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Hypervisible Nurses

Effects of Circulating Ignorance and Knowledge on Acts of Whistleblowing in Health

Perron, Amélie PhD, RN; Rudge, Trudy PhD, RMHN, RN; Gagnon, Marilou PhD, RN

Author Information
doi: 10.1097/ANS.0000000000000311
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Abstract

NURSES OFTEN find themselves in disturbing situations where they perceive it is their duty to report serious shortcomings or wrongdoing within their workplace. In doing so, these nurses take significant personal and professional risks to safeguard patient safety and quality care. Interestingly, today's health care organizations (HCOs) are more equipped than ever to track and monitor the safety and quality-of-care processes. Through numerous protocols, safety checks, quality indicators, and documentation, and charting requirements, HCOs generate and collect endless supplies of data that should help them appropriately address poor care processes. Yet these considerable amounts of information do not necessarily lead to the identification of critical issues or coherent actions to remedy them. This is so despite dominant managerial thinking that claims to privilege effectiveness, performance, flexibility, cost-effectiveness, accountability, and patient (consumer) welfare.

Near and Miceli1 defined whistleblowing as a process involving at least 4 elements:

  1. The whistleblower. A former or current member of an organization who is aware of wrongdoing but cannot rectify the situation on her own.
  2. Whistleblowing. The act of disclosing unethical and/or illegal practices to persons who may directly or indirectly bring about change.
  3. The complaint receiver. A person who is hierarchically above the whistleblower (internal whistleblowing) or a third party (external whistleblowing).
  4. The organization. An organization at the center of the whistleblowing who is called upon to respond to the disclosure of wrongdoing.

The available literature positions whistleblowing as a sign of organizational failure, in that the organization to which wrongdoing was reported failed to act on the information provided. It also highlights gruesome consequences for the whistleblower, including reprimands, ostracism, questioning of her competence, loyalty put in doubt, arbitrary performance evaluations, disciplinary action, job reassignment, demotion, character assassination, suspension, threat of a lawsuit, loss of wages and loss of employment, anxiety, depression, and in some cases suicidal thoughts,2,3 which can extend over several months. During this time however, the original wrongdoing often remains unaddressed by those in authoritative positions.4,5 As a result, there is a consensus among experts that reinforcing internal reporting channels constitutes a key step toward the avoidance of whistleblowing events.6,7

Whistleblowing has been examined from various angles over the past 40 years (eg, business ethics, sociology, cognitive psychology, justice theory, and political philosophy), framing whistleblowing as an individual moral act, a sign of organizational dysfunction, or a product of power imbalances.5 No one has yet examined whistleblowing as a matter of epistemology. Whistleblowing can be understood as a process resting on the (im)proper transmission of critical knowledge in an organization; for example, knowledge about poor care or wrongdoing. However, we wish to push this inquiry further, using the lens of the sociology of ignorance (SOI) to rethink whistleblowing and in particular the failures it brings to light.

This article aims to highlight the way nurses get caught in the strategic or the problematic circulation of knowledge and ignorance, which can culminate in acts of whistleblowing. Such examination goes beyond simplistic explanations of whistleblowing, for instance as resulting from power imbalances, nurses' concerns being “ignored” by managers, or from administrators acting in “ignorant ways” in the face of disturbing reports. Instead, the SOI helps us understand how whistleblowing is borne out of the complex and strategic circulation of knowledge and ignorance that spells multiple and intersecting epistemic positions for nurses. Through the lens of the SOI, we explore the way narrow understandings of risk, safety, and quality create organizational blind spots as well as forms of willful ignorance on the part of administrators. Furthermore, distrust of health professionals, which is at the heart of managerial ideology, positions nurses as untrustworthy and illegitimate speakers in the “business” of the organization.8 Organizational failings therefore remain concealed, while nurses become hypervisible, both as faulty care providers and as problematic information brokers. We believe that unpacking the organizational identity of those agents who attempt to report organizational problems (eg, patient safety issues, wrongdoing, and illegal acts) is a necessary step toward understanding the significance of whistleblowing events in an organization and their consequences for whistleblowers. Before delving into this analysis, we will briefly introduce the tenets of the SOI.

Statement of Significance

What is known or assumed to be true about this topic:

Nurses often find themselves in disturbing situations where they believe it is their duty to report serious shortcomings or wrongdoing within their place of work. As nurses are consistently tasked with the duty to speak up in order to safeguard patient care safety and quality, many struggle with the difficult process of reporting care issues, and many more express feeling disturbed, disheartened, and betrayed when their efforts do not lead to corrective actions on the part of organizational leaders. Furthermore, many nurses who engage in acts of reporting and whistleblowing describe subsequent acts of reprisals against them, such as reprimands, discipline, ostracization, critique of their performance and competence, and even loss of employment.

Whistleblowing has been examined from various angles over the past 40 years, including business ethics, sociology, cognitive psychology, justice theory, and political philosophy. These analyses usually frame whistleblowing as an individual moral act, a sign of organizational dysfunction, or a product of power imbalances. As a result, there have been consistent calls to empower employees in organizations to help them blow the whistle more easily when poor and unsafe care practices occur. Similarly, organizations have been called upon to commit to safety and transparency cultures as a way to reduce the necessity for acts of whistleblowing. And finally, from a policy perspective, there have been calls for improved internal reporting procedures and stronger whistleblower legislation to protect whistleblowers.

What this article adds:

This paper discusses nurse whistleblowing using a little-known approach called the sociology of ignorance. The sociology of ignorance is a form of sociology of (non)knowledge that rests firmly on feminist scholarship. In this article, we approach whistleblowing as a matter of epistemology and antiepistemology (ignorance), which helps us unpack the complex epistemic transactions that unfold in an organization where wrong doing occurs and which nurses feel compelled to report. In this epistemic landscape, nurse whistleblowers are assigned particular positions that make the enactment of their moral agency difficult. Better reporting mechanisms and stronger legislation are routinely called for in order to support and protect those who report wrongdoing, yet these mechanisms have been shown to fall very short of their protective mandate. Consequently, we further use the sociology of ignorance to discuss the issues underlying reporting policies and whistleblower protection laws, uncovering some built-in mechanisms that make them fail the very people they are meant to protect.

