Patient Advocacy and Whistle-Blowing in Nursing: Help For the Helpers by Sharon L. Andersen, RN, EdD
This article examines the phenomenon of whistle-
Sharon L. Andersen, RN, EdD, is Nursing Instructor, Kwantlen College, Surrey, British Columbia, Canada.
blowing and its antecedent dynamics, including invidious organizational tactics that are employed to silence patient advocates. Moral distress and moral outrage are identifed and described as manifestations of the stress that nurses experience when acts of patient advocacy are subverted. Recommendations are ofered to empower and protect present and future practitioners who may
I n education we encourage students to be patient advocates, to be proactive in promoting and defending the welfare of those entrusted to their care (Moloney, 1986). Students who graduate will apply what they have learned when attempting to remedy situations that involve patient abuse and neglect. Some are quite successful and, to their credit, cause improvements in the quality of patient care. Others discover that admirable intentions and the best problem-solving skills are ineffectual when they are confronting the unexpected-an administration invested in concealing, rather than rectifying, its deficiencies. In this case, whistle-blowing may be the only viable solution for those who are committed to patient advocacy. Whistle-Blowing
befaced with having to take on the role of whistlePast and Contemporary Whistle-Blowers
blower. Research initiatives are also suggested.
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Whistle-blowing and the forces that lead to it are poignantly illustrated in literature and case studies. In Ibsen’s play, ”An Enemy of the People” (1882/ 1963), Thomas Stockmann outlined recommendations to decontaminate the town’s mineral baths, which had caused bathers to become ill. His findings were dismissed as a ”hallucination” and he was labelled an ”enemy of the people.” He was discharged from his position as the spa’s medical director, and his home was stoned by an angry mob of his former friends and colleagues. Karen Silkwood discovered health hazards at one of Kerr-McGee’s nuclear materials plants in an area where plutonium fuel rods were produced. Management tried to conceal the facts, and she was forced to go outside the plant to union and government officials for help. Ms. Silkwood met an untimely death in a car ”accident” en route to testify in defense of her allegations (Ewing, 1978). Sandra Bardenilla, nursing supervisor, was 5
r
Patient Advocac and Whistle-Blowing in Nursing: Help For the He pers
directed by a physician to render unethical and potentially illegal care to a comatose patient. She discussed her objections with the physician and was chastised. On appealing to the director of nursing she was advised to "be quiet and apologize to the physician" (Fry, 1989). Ms. Bardenilla chose not to engage in unethical and illegal nursing actions. The patient died. She resigned, and reported the physicians involved to the state and professional authorities. The doctors were charged with murder and acquitted later (Court of Appeals of the State of California, 1983; Superior Court of the State of C alifornia for the County of Los Angeles, 1983). Ms. Bardenilla, on the other hand, received no support from the profession and had difficulty finding employment as a result of her actions (Fry). These scenarios are not uncommon; in fact, they have occurred with remarkable frequency since the 1970s (Harris, 1981; Robbins, 1978).
negligence, abuses, or dangers that threaten
Whistle-Blowing Defined
the public welfare.
Whistle-blowers are people who apply their expertise or knowledge about the organization in which they work to expose negligence, abuses, or dangers that threaten the public welfare (Bok, 1980).Besides protecting the public, one may engage in whistle-blowing to expose personal victimization, as in cases of sexual or personal harassment, discrimination, and the unjustified denial of tenure or promotion (Theodore, 1986). Whistle-blowing is not ordinarily the first recourse in drawing attention to a problem; all sources for problem resolution should first be exhausted within the employing agency (Petersen & Farrell, 1986).When the administration is nonresponsive, engages in cover-up, or attempts to silence or discredit the employee, and when harm to others or self is imminent, the individual makes a public disclosure of the situation (Ghiselin, 1989)."Going public" includes disclosing the facts and dangers to groups such as the professional association, the union, and the media. Resolution of the problem from within the organization would be the most logical and appropriate response; unfortunately some employers ignore the 6
warnings of their employees. As Ewing (1978)explains,
. . . not only are they not to be heard, but also not to be seen. It is as if the voices of criticism-the whistle-blowers-were the Sirens of Greek mythology, and top executives were the sailors of Ulysses who, in order to pass by without being seduced, stopped one another's ears with wool (p. 11).
