenses.
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13. AORN Recommended Practices Committee. Recommended practices for the prevention of unplanned perioperative hypothermia. AORN J. 2007;85(5):972–974, 976–984, 986–988.
14. van Beuzekom M, Boer F. A comparison of US, UK, and Dutch perioperative staffing practices. AORN J. 2006;84(4):632–641.
15. Goldberg J. Author's response to letter to the editor: respecting the role of the surgical technologist. AORN J. 2008;88(5):711–713.
16. Gallagher A. Whistleblowing: What influences nurses' decisions on whether to report poor practice? Nurs Times. 2010;106(4):22–25.
17. Murray JS. The Paul Revere freedom to warn act: legislation to protect federal whistleblowers from retaliation. Am J Nurs. 2008;108(3):38–39.
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