THE SOCIOLOGY OF IGNORANCE AS A USEFUL FRAMEWORK FOR NURSING

The SOI is an approach that has been developed over the past 30 years or so by authors from diverse fields, such as political science, feminist studies, philosophy, biology, economics, and history. Ignorance is understood as encompassing that which is not known, cannot be known, or refused to be known9; that is, it encompasses all forms of “nonknowledge” that make up any epistemic space alongside knowledge10; in this sense, ignorance includes such states of nonknowing that are brought about by doubt, censorship, confidentiality, forgetfulness, secrecy, denial, deceit, omission, suppression, and indifference, for example.11 As such, the SOI is interested in the discourses and practices that emerge through patterns of systemic nonknowledge and that shape our world. The premise of the SOI is that social and economic processes rest more on what we do not know than on knowledge.11,12 This perspective contradicts longstanding claims that knowledge constitutes the main driver of social life11,12 since knowledge is largely believed to define our modern world and its so-called knowledge societies and economies, while ignorance is usually viewed as banal, uninteresting, and as requiring to be “fixed” with knowledge. Far from being a wholly neutral or negative absence of knowledge, ignorance is understood by SOI scholars as a productive social force, a regular feature of everyday practices and decisions, and as a space rife with interests, tensions, contradictions, and power struggles.9–12 Much like knowledge, ignorance can direct one's attention in a specific direction; it can induce thoughts, perceptions, ideas, and emotions; it can be deployed in order to produce (or avoid) certain outcomes; and it can serve as a commodity. In other words, while ignorance is often portrayed as a negative or dangerous feature of contemporary societies, SOI scholars balance this view by highlighting the manifold effects, both negative and positive, of ignorance.

One of the central foci of the SOI is the production of particular epistemic positions across states of ignorance.10 Such epistemic positions may include for instance oppressed, oppressing, resistant, emancipated, invisible, impartial, or apathetic subject positions, all of which hinge on the (in)ability of persons or groups to access knowledge, withhold knowledge, impart knowledge, and/or use knowledge. Such epistemic positions are not fixed and predetermined: they come with varying levels of power and legitimacy within particular social spaces and contexts. For example, in health care settings, privileged access to key organizational reports and managerial tools provides certain agents, such as administrators, with greater opportunity to influence the strategic direction of an HCO. Meanwhile, those without such access (ie, those who remain “ignorant” of such information [many, if not most, nurses for example]) are excluded from decision-making processes.8 This is so despite the fact that they can hold other kinds of important information (eg, knowledge about clinical processes, professional dynamics, or organizational deficiencies). In other words, some organizational agents' restricted access to dominant knowledge and tools renders them less persuasive and less visible in managerial processes. Ignorance however does not necessarily translate into a disadvantaged position. For example, it is generally accepted that the maintenance of ignorance about a patient's file through confidentiality can protect that patient's interests and capacity for self-determination.9 Similarly, claiming ignorance can help avoid being held responsible for negative outcomes-a strategy largely used by industries that market harmful products.11,12 The critical examination of epistemic positions in the SOI is significant because epistemic practices-that is, the exchange and the circulation of knowledge and ignorance-rest on social relationships, meaning that they can transform patterns of authority, credibility, and legitimacy.10 In the context of nurse whistleblowing, we believe this is a key dimension that cannot be overlooked, as we shall see further next.

Along with ignorance scholars, we consider that ignorance is not the opposite of knowledge and it is not a complete void: it is historically, spatially, and temporally bound; it shapes both what we know and do not know; and it rests on conflicting forms of knowledge.10,12 We therefore contend that ignorance is a system of knowing in its own right because it is enmeshed in power relationships and it produces discourses and practices. Importantly, it involves various epistemic positions because, as seen earlier, some forms of knowledge will dominate in specific contexts, while others will be dismissed; this means that some “knowing” subjects will be afforded authoritative positions in a given system, while others will not.10 This perspective allows us to understand an HCO as an epistemic space where knowledge and ignorance continually intersect. In this space, nurses, administrators, patients, and others figure as epistemic agents—a point we shall return to later. Getting back to the matter at hand, whistleblowing, disclosure about wrongdoing in the HCO can be understood as a process of complex epistemic transactions between the aforementioned epistemic agents because disclosed information about wrongdoing can challenge and disrupt established patterns of knowing and thinking in the organizational landscape.

IGNORANCE AS A FEATURE OF CONTEMPORARY HEALTH CARE ORGANIZATIONS

In examining whistleblowing as an epistemic process, using the SOI as an explanatory framework includes various analyses: organizational denial, secrets, and taboos; the linear thinking, the traditions, the bureaucratic tools or the incentives that can, each in their own way, encourage overlooking certain aspects of organizational wrongdoing; the kinds of organizational recording that are avoided or incomplete, thus eliminating alternative explanations for wrongdoing; and the way individual or organizational processes filter the information that would otherwise allow for a more multivocal account of the situation that led to a whistleblowing event.9

Most researchers commenting on disclosure and whistleblowing in health care identify specific sources of missed understandings and actions that can lead to disastrous events. For example, Macrae13(p441) states that “In healthcare organisations some of the key sources of missed, miscommunicated or misinterpreted signals of risk are closed professional cultures, competing and conflicting demands, and the inherent ambiguity of many forms of adverse events.” While these factors are unquestionably significant, their underlying epistemic features are never brought to bear in the analysis of whistleblowing as an organizational event.