Whistle-blowers are people who apply their expertise or knowledge about the organization in which they work to expose
Elements of Whistle-Blowing Bok (1989a) contends that there are three elements that, when combined, account for the negative reactions toward the whistle-blower: dissent, breach of loyalty, and accusation. Dissent is a form of public disagreement; in whistle-blowing, however, dissent is narrower in scope. It includes challenging authority or majority opinion, alerting the public to a risk, and assigning responsibility for that risk (Bok). In other words, one is not merely stating disagreement with others on a subject or a position; one is pointing out dangers and detailing the inadequacies that led to the dangers. This is precisely what Dr. Stockmann, Ms. Silkwood, and Ms. Bardenilla did. Corrective action may entail considerable expense; it may disrupt the status quo and damage the reputation of an organization and its employees. A mature and morally responsible administration will, nevertheless, respond with an impartial and objective factNursing Forum
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finding inquiry. This type of agency invites problem identification and suggestions for improvement, for it recognizes that The true organizational loyalists . . . are not the people who pretend they do not see anything wrong, but rather those who shout the defects from every rooftop while trying to pull together a team to eliminate them (Kanter, 1983, p. 143). An organization lacking in the necessary qualities will respond defensively, exhibiting a posture of thinly disguised contempt toward the ethical employee (Brown-Stewart, 1987). It will invest its energies in a concerted effort to dismiss or cover up the problem and to silence the whistle-blower. The alarm sounded by whistle-blowers is regarded as a breach ufluyalty; like calling a foul on one’s own team (Bok, 1989). Administrators and colleagues perceive the whistle-blower’s actions as a form of betrayal of the agency, the profession, and friends. For the whistle-blower, loyalty to colleagues and the organization conflicts with loyalty to the public welfare. The conflict is strongest for those who take seriously their responsibilities to the public, yet also have close bonds of allegiance and commitment to the profession, to colleagues, and to the organization (Bok, 1989; Petersen & Farrell, 1986). The element of accusation arouses the strongest reaction from within the organization or profession. Here, the whistle-blower tries to identify who is/was responsible for the negligence or abuses that threaten public welfare (Bok, 1989a).The charge may be one of unethical or unlawful conduct by colleagues or superiors. This will arouse alarm, hostility, and a scrambling to cover u p inadequacies and protect professional reputations. The whistle-blower may find that the administration and colleagues attempt to discredit her as a way of attacking the credibility of her findings (Robbins, 1978). Isolation, persuasion, modified interrogation tactics, brainwashing, and harassment are techniques Nursing Forum
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that have been employed to control and silence dissident employees (Andersen, 1990; Bok, 1989b; Theodore, 1986). The whistle-blower faces being discharged and may even find future employment difficult as a result of blacklisting within the professional community (Schaefer, 1990; Theodore, 1986). These measures are shocking but not uncommon. Bureaucratic settings employ them quite often to achieve conformity and compliance (Grosman, 1989; Robbins, 1978). Thomas Stockmann lost his job and was harassed in his home, Sandra Bardenilla had difficulty finding employment, and Karen Silkwood lost her life trying to protect others. In view of the severe repercussions that a whistle-blower experiences, it is worth investigating what leads an individual to choose such action in the first place.
When a nurse encounters patient abuse or neglect she can select a course of action from three basic options: exit, voice, and loyalty.
