The barriers to speaking up

Where is the regulatory framework for managers to actively listen, believe, and act expediently on information?

What stops people from speaking up when there is a serious problem? Even if the problem is so serious it might take a human life? These questions were raised at a conference on medical professionalism at the RCSI in April. Attendees heard a variety of perspectives including from John Devitt, CEO of Transparency International Ireland, and Dr Ravi Jayaram, a paediatrician at Countess of Chester Hospital who had raised serious concerns with hospital management about former neonatal nurse Lucy Letby.

Despite a range of legal and regulatory tools, it remains difficult to speak up. Understanding the reasons behind the reluctance to raise alarm is key to making any service better. I believe the reasons are fear of personal and professional consequences, lack of trust in the system, and apathy. The last reason is the most dangerous for patients.

Fear is a normal response arising out of a common desire to go in, do your job, and live quietly. It becomes a real obstacle to speaking up when there are known negative consequences to doing so. For example, colleagues who spoke up may have been assigned more work to do, relegated to tasks below their abilities, or even disciplined. They may have been shunned by workers close to them if there was an element of blame. Systems often don’t welcome problems being highlighted by staff and the response from decision-makers may be uncomfortable at best and destructive at worst.

Lack of trust in the system is partly due to the negative impact of speaking up, but it’s also due to a lack of belief that in speaking up, something might change. If you are very junior in a system, it’s easy to think that no-one will listen to you, so what’s the point of trying. Staff a bit further along may have witnessed others speaking up without subsequent improvements and have come to the same conclusion.

Apathy is dangerous. In 2010 an inquiry into patient deaths in Stafford Hospital in England described the dehumanising effect of poor care. People can strip out the compassionate human both in themselves and in those they are looking after, when faced with overwhelming demands and lack of leadership. It is a coping mechanism because seeing people suffering that you are unable to help is just too painful. Pain is replaced with disengagement. Nothing will change then.

Viktor Frankl, psychiatrist and Holocaust survivor, wrote extensively about this. Importantly, he also described those who did not succumb to apathy. They were people who coped in a different fashion. Their resilience lay in the narrative of meaning that they created around human life. This was also why, despite the bleakest of circumstances, it was possible to stay purposeful. Speaking up gives purpose.

When we look at those who have spoken up and driven change, such as Philomena Lee, or the Dunnes Stores workers in the 1980s, the way they spoke up is instructive: They played the ball, not the man. They were persistent in their pleas for change. They drew on personal experience. Undoubtably, they had courage too. But even beyond bravery, they believed so strongly in what they knew was true and what they knew had to change, that they were undeterred by opposition. They expected, perhaps almost welcomed, opposition as they realised that it meant they were getting closer to the heart of vested interests.

In recent years, the attention has been on protecting whistleblowers. But what of the decision-makers receiving the disclosure of unpleasant information? To fully complete the picture of speaking up, it’s necessary to examine the actions of managers who get told that there is harm occurring on their watch. Their capacity to listen with empathy, to enquire with genuine and unbiased curiosity, and to instigate action to address a pressing safety concern is essential. It is not an easy task as they are generally struggling to balance many demands on resources and have their own professional targets to meet. It is a fact that a report of harm to a manager can be a perceived attack on the status quo – which they have a stake in preserving.

In recent years, the attention has been on protecting whistleblowers. But what of the decision-makers receiving the disclosure of unpleasant information?

This is why external ‘watchdogs’ are necessary. We have regulation of health and social care professionals. Staff and regulators work within existing legislation and professional guidelines. The Guide to Professional Conduct and Ethics for Registered Medical Practitioners, published by the Medical Council, reinforces the duty of doctors to raise concerns about deficits in patient care. All staff can use the protection of the Protected Disclosures Act. That’s the framework for speaking up.

But where is the regulatory framework or obligation for managers to actively listen, believe, and act expediently on information? Without a statutory mandate, it appears that the completion of the circle of reporting on safety is missing an important safeguard.