In today's so-called knowledge society and knowledge economy, HCOs and their administrators routinely claim to work according to key principles such as quality, safety, performance, efficiency, and risk management, all of which are thought to properly balance HCOs' responsibilities toward patients, employees, and funder. These objectives require considerable amounts of information to track processes, resource use, and outcomes. Indeed, today's HCOs are more equipped than ever to track and monitor the safety and the quality of care processes. Through numerous protocols, safety checks, quality indicators, and documentation requirements (in which nurses are heavily enrolled), HCOs generate and collect substantial data that should help them efficiently address organizational problems that can affect their ability to provide competent and ethical patient care.

As such, though we could think that HCOs know everything they require in order to function “optimally,” we suggest a number of ways in which they in fact limit information they critically need to perform according to their stated goals:

  1. HCOs tend to use narrow definitions of key notions such as safety, quality, risk, and performance.14 For example, risks to care are assumed to come from individual care providers either not delivering proper care or not following standard protocols, versus stemming from the bureaucratic or managerial structure of the organization.12 Quality is assumed to come from standard policies and other so-called objective organizational artifacts governing nurses' practice, not from nurses themselves.9 Patient harm is assumed to mean errors in care, excluding various forms of injustice and indignity embedded within care structures (see for example Nabhan et al15). The term value is saturated with notions grounded in economics, finances, and business rather than patients' own personal meaning, social justice, or professional ethics. Such utilitarian ontological limitations of key concepts result from their being forced into preexisting policy agendas,16 resulting in missed understandings about organizational patterns and practices.
  2. As a result, there is a strong refusal to question certain factors5,12,13,17 that directly or indirectly impact care. In health care such factors may include for example organizational priorities, rules, and hierarchies; resource allocation; staffing ratios; technology use; drug or medical device safety; or the actions of particular individuals such as a top administrator or a “star” physician.17 When care-related issues arise, usual explanations are privileged, such as an individual nurse's lack of competence, organization skill, or professionalism, rather than environmental factors.2,4,5
  3. Related to the previous item, certain patterns of occurrence or recurrence of errors, poor practice, or adverse events can go unnoticed or are dismissed as coincidental, circumstantial, or unimportant.17 Certain data gathering tools can increase the likelihood of this.18 For example, in the context of adverse drug reactions, some reporting tools have been identified as failing to capture key details, which thwarts detection and/or resolution efforts.19
  4. There is a lack of investigating concerns properly and genuinely, especially when identified concerns are not consistent with the organization's definition of what counts as a problem, require thinking beyond habitual explanations, and/or call for solutions that fall outside the usual management approach.17,20
  5. There is overconfidence in certain tools or certain individuals to perform the way they are supposed to,18 meaning that signs of poor performance are neglected (ignored) or the cause of such poor performance is assumed to come from elsewhere.
  6. Finally, limiting one's understanding of occurrences to immediate/proximal causes also contributes to the overlooking of key information from a broader context. For example, if an incident happens that jeopardizes a patient's wellbeing, the first and main focus of the investigation will be the care provider involved, while environmental or organizational factors will not be brought up in the investigation with the same intensity, if at all, despite their contribution to the incident.17,20

When organizational issues arise, the aforementioned factors shift an administrator's gaze and interpretation of problems, meaning that critical information is overlooked and forgotten. Macrae13(p442) argues that a story about health care wrongdoing is in actuality

a story of leaders, supervisors and regulators interpreting data in a way that confirmed and supported existing beliefs and assumptions about safety, discounting or overlooking data that conflicted with those beliefs, and failing to actively seek out and explore disconfirming cases.

Vaughan21(p392) describes this process as “a way of seeing that [is] simultaneously a way of not seeing,” which is a key precursor of serious failures in health care. The systematic nature of such “unseeing” is what leads Macrae13(p441) to note that “disasters are essentially organised events. To occur, they typically require the systematic and prolonged neglect of warning signs and signals of danger, creating deep pockets of organisational ignorance, organisational silence and organisational blindness.” Organizational unseeing, such as selectively interpreting reports from concerned clinicians (or dismissing such reports), can lead to blind spots remaining unchecked and reported concerns being improperly addressed.9 This sharply increases the likelihood of a serious incident, which can lead to a whistleblowing event. Failure to act on a reported concern begins with the propensity to pay excessive attention to specific knowledge that fits preconceived notions of organizational challenges, to the detriment of other forms of knowledge conveyed by hitherto unremarkable agents in the organization.

Pidgeon and O'Leary22(p22) assert that “an organization is of necessity defined not so much by what its members attend to but by what they choose to ignore.” We believe that for nurses who report wrongdoing, the difficulty lays not so much in their ability to identify practices or processes that jeopardize safety or quality, but in the fact that the reporting of these necessarily occurs in an epistemic space rife with knowledge and ignorance relations that define specific, and often rigid, subject positions. In that epistemic space, some authors argue, interpretation of internal disclosures and acts of whistleblowing rest, not so much on facts, but on the epistemic agency of various stakeholders (eg, nurses and administrators).23,24

NURSE WHISTLEBLOWERS IN HCOs: FROM INVISIBILITY TO HYPERVISIBILITY

In the scientific and gray literature, nurse whistleblowers are often portrayed as individuals with particular qualities (eg, virtue, courage, and dedication), a strong work ethic, and a drive to act with integrity. Whistleblowers' personality traits have been described extensively,17 which perpetuates the perception that the individual whistleblower, rather than the HCO, is the object of interest, the center of deliberation and evaluation when whistleblowing has occurred. Such analyses and representations do not consider the whistleblower as an epistemic agent and they do not probe the complex arrangements that situate her or him as a challenging information broker in the HCO.

Nurses' paradoxical position in HCOs has been discussed extensively.8,25,26 Various studies have highlighted nurses' longstanding position as invisible and unheard subjects in HCOs and in health systems more broadly (see, for example, Allen25 and Urban26). Many of these analyses highlight the different kinds of knowledges that nurses use in the course of their work and the extent to which such knowledges fit (or not) within the broader care system.25 This had led several influential nursing authors to conclude to nurses' invisibility in HCOs despite constituting the largest health care workforce and the strongest presence with patients and families, and despite the rich array of knowledges that underpin nursing care.25 In our view, this enduring invisibility of nurses and their knowledges mediates nurses' claims to epistemic legitimacy in HCOs.