Antecedents to Whistle-Blowing
The Emergence of Moral Distress When a nurse encounters patient abuse or neglect she can select a course of action from three basic options: exit, voice, and loyalty (Hirschman, 1970). She may leave the organization, confront the problem by speaking out about it, or remain silent, placing self-interest or loyalty to the organization above patient accountability. Patient advocates choose voice, thereby making a moral decision to take action. However, in nonresponsive or defensive organizations, institutional constraints are applied that obstruct the nurse’s ability to act on her decision (Crisham, 1981).These constraints may be either overt or covert, consisting, for example, of punishments, 7
Patient Advocac and Whistle-Blowing in Nursing: Help For the He pers
K
verbal threats, or the ”silent treatment” (Nader, Petkas, & Blackwell, 1972). Institutional constraints generate moral distress, which is a product of the dissonance that arises when one cannot carry out the desired actions to implement a moral decision (Jameton, 1984).The distress a proactive nurse experiences may be manifested in many ways: feelings of anger, depression, isolation, alienation, loss of self-worth, weeping, palpitations, headaches, diarrhea, guilt, sleep disturbances, and concerns of being a burden to support persons (Wilkinson, 1987/88). In order to protect the patient and subsequently relieve the moral distress, the nurse seeks assistance through the administrative hierarchy, progressing methodically through the channels of command from head nurse to chief executive officer. The belief that surely someone in administration will take action on the problem once its existence is known compels the advocate to continue up the hierarchy, fighting resistance at each level, in search of a responsive administrator (Whyte, 1957). As time passes and the problem remains unresolved, concerns for patient welfare as well as the discomfort of moral distress are heightened by a sense of urgency. Nevertheless, the nurse has hope and conviction that an administrator, at some level, will address the problem (Maccoby, 1988). Whistle-blowing is not yet entertained as a possible course of action; one still believes that ultimately the system will work properly. Advancing up the administrative ladder conveying concerns about patient care will successively expose the deficiencies and nonresponsiveness of employees throughout all echelons (Kanter, 1983). The result is additive: The higher one goes the greater the scope and number of those implicated, directly or indirectly, in the patient abuse or neglect. As a result, the advocate will encounter anger directed from personnel in several levels of the organization. She becomes socially ostracized and avoided even by those not implicated in the abuse or neglect. The closer one gets to the executive level of the hierarchy, the more it becomes apparent that administrators, managers, and staff are equally defensive and 8
dismissive in response to the advocate’s concerns. Kantrow (1984) articulates the circular reasoning used to legitimize dismissal of the advocate’s complaints: What exists in the present is the distilled product of long experience, examination, and challenge and is, therefore, probably the right way for things to be. If something were grossly wrong with those arrangements, they would never have survived intact as long as they have. The mere fact that they exist is compelling evidence that what exists is right (p. 74). This is what Bernstein and Rozen (1989) call “dinosaur brain thinking,” and it is represented in Kanter ’s (1968, 1972, 1983) concepts of organizational commitment and immortality. When this belief prevails in an agency, patient advocacy is interpreted as nonconforming or aberrant behavior that represents a threat to the status quo (Mann, 1977). The system then breaks down into adversarial factions of good guys (us) versus bad guys (anyone not like us), and the thrust of loyalists is then directed at driving the deviant from the system (Bernstein & Rozen, 1989; Russell, 1958).Slater (1990) calls this the operationalization of the ”Toilet Assumption-the notion that unwanted matter, unwanted difficulties, unwanted complexities and obstacles will disappear if they’re removed from our immediate field of vision” (p. 19).
The Emergence of Moral Outrage The perception of the advocate as a threat marks a critical turning point in the organizational dynamics and the behaviors of the advocate. Initially the advocate was regarded as a nonconformist, a dissident, or a troublemaker. Social controls such as institutional constraints were applied to pressure the advocate to be silent, to stop ”rocking the boat”, and to conform. Once the patient advocate is seen as a danger to the system, however, the organizational posture becomes Nursing Forum
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more aggressive and invidious in character. The continued denial of and nonresponsiveness to patient abuse and neglect is now compounded by attacks on the credibility, integrity, and emotional stability of the advocate (Bok, 1980). The nurse becomes the focus, and the patient care problem is interpreted by organizational loyalists as a product of the advo-
The perception of the advocate as a threat marks a critical turning point in the organizational dynamics and the behaviors of the advocate.