As indicated earlier, HCOs are suffused with epistemic positions that situate organizational agents (eg, nurses, managers, patients, and others) in particular ways based on their respective claims to knowledge. Epistemic positions do not exist in vacuums; they are in continuous interaction with one another and these articulations are ultimately governed by the dominant epistemic register, grounded in a managerialist paradigm,8,14 permeating the organization as a whole. Plural epistemic positions in HCOs multiply the ways for identifying a subject as a “knower” of something in the organization. A nurse for example is simultaneously positioned and recognized as a clinician with expertise and skills, a worker who ought to understand the duty to be loyal to her employer, a public servant working for the public good, a team member who needs to know the importance of being dependable and cohesive, a professional cognizant of interprofessional dynamics, and an employee with legislated workplace rights. These epistemic positions overlap to the extent that the sociocultural, professional, legal, scientific, and technical discourses on which they rest intersect. They create important tensions in the way they define contradictory subject positions for nurses.

Written and unspoken codes, practices, policies, and laws (including those outlining reporting processes or whistleblower protection, which will be discussed later) saturate the organization, each epistemically defining and positioning nurses differently and spelling different sets of obligations, especially when wrongdoing occurs. We suggest that a nurse's knowledge about wrongdoing will be evaluated against her assigned epistemic position in the organization. All epistemic positions involve distinct consequences should a nurse (as epistemic agent) engage in whistleblowing; that is, they each determine the extent to which an act of whistleblowing will be deemed justified and acceptable, or not, depending on how the act of whistleblowing upholds or interrupts prevailing epistemic arrangements.

In keeping with the SOI, we believe these epistemic arrangements should be further teased apart. Based on our review of the literature and key whistleblowing events involving nurses (eg, Mid Staffordshire NHS Trust case in the United Kingdom,27 the Bundaberg case in Australia,28 and the Winnipeg case in Canada29), we argue that nurse whistleblowers in HCOs are constituted as problematic epistemic agents because their nursing knowledge is often discordant with organizational business; it is not drawn from the same register as managerial officers'; and it is not the “right” kind of knowledge to make them credible, authoritative, and influential in the HCO.8,9,25 In keeping with our discussion earlier, this creates epistemic tensions that culminate in some kinds of knowledges (ie, some kinds of observations, understandings, intuitions, and testimonials) being valued, and others being disregarded and neglected—and therefore some kinds of subjects deemed convincing and legitimate, but not others. The literature and the cases reviewed suggest that nurses appear to belong to the latter group.

The literature on whistleblowing clearly shows that, when reporting problems, nurses use multiple strategies to convey their message, such as discussing the matter informally with peers, sending e-mails and making phone calls to relevant individuals (eg, supervisor, manager, and compliance officer), filling out incident reports, raising the issue at team meetings, informing union representatives, lodging formal complaints, consulting the institutional ethics committee, and, more recently, using social media.2,4,5,17,23,28–33 However, despite these efforts, nurses who report issues often note that the resolutions they seek are not implemented. According to the available literature, a lack of resolution of a reported concern suggests that solutions put in place were ineffective, that the nurse who reported the issue was not heard or that her concerns were deemed unpersuasive or unfounded. When the reported concern remains unaddressed, issues persist; in some cases, they worsen.5,23,28,29,31,34–37 This can heighten the nurse's concerns and her resolve to identify alternative channels to communicate these. Multiple authors agree that lack of resolution is in fact the main driver of a nurse's decision to circumvent the processes in place, deemed ineffective or counterproductive, and to escalate her concern and resort to whistleblowing.2,4,5,23,28,30,34,37

Asymmetrical epistemic configurations in HCOs are exemplified by the way certain epistemic agents, namely those responsible for handling reports of problems and wrongdoing, react to troubling information, such as information about organizational failure or wrongdoing. Our literature review on whistleblowing indicates that those tasked with managing concerns make decisions (to follow up or not) based on particular patterns of thinking and knowing that can be difficult to disrupt. In particular, Dixon-Woods et al20 argue that efficient organizational responses to reported wrongdoing ultimately depend on administrators' attitudes and perceptions. They categorized these attitudes in 2 categories: problem-sensing and comfort-seeking. Problem-sensing describes a disposition and willingness to look for and identify organizational fallibilities that could lead to critical incidents. This requires the collection and use of multiple sources of data and metrics including informal ones so as to stay alert to critical information that might otherwise be missed. They further observed that when problems are identified, solutions are not limited to sanctioning staff but rather aim to address weaknesses and gaps in a more systemic and supportive fashion.20 In contrast, the authors note that comfort-seeking administrators tend to limit their investigation, to privilege good news over uncomfortable ones, to avoid complaints and those who make them, and to cast those who report problems as unruly and troublemakers. When a nurse for example reports situations that suggest poorer organizational performance than claimed, this can be perceived as threatening news. Research shows it is routinely met with skepticism, mistrust, defensiveness, and resistance.2,5,17,20 Distance between the administrator and the whistleblower is established, thereby reducing the likelihood of corrective actions.4,24,31 In other words, comfort-seeking behaviors interrupt the flow of essential knowledge and maintain organizational ignorance and blind spots.20 This is so because the whistleblower's concerns challenge existing rigid beliefs22—and their epistemological assumptions—about the organization's processes. Lack of attention to reported issues means that these epistemic assumptions remain uncontested and unchanged, while the whistleblower is perceived as a troublesome individual with suspicious motives, an outcome we will discuss in more detail next.

Indeed, the literature indicates that a nurse who reports wrongdoing is often assumed to misunderstand organizational issues and therefore to constitute an unreliable source of information.4,28–30 This is achieved through the (often public) depiction of the whistleblower's observations as inaccurate, ill-informed, or suspicious; her understanding of the situation as incomplete, uninformed, or misleading; and the whistleblower as an undependable or deceitful informant3–5,23—all of which produce precarious and vulnerable subject positions for the nurse because of her purported ignorance of what is “actually” happening in the organization (for a prominent example of this, see Sinclair29). The testimonials of nurses who disclose wrongdoing are often insufficient to disrupt the organization's thinking patterns, which reinforces established epistemic positions in the organization: nurses are cast as naïve, misinformed, overly sensitive, and uneducated about organizational business, while other actors such as administrators and physicians are assumed to understand it, to have the full picture, to be better trained in administrative science, and therefore to be the most skilled problem-solvers.17,28,29

As seen earlier, as concerns remain unaddressed, a nurse can decide to escalate her concerns, which we argue is an attempt on her part to force her crucial (but disqualified) knowledge into the organization's epistemic landscape, and more specifically into the realm of intelligible and credible information. We believe that, by doing this, she subverts the stiff delineation between what is “known” and “what is unknown” and “what is refused to be known”; she disputes her organizational identity as an untrustworthy knower; and she resists her assigned epistemic position.

We contend that this process will lead the nurse whistleblower to become “out of place” in the organization's master narrative about performance, safety, and quality. As a result, she may become increasingly perceived as the “problem” that needs to be managed instead of the situation she is reporting. In the context of organizational wrongdoing, the struggles for epistemic legitimacy are such that the whistleblower often becomes cast as the wrongdoer, as opposed to those actually involved in the reported misconduct.5,17 A nurse whistleblower, by the virtue of the uncomfortable knowledge she holds, is construed as a problem and a risk rather than a crucial component of the organization's safety checks.

The epistemic positionalities and struggles described earlier make a nurse whistleblower visible, and even hypervisible, in new ways, shifting her epistemic status in the HCO. While nurses remain largely invisible in contemporary care settings,25,26 they become precariously “hypervisible” in the context of whistleblowing. Because whistleblowing is typically undertaken by a single person, the literature and media reports show that most attention is quickly drawn to this person's action, motives, and performance.2,4,5,17,23 Evaluations of these elements are often negative, resulting in uneasy, withdrawn, penalizing, and/or retaliatory responses from administrators and, often, peers3 with often devastating effects for the whistleblower.2 In particular, the literature suggests that the poor handling of reported concerns brings a whistleblower to the attention of authoritative agents through the HCO's internal channels. For instance, her increasingly insistent approach to convey her concerns will be noted, as will be her compliance with (or rejection of) directives from her superior(s); her record as an employee will be scrutinized; earlier performance reports will be examined with a fresh look in search of past misdemeanors (however trivial); personal matters unrelated to her employment (eg, health or family issues) may be used to discredit her reports; and she will be the object of deliberations at various levels within the HCO as administrators decide how to rein her in (eg, they may give her a disciplinary notice or suspend her without pay) and how this will be justified (eg, they can claim she violated organizational policy or disobeyed a direct order from her manager).2,3,17 From naïve and ill-formed, a whistleblower is often further branded as attention-seeking, acting in bad faith, disloyal, and defiant; sometimes going as far as paranoid and mentally unstable.2,31 Such strategies are further used to ascertain the dubiousness of the whistleblowing act, her motives, her actions, and her character, while organizational failings are left out of the discussion (ie, they are ignored). The whistleblower, expecting (or at least hoping) that her disclosure would lead to a productive and positive resolution, is left with the harsh reality that she has been betrayed by the very organization and people whose mission and mandate she sought to support.2

Based on the SOI, we argue that the organization's response to the act of whistleblowing is meant to reestablish and stabilize its epistemic space, in large part by reinforcing the whistleblower's epistemic position as untrustworthy through damaging labels. Indeed, labels suggesting insubordination and disloyalty are dangerous ways of being visible and “known” as an employee in the HCO. Furthermore, because the whistleblower is cast as a disruptive worker who needs to be “fixed,” such labels allow a disclosure about clinical, professional, or legal wrongdoing to become reduced to a management and human resources issue. As a result, a nurse's disclosure can disappear into administrative channels as a matter to be managed confidentially between an employer and a staff member. This further closes off administrators' understanding of the reported problem, thus increasing organizational blind spots and ignorance while opening up new courses of action programmed into the bureaucratic structure of the HCO (eg, formal reprimand, demotion, and spontaneous performance review,38 many of which can serve to retaliate against the whistleblower5,23,30,35,39). During this process, alternative epistemic positions for the nurse whistleblower become more and more unintelligible (ie, they are increasingly ignored): perceptive, competent, loyal to the HCO's mandate, team player, professional, focused on safety and quality, compliant with administrative and bureaucratic requirements, rational, reasonable, responsible citizen, or faithful public servant.

The literature shows the various ways in which, following a disclosure, the nurse whistleblower is depicted as ignorant by the HCO; for example, ignorant of facts,29 ignorant of policies and procedures,5 or ignorant of professional norms and standards.32,33 This representation can be amplified through the reporting of the nurse whistleblower to her professional college (for a stark example of this, see Lewis and Norman32 and Picard33). The solutions, then, target the individual rather than organizational or systemic causes and their epistemic configurations. We contend that constructing the whistleblower in this way, especially when done publicly, serves to preserve the prevailing epistemic order of the HCO, one in which the whistleblower's primary offence is that of epistemic disobedience.35

INSTITUTIONAL REPORTING POLICIES AND WHISTLEBLOWING LEGISLATION: COMPOUNDING HYPERVISIBILITY AND IGNORANCE

Institutional policies

In order to curtail the negative consequences described previously and the substantial distress they generate, more and more organizations adopt policies outlining the right of employees to report issues without suffering reprisals. Tsahuridu40 notes that while the number of seemingly good quality bureaucratic and legal protections for whistleblowers has increased substantially over the years, so have acts of whistleblowing but also reports of retaliation from the organizations involved.