cate’s magnified or distorted perceptions. The harassment is reinforced in the collective by the administration’s denial or dismissal of the advocate’s requests for intervention on behalf of the patient (Grosman, 1989). Every aspect of the advocate’s performance is now scrutinized for flaws. She may be given more work than she can possibly complete, or may be debased with assignments consisting exclusively of menial tasks (Nader et al., 1972). The personal attacks on the advocate turn the moral distress she has experienced into moral outrage. Moral outrage is a product of the emotional turbulence, pain, incredulity, indignation, and rage that the advocate experiences. It occurs when a logical attempt to solve a moral problem results in denial of the problem and an assault on the nurse’s integrity by those who have sacrificed their integrity and the welfare of patients to preserve the status quo of submarginal performance. The psychobiological remnants of moral distress are then compounded by the experience of moral outrage. When moral outrage occurs, the advocate directs Nursing Forum
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her efforts toward a broader scope of activities. She seeks protection for the patient, verification of the accuracy of her perceptions as a defense against attacks on her credibility, and retribution for the moral injuries she has sustained (Murphy & Hampton, 1988). The hope of problem resolution is abandoned when the advocate discovers that even the chief executive officer is, at best, noncommittal in response to her concerns. As a result, whstle-blowing is then entertained as a viable solution (Schattschneider, 1960), one that will remedy the patient care problem, reaffirm the advocate’s credibility, and relieve the moral outrage. The dynamics that precede whistle-blowing are, in many respects, similar to those that follow disclosure. The primary difference is that the intensity of bureaucratic resistance is often greater when one makes a public disclosure of organizational inefficiency, corruption, or abuse. Moreover, the hardship for the proactive nurse may be even greater after disclosure for she may by now be unemployed. She may have minimal social support and no protection from the professional association (Chalk & von Hippel, 1979). If we are truly committed to patient advocacy, then we must consider ways to ensure that nurses receive support in fulfilling this role, even in its most extreme form-whistle-blowing. Recommendations These may not be the best of times. I doubt that they are the worst of times. What is certain is that they are our times (Neylan, 1989, p. 5). For our times we are encouraged to “avoid committing resources to initiatives that contribute to the status quo” and to use the stresses we experience in practice as springboards for constructive change (Neylan, 1990a, p. 24; 1990b). The following recommendations are offered with the wisdom of this advice in mind. 9
Patient Advocacy and Whistle-Blowing in Nursing: Help For the Helpers
Recommendation #1
Recommendation #4
Petition state and provincial nurses’ associations to introduce guidelines for the resolution of professional practice problems and an RN consultation service, modeled after the Registered Nurses‘ Association of British Columbia (RNABC) prototype.
Petition the International Council of Nurses, national, state, provincial, and district nurses‘ associations to lobby for legislation to protect nurse whistle-blowers who are acting within the scope of professional standards and ethics.
Every act of patient advocacy is a potential whistleblowing incident and nurses have not been prepared to address the latter. The RNABC has established guidelines for the resolution of professional practice problems and a consultation service that RNs may contact for advice.
The United States has passed legislation to protect whistle-blowers employed in government sectors (Government Accountability Project, 1977). Yet no such legislation exists to protect nurse whistle-blowers acting in agreement with standards or professional practice and the code of ethics for nursing. Recommendation #5
~
~~
~
Every act of patient advocacy is a potential whistle-blowing incident and nurses have not been prepared to address the latter. Recommendation #2
Establish local and regional mentor networks of former nurse whistle-blowers under the auspices of the professional association for the purpose of providing support, networking, and guidance to those engaged in whistle-blowing. The manifestations of moral distress and moral outrage, and the harassment and ostracism whistleblowers experience can have devastating effects on proactive nurses. Yet there is no formal support service in existence for the whistle-blower.
Petition the bargaining agent for nurses (either union or professional association) to negotiate a contract clause granting union officials the right to specih and monitor criteria for working conditions to alleviate the harassment and ostracism of whistle-blowers. Grosman (1989)cautions, ”It is all very well to pass legislation to protect whistle-blowers, but the whistleblower must survive in a hostile environment long after the deed is done” (pp. 35-36). Presently, there is no protection for the nurse who blows the whistle and chooses continued employment in the accused agency. Recommendation #6
Recommendation #3
Apply censure with public disclosure to healthcare agencies that fail to support professional nursing conduct or engage in the abuse of RNs in all levels of the hierarchy. Further, institute a process of commendation to alert nurses to supportive work environments; conduct these processes under the auspices of the professional nurses association.
Empower students in nursing-education programs by instructing them in all aspects of patient advocacy, including whistle-blowing. In addition, urge faculty to role model, rather than discuss, advocacy behaviors that are in agreement with the Code of Ethics for Nurse Educators (Rosenkoetter, 1983). Advise students about current sources of support for whistle-blowers as a matter of course.