Tsahuridu's observation suggests that policies do not deter ill-treatment of persons who disclose wrongdoing.40 A lens framed by the SOI helps the formulation of explanations as to why this is the case. Policies, procedures, and laws focusing on disclosure are of particular interest for our discussion because they are assumed to provide a clear pathway to action and confer protection on the dutiful whistleblower, both of which are meant to eliminate the risk for negative repercussions. The scholarly and gray literature are rife with optimistic views of how such policies and legislations are useful and effective, requiring chiefly that an organizations' administrators and employees be aware of its provisions and that top management commit to them (see for example Barnett41). We shall therefore turn our attention to those authoritative texts, paying special attention to the way they mediate the strategic interplay between knowledge and ignorance when disclosures are made.

Most, if not all, HCOs are equipped with internal reporting policies that spell the various steps to be undertaken by someone who wishes to alert organizational administrators to wrongdoing.36 Policies are meant to circumscribe how reporting should be undertaken, the obligations of the whistleblower, and the kinds of protection she is entitled to (eg, confidentiality; fair process) and under which conditions. Typically, a person who wishes to alert her organization about organizational wrongdoing must inform her immediate superior. The complaint must often be packaged a certain way for it to be processed (eg, submitted in writing or using a specific form; including sufficient details to launch an investigation; supplemented with evidence). If corrective actions are not implemented within a period specified in the policy, additional steps are usually permitted, such as the involvement of other persons in addition to the original addressee of the complaint. Institutional policies describe how a person who makes a disclosure can work her way up the organizational ladder, gradually involving agents at increasing levels of the management structure before senior executives may be contacted.5,17,36 Failure to comply with these steps can lead administrators, first, to determine that the whistleblower is not acting in good faith and to discipline her,5,31 and second, as a result, to question the trustworthiness of the disclosure and to interrupt its circulation across organizational channels.17,36

Indeed, interestingly, punishment of the whistleblower usually hinges on the allegation that her disclosure is not the “real” issue but rather the way she went about it.17,31 More specifically, administrators can charge that she did not follow established procedures for reporting concerns and that this confirms her identity as an insincere or insubordinate employee—an additional perilous subject position that legally opens up a range of disciplinary actions against her.4,17,31,35 It is not surprising then that, though institutional reporting policies are meant to be objective, clear-cut, efficient, and uncontroversial, multiple studies over the past 3 decades show that service providers such as nurses have little faith in such procedures, while senior administrators are confident they function as they are meant to.5,20,28,42 For example, a study in the UK's National Health Service (NHS) showed that 90% of senior leaders thought that complaints were handled appropriately, compared to only 26% of nurses.42 This may be explained by the documented tendency of administrators to limit the scale of their investigations (discussed previously) and narrow the scope of effective remedial actions, assuming any are implemented at all.17 Drawing on the significant wrongdoings that took place in the midst of the Mid Staffordshire NHS Foundation Trust scandal (for details on the scandal, see Francis27), and the lopsided recommendations that ensued, Butterworth43(p533) notes that “[The] response, as usual, is to punish those most visibly accountable and ignore the significant contribution made by those running a flawed and badly managed system,” leaving the latter and their lack of response “hiding in plain sight.” This suggests that reporting policies and procedures are not as objective and neutral as they are purported to be, while the whistleblower is left with the cognitive and emotional labor of managing the bleak dissonance between how the whistleblowing process is unfolding versus how it ought to unfold as per the official policy.2,31

In our view, such policies can be understood as epistemic devices to the extent that they govern the way a particular kind of knowledge (ie, about organizational issues) is to be produced and conveyed to the appropriate agents. In keeping with the SOI, such knowledge-generating procedures need to be put in contrast with other institutional policies that put limits on the flow of organizational knowledge both within and without the HCO. For example, confidentiality requirements, prohibition to speak about organizational business to other entities (eg, the media), and gag orders are all epistemic devices—or antiepistemic devices, rather—that constrain who can convey knowledge, what can be known, and who can know. All of these are built into employees' contracts with the organization, working explicitly to protect its interests, business, and reputation. These antiepistemic devices mean that information about wrongdoing needs to be corralled and funneled into specific bureaucratic channels to “efficiently” reach the “right” persons who can act on it.

Several authors suggest that institutional reporting and whistleblowing policies are implemented mainly to comply with legal requirements, rendering them essentially inoperable (see for example Cailleba and Charreire Petit44). Policies may be worded in neutral, even reassuring terms, but Ash17(p41) observes sardonically that, after deciding to move ahead with a disclosure, “in fulfilling their side of the employment contract, [employees] find they have to negotiate, with all the care of someone ploughing a field of activated landmines, the tripwires of their employer's whistleblowing policy and procedure.” As mentioned earlier, people who disclose organizational issues must strictly follow the procedure in place, otherwise their “real” intentions are put in doubt. In other words, when engaging in the designated reporting channels, the whistleblower must prove, throughout the entire process, that she upholds the highest level of proper conduct (and has also done so in the past), since this can be used against her (for an example of the criteria used for determining and evaluating a whistleblower's past and present conduct, see Fletcher et al23 and Adler and Daniels38). Interestingly however, standards seem higher for whistleblowers than for the organization itself: while virtuous behavior is expected of the whistleblower going through an arduous disclosure process, the same does not necessarily hold true from the organization. Martin39(p120-121) for example describes how small-scale attacks on the whistleblower are not only effective in curbing a whistleblower's actions but are also easy to disguise as legitimate corporate policy:

[T]here are many subtle ways for employers to undermine employees without providing clear-cut evidence of reprisals. Rumours and ostracism are two of the most common responses encountered by whistleblowers but are virtually impossible to document. Petty harassment is also potent. It might mean such minor things as unavailability of a company car, awkward rosters, slowness in processing claims, or requests for excessive documentation. Ostracism itself can cause the equivalent of petty harassment, as a worker is denied access to everyday information needed to do the job efficiently. At a more serious scale are job reassignments that reduce or increase work demands, either setting up the employee for failure or making the job tedious; in both cases it is often easy to camouflage the changes as necessary due to changes in the work environment or to a more general organisational restructuring. Ironically, it can be more difficult for an employee to deal with subtle undermining than with a more obvious attack such as demotion or dismissal. Subtle harassment can lead some employees to blame themselves whereas blatant attacks are more readily understood as reprisals.

For a remarkable example of how organization leaders can be coached to veil their actions against whistleblowers so as to remain within what is legally permissible, see Adler and Daniels,38 paying special attention to the language used and how this discursively and epistemically constructs the whistleblower as a wrongdoer and a liability. What is interesting here is how such actions govern the way information about the wrongdoing, the whistleblower, and the organization's response circulates and contributes to the dominant narrative; and how ignorance is effectively maintained, in particular about corporate accountability regarding both the originally disclosed wrongdoing and the subsequent treatment of the whistleblower. Therefore, the purported protective features of reporting policies, their incentive effect, and their ability to transform entrenched organizational epistemic arrangements must be questioned.

People who wish to disclose organizational wrongdoing must first use internal channels before “outing” the information, and this avenue still remains whistleblowers' preferred course of action.17,24,36,37 In the absence of corrective actions by the organization, they may decide to blow the whistle externally.23,30,45 Over the years, numerous countries have adopted statutes in order to protect whistleblowers who publicly come forward with sensitive information in the service of public safety or interest. Our analysis framed by the SOI shows that epistemic mechanisms similar to those described previously are at play here too.

Whistleblowing legislation

Whistleblowing legislations serves to set out a safe mechanism for whistleblowers to make a disclosure (eg, by legally requiring the creation of a special independent commissioner who can launch an investigation into the allegation) and/or to provide a legal recourse for whistleblowers who have suffered illegal retaliation from an organization (usually their employer) after having made a public disclosure (the latter is commonly referred to as whistleblower protection law given its more specific legal focus). These laws set out stringent criteria for the report to qualify as a “protected disclosure” (whistleblowing) and therefore for the whistleblower to benefit from legal protection7 (for a detailed analysis of the restrictions of Canadian federal legislation, see Tweedie46; for the US context, see Yeh47). This means that straying from these conditions strips the whistleblower from any protective mechanism afforded by the law. It is also worth noting that whistleblower protection laws are not meant to force an investigation of the actual disclosure and its resolution by the organization: they specifically serve to protect qualifying whistleblowers against retribution from the organization involved. For example, under such laws a whistleblower can sue her employer for wrongful dismissal if she can prove it was motivated by retaliation following an act of whistleblowing. If successful, the organization could be legally forced to reinstate the whistleblower in her original position; it will not, however, be forced to investigate and remedy the wrongdoing that caused the disclosure in the first place, thereby leaving that blind spot intact. Martin39(p121) describes this problem as follows:

Whistleblower laws put the focus on whistleblowers and what is done to them. An unfortunate feature of this focus is a relative neglect of the original issue about which the employee spoke out. Whistleblower laws do not and perhaps cannot require an investigation into an employee's allegations. During the drawn-out process of assessing whether reprisals have occurred, the original issue is not addressed. For a dismissed whistleblower, “success” usually comes in the form of a settlement, not a reinstatement; success in terms of organisational reform is not part of the agenda of whistleblower laws.

Disturbingly, current analyses show that few whistleblowers who attempt to seek legal protection under these laws actually receive it,7,39,48,49 which can have a strong deterrent effect on anyone with sensitive information regarding wrongdoing in their workplace. Put another way, if existing statutes have built-in mechanisms that render them “without teeth,” then failing epistemic arrangements in organizations will remain unaddressed and wrongdoing will continue to occur.

Various reasons have been proposed to explain the poor performance of whistleblowing legislation.7,39,49 Two of these are of particular interest in light of their epistemic and antiepistemic underpinnings: the first is the rigid criteria mentioned earlier and the other is the burden of proof. First, the criteria used to determine whether a disclosure qualifies as a “protected disclosure” under the law include for example the permissible channels that the whistleblower is legally allowed to use to go public. Interestingly, many statutes include going to the police, an ombudsperson, a special commissioner, or an elected official but exclude alternative channels such as the media. This closes off an option that can prove extremely effective because it is set outside of inflexible bureaucratic channels. Thoms50(p83) contends that “whistleblower legislation strives to control the agenda of whistleblowers and to contain their disclosures to channels which are under the purview of the state.” Martin39(p123) heavily criticizes such closing off, arguing that

The law's failure to protect whistleblowers who go to the media is a clear indication that the law is oriented to domesticating dissent rather than empowering the whistleblower or putting priority on action against wrongdoers. To take advantage of the law requires that the whistleblower pursue official channels that keep the matter of concern under wraps, with no alert given to wider constituencies that might apply pressure for action. Given that the procedures involved may take months or years while the problem remains unchallenged, this provides a perfect method to minimise challenges to organisational hierarchies.

We saw earlier how such hierarchies rest on the strategic flow and interruption of information in the organization. Soliciting the media can be a useful route for whistleblowers, especially if internal channels have proven to be unsuccessful or corrupt.7,31,45 Eliminating this route as a protected channel for whistleblowing obstructs one direction from which information disruptive to organizational knowledge/ignorance configuration can come.

Second, most whistleblowing laws put the burden of proof on the whistleblower; that is, the whistleblower is given the monumental epistemic responsibility to ensure her information about the wrongdoing is correct and that it is properly substantiated; and that her allegation regarding any retaliation is also supported with appropriate evidence (we have seen earlier how retaliatory actions by an organization can be passed off as lawful). This may prove very difficult to do because a whistleblower may not know what she should be looking for (ie, she is ignorant of her ignorance) and given that a whistleblower's access to key information is often restricted following an act of whistleblowing (see for example the advice provided to managers by Adler and Daniels38 in that regard; see also Ahearn2). Here again, the whistleblower gets caught up in power plays centered on the management of knowledge and ignorance, but these remain concealed as one of the multiple blind spots of whistleblowing policies and statutes. For these reasons, Martin39(p121) believes that “whistleblower laws are a form of symbolic politics, serving to give the appearance of political action without any substantive change in institutional dynamics.”