Journals and newsletters provide public disclosure to employers of nurses who have received warnings, licensure suspensions, revocations, and reinstatements. Yet until recently no parallel mechanism has existed to warn nurses seeking employment of agencies that sanction RNs for behavior illustrating professional role enactment (e.g., patient advocacy). In April, 1989, the Ontario Nurses’ Association intro-
10
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duced censure against one Toronto hospital for the employer’s attempt to “deal(s) with its employees in an unfair manner” (BCNU, 1990, p.4). In addition, there is no mechanism to protect nurse administrators who are dismissed for supporting proactive behaviors among their nursing staff. Last, no forum exists to advise nurses of environments that support the professional role. The American Association of University Professors (AAUP) imposes censure on universities that impede professorial role enactment. Censure is publicly disclosed by journal and newsletter, monitored, and removed only by the AAUP. Universities are eager to obtain AAUP reinstatement and do so by improving the treatment of their faculty, because the disclosure of censure limits their ability to attract desirable faculty. Recommendation #7
Integrate research efforts to clarih the incidence, patterns, and effects of whistle-blowing among nurses. In addition, encourage research initiatives to include path analysis and time series designs to explore the phenomenon and effects of whistle-blowing over time. Wilkinson‘s (1987/88) research confirmed that moral distress occurred at a frequency of not less than once weekly for RNs. Aside from this report, there are no statistics on the incidence of moral distress and moral outrage among nurses. There are no figures on the frequency of whistle-blowing, nor have we many data on the patterns or effects of such proactjvity. Grosman (1989) points out that “A trust betrayed is not easily resuscitated” (p. xiii). In other fields, betrayed trust and continued harassment post-whistle-blowing have driven public advocates out of their chosen professions into marginal jobs (Ewing, 1978). Do nurses who have engaged in whistle-blowing remain in the profession, or have we driven them out to preserve a status quo of submarginal performance? Recommendation #8
Target research efforts to examine the phenomena of Nursing Forum
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learned helplessness, instrumental passivity, and their efects on proactive nursing behaviors such as patient advocacy. In Hutchinson’s (1990) study of responsible subversion (rule bending), the findings confirmed a decrease in patient advocacy behaviors in RNs who had been punished for bending bureaucratic rules to protect patients. Wilkinson (1987/88) and Andersen (in press) cite futility in past actions as contributing to moral distress and a decline in patient advocacy. According to the theories of learned helplessness and instrumental passivity, helplessness and passivity replace assertiveness and control-taking behaviors when the environment reinforces the latter and ignores or punishes proactive behaviors (Baltes, 1982; Baltes & Skinner, 1983; Braden, 1990; Raps, Peterson, Jonas, & Seligman, 1982; Seligman, 1975).What we do not know is the extent to which sanctions for proactive behaviors contribute to learned helplessness, instrumental passivity, failure to fulfill the patient advocate role, or support the proactive behaviors of one’s peers. Simply reversing the roles of the oppressor and the oppressed will not achieve a healthy outcome. Recommendations such as censure are offered not with retribution in mind, but rather as a means of initiating improvements for entrenched systems. Conclusions It is the hardest thing in the world to maintain an individual dissident opinion, as a member of a group. . . (Those who are able to d o so) are few. Very few. On them depends the health, the vitality of all our institutions (Lessing, 1986, p. 50,54). We need to be sensitized to the fact that whistleblowers in nursing are not enemies of the people. They are our patient advocates; the watchdogs of our practice and the guardians of professional excellence. Our task is to ensure that these men and women receive the support they need to fulfill the advocacy role. Our responsibility as professionals is to ensure that our colleagues never stand alone again. 11
Patient Advocacy and Whistle-Blowing in Nursing: Help For the Helpers
References Andersen, S. (1990).Nonconformity and personal harassment ofuniversity faculty. Unpublished manuscript. Andersen, S. (in press). Student preceptorships: Do they affect moral reasoning? Nurse Educator. Baltes, M. (1982). Environmental factors in dependency among nursing home residents: A social ecology analysis. In T Wills (Ed.), Basic processes in helping relationships (pp. 405-425). New York Academic Press. Baltes, M., & Skinner, E. (1983). Cognitive performance deficits and hospitalization: Learned helplessness, instrumental passivity, or what? Comment on Raps, Peterson, Jonas, and Seligman. Journal of Personality and Social Psychology, 45(10), 1013-1016. Bernstein, A., & Rozen, S. (1989). Dinosaur brains: Dealing with all those impossible people at work. New York: Wiley. Bok, S. (1989a). Secrets: On the ethics of concealment and revelation. New York: Vintage Books. Bok, S. (1989b). Lying: Moral choice in public and private life. New York: Vintage Books. Bok, S. (1980).Whistleblowing and professional responsibility New York University Education Quarterly, 11(4),2-10, Braden, C. (1990). Learned self-help response to chronic illness experience: A test of three alternative theories. Scholarly Inquiry for Nursing Practice: A n International Journal, 4(1), 23-41. British Columbia Nurses’ Union. (1990). Blacklisting still in effect at Toronto General Hospital. BCNU Reports, 9(3), p.4. Brown-Stewart, P. (1987). Thinly disguised contempt: A barrier to excellence.journal of Nursing Administration, 17(4),22-26. Chalk, R., & von Hippel, F. (1979). Due process for dissenting whistleblowers. Technology Review, 81,48-55. Court of Appeals of the State of California. (1983). 2d Appellate District, Division 2. Barber and Nejdl v. Sup. Ct., 2 Civil 69350, 69351, Ct. of App. 2d dist., Div. 2, Oct. 12, 1983; Barber v.
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Superior Court of California, 147 Cal. Appel. 3d, 10006, 195 Cal. Rptr. 484 (1983). Crisham, P. 91981). Measuring moral judgment in nursing dilemmas. Nursing Research, 30(2), 104-110. Ewing, D. (1978). The employee’s right to speak out: The management perspective. Civil Liberties Review, 5(3), 10-49. Fry, S. (1989). Whistle-blowing by nurses: A matter of ethics. Nursing Outlook, 37,56. Ghiselin, M. (1989). Intellectual compromise: The bottom line. New York: Paragon House. Government Accountability Project. (1977). A whistle-blower’s guide to the federal bureaucracy. Washington, DC: Institute for Policy Studies. Grosman, 8 . (1989). Corporate loyalty: A trust betrayed. Toronto, Penguin. Harris, M. (1981). Why nothing works: The anthropology of daily life. New York: Simon & Schuster. Hirschman, A. (1970). Exit, voice, and loyalty. Cambridge, MA: Harvard University Press. Hutchinson, S. (1990). Responsible subversion: A study of rulebending among nurses. Scholarly lnquiryfor Nursing Practice: A n lnternational Journal, 4(1), 3-17. Ibsen, H. (1963). An enemy of the people. In M. Meyer (Trans.), Ibsen’s plays: Two (pp. 107-223). London: Methuen. (Original work published 1882). Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall. Kanter, R. (1983). The change masters: Innovation and entrepreneurship in the American corporation. New York: Simon & Schuster. Kanter, R. (1972). Commitment and community: Communes and utopias in sociological perspective. Cambridge, MA: Harvard University Press. Nursing Forum
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Kanter, R. (1968).Commitment and social organization: A study of commitment mechanisms in utopian communities. American Sociological Review, 33,499-517.
Rosenkoetter, M. (1983). A code of ethics for nurse educators. Nursing Outlook, 31,288. Russell, B. (1958). The will to doubt. New York Phlosophical Library.
Kantrow, A. (1984). The constraints of corporate tradition: Doing the correct thing, not just what the past dictates. New York Harper & Row. Lessing, D. (1986). Prisons we choose to live inside. Toronto: CBC Enterprises. Maccoby, M. (1988). W h y work: Motivating and leading the new generation. New York: Simon & Schuster. Mann, D. (1977). Participation, representation, and control. In J. Scribner (Ed.), The Politics of Education (pp. 67-93). Chicago: University of Chicago Press. Moloney, M. (1986). Professionalization of nursing: Current issues and trends. Philadelphia: Lippincott. Murphy, J., & Hampton, J. (1988). Forgiveness and mercy. New York: Cambridge University Press. Nader, R., Petkas, R., & Blackwell, K. (1972). Whistle Blowing. New York Grossman.