What is clear is that despite whistleblowing policies' and laws' commitment to an objective, rational, and fair process, the focus continues to be misplaced: their supposedly stringent confidentiality requirements do not protect the whistleblower from becoming hypervisible and from carrying a disproportionate amount of responsibility for complex epistemic processes. And while the whistleblower's actions, personality, work performance, and even family and health issues are dissected as a result of this hypervisibility, there seems to be no qualm, in any of the literature reviewed, about the asymmetry of ethical conduct expected of the whistleblower compared to the organization. In other words, the hypervisible whistleblower must engage in what we might call “hyperethical” conduct to confirm the legitimacy of her own person and therefore her disclosure, keeping her composure even in the face of organizational inaction and, later, retaliation. By contrast, organizations can and do stray from proper conduct (eg, not respecting the whistleblower's anonymity or confidentiality, harassing or intimidating her, and demoting or firing her) but history consistently shows, across many countries, that they suffer little or no consequences for doing so.5,48,49 The fixation on “knowing” the whistleblower thoroughly has been heavily criticized by multiple authorities and experts who consider that it does nothing more than detract from the real issue at hand, which is the alleged wrongdoing.6,7 Reporting policies and whistleblowing legislation meant to address wrongdoing and improve organizations may therefore maintain this problematic state of affairs.

Burdensome, misfocused, and unfair policies and legislation mean that people with critical information in the public interest will not come forward, thus maintaining ignorance about organizational failures and wrongdoing. In this way, they can powerfully contribute to the status quo, in spite of their mandate to the contrary. We suggest that such built-in mechanisms for their limited efficacy (at best) or failure (at worst) can have a strong predictive effect on the experience of whistleblowers in general, regardless of the context.7,31 The literature reviewed shows remarkable uniformity in whistleblowers' experiences, perhaps because weaknesses are repeated across policies and laws, regardless of jurisdiction. What stands out from our view grounded in the SOI is the way they work to construct whistleblowers as problematic knowers, or rather as “ignorant” agents in the organization. Put another way, policies and whistleblowing legislation multiply dangerous epistemic positionalities through built-in mechanisms of failure. Whistleblowers, then, exemplify why knowledge is not power at all. Though it would be easy to assume that a whistleblower would be in a position of power thanks to her privileged knowledge about organizational wrongdoing, her heightened visibility and epistemic responsibility means she was never so at risk: where whistleblowing is concerned, knowledge that is unwelcome in the epistemic space of the organization spells considerable vulnerability for she who holds it. Because of this, “better” whistleblowing policies or the “empowerment” of nurses constitutes weak solutions to the issue of whistleblowing as long as they do not address epistemic configurations of HCOs nor tackle invisible and hypervisible positions generated through and by acts of whistleblowing.

CONCLUDING REMARKS

We have argued in this article that nurse whistleblowing is not so much a product of individual personality traits or of organizational dysfunction than a matter of epistemic arrangements and tensions among epistemic positions available in an organization. Information relayed by nurses that could require a rethinking of organizational practices, that challenge authoritative knowledge, and/or that spell a flattening of hierarchies will disrupt established epistemic arrangements. These arrangements are products of longstanding, power, knowledge, and ignorance relationships that determine the configuration of epistemic legitimacy in HCOs.

Therefore, focus on the whistleblower rather than the rehearsal of (anti)epistemic processes and their effects on agency is misplaced: what should be examined instead is the way nurses' social environment enables or restricts their epistemic agency, and defines the value or the risk attached to the knowledge they manage in their daily practice.9 While the plight of nurse whistleblowers as extensively described in the literature could be “simply” understood as a product of unequal power relationships, we can see through the lens of ignorance that such a problem cannot be resolved through the empowerment or emancipation of nurses: the issue lies not with/in nurses but with their epistemic status within HCOs. Similarly, adding policies about the handling of complaints and the implementation of a safety culture, though important, will likely not in and of themselves solve the problems of HCOs determined to maintain existing epistemic arrangements, because these policies do not treat whistleblowing as a struggle for epistemic legitimacy.

From the perspective of SOI, the activities of whistleblowers and organizations can be analyzed from the interactions between knowledge and ignorance; visibility and invisibility; voice and voicelessness. Using the concept of ignorance to frame acts of whistleblowing is not merely a consideration of a lack of knowledge, but concerns a set of knowledge/ignorance-based positions available for whistleblowers. Like knowledge, ignorance circulates through the buildup to and eruption of a whistleblowing event. Epistemic agency and available positions flow from operations of ignorance as they do from knowledge.10 And, as with knowledge, power and discursive positions convey the play between ignorance and epistemic stances that nurses, managers, and others take up, providing a more nuanced account of whistleblowing events. Understandings of ignorance that underpin such an analysis do not figure it as deficiency or gap, but as forms of knowledge that include discredited or devalued information.

We believe that examining the interaction of different epistemic positionalities provides a novel and fertile angle of analysis of whistleblowing events. Shifting attention to these multiple and interdependent positionalities helps interrupt the way nurses become hypervisible through a whistleblowing event, by shifting our gaze to the HCO where influential epistemic agents can work to maintain organizational blind spots and ignorance. As such, various scholars and experts have advocated for further research focusing on

whistleblowing as an unfolding, situated and interactional process and not just a one-off act by an identifiable whistleblower. In particular, we need more evidence and insights into the tendency for senior managers not to hear, accept or act on concerns about care raised by employees.5(pvi)

We firmly believe the SOI is a useful framework to support such research, because it helps us reconsider organizational (anti)epistemic processes and their effects, and nurses as particular agents in an epistemic space rife with strategic relations that make certain types of narratives intelligible and credible, but not others. This shift helps move the focus and the accountability not on the individual nurse whistleblower, but back on the institution itself and the epistemic structures on which it rests.

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Keywords:

antiepistemology; epistemology; nurse whistleblowing; organizational blind spots; organizational wrongdoing; reporting; safety culture; sociology of ignorance

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