Schaefer, W. (1990). Education without compromise: From chaos to coherence in higher education. San Francisco:Jossey-Bass. Schattschneider, E. (1960).The semisovereign people: A realist’s view of democracy in America. New York Holt, Rinehart & Winston. Seligman, M. (1975). Helplessness: On depression, development, and death. San Francisco: Freeman. Slater, P. (Ed.). (1990).The pursuit ofloneliness: American culture at the breaking point (3d ed.). Boston: Beacon. Superior Court of the State of California for the County of Los Angeles. (1983, May 3). People of the State v. Neil Barber and Robert Nejdl. Tentative decision. Theodore, A. (1986). The campus troublemakers: Academic women in protest. Houston: Cap &Gown. Whyte, W. (1957). The organization man. New York Simon & Schuster.
Neylan, M. (1990a). Nurses must bridge the waters between the present and future goals. RNABC News, 22(3), 23-24. Neylan, M. (1990b). President’s message: A new initiative for the 90s. RNABC Nezus, 22(1),5. Neylan, M. (1989). President’s message: Setting sail. R N A B C News, 21(5),5. Petersen, J., & Farrell, D. (1986). Whistleblowing: Ethical and legal issues in expressing dissent. Dubuque, IA: Kendall Hunt. Raps, C., Petersen, C., Jonas, M., & Seligman, M. (1982). Patient behavior in hospitals: Helplessness, reactance, or both? rournal of Personality and Social Psychology, 42, 1036-1041. Robbins, A. (1978). Dissent in the corporate world: When does an employee have the right to speak out? Civil Liberties Keoiew, 5(3),6-10.
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Wilkinson, J. (1987/88). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16-29.
Acknowledgment This paper is dedicated to the Ontario Nurses’ Association in gratitude for its courage in taking a stand to protect its members from unfair treatment by employers.
Notation Dr. Andersen invites nurse whistle-blowers interested in participating in research on this subject to contact her at Kwantlen College, PO Box 9030, Surrey, British Columbia, Canada V3T 5H8. 13
This article examines the phenomenon of whistle-
Sharon L. Andersen, RN, EdD, is Nursing Instructor, Kwantlen College, Surrey, British Columbia, Canada.
blowing and its antecedent dynamics, including invidious organizational tactics that are employed to silence patient advocates. Moral distress and moral outrage are identifed and described as manifestations of the stress that nurses experience when acts of patient advocacy are subverted. Recommendations are ofered to empower and protect present and future practitioners who may
I n education we encourage students to be patient advocates, to be proactive in promoting and defending the welfare of those entrusted to their care (Moloney, 1986). Students who graduate will apply what they have learned when attempting to remedy situations that involve patient abuse and neglect. Some are quite successful and, to their credit, cause improvements in the quality of patient care. Others discover that admirable intentions and the best problem-solving skills are ineffectual when they are confronting the unexpected-an administration invested in concealing, rather than rectifying, its deficiencies. In this case, whistle-blowing may be the only viable solution for those who are committed to patient advocacy. Whistle-Blowing
befaced with having to take on the role of whistlePast and Contemporary Whistle-Blowers
blower. Research initiatives are also suggested.
Nursing Forum
Volume 25, No. 3,1990
Whistle-blowing and the forces that lead to it are poignantly illustrated in literature and case studies. In Ibsen’s play, ”An Enemy of the People” (1882/ 1963), Thomas Stockmann outlined recommendations to decontaminate the town’s mineral baths, which had caused bathers to become ill. His findings were dismissed as a ”hallucination” and he was labelled an ”enemy of the people.” He was discharged from his position as the spa’s medical director, and his home was stoned by an angry mob of his former friends and colleagues. Karen Silkwood discovered health hazards at one of Kerr-McGee’s nuclear materials plants in an area where plutonium fuel rods were produced. Management tried to conceal the facts, and she was forced to go outside the plant to union and government officials for help. Ms. Silkwood met an untimely death in a car ”accident” en route to testify in defense of her allegations (Ewing, 1978). Sandra Bardenilla, nursing supervisor, was 5
r
Patient Advocac and Whistle-Blowing in Nursing: Help For the He pers
directed by a physician to render unethical and potentially illegal care to a comatose patient. She discussed her objections with the physician and was chastised. On appealing to the director of nursing she was advised to "be quiet and apologize to the physician" (Fry, 1989). Ms. Bardenilla chose not to engage in unethical and illegal nursing actions. The patient died. She resigned, and reported the physicians involved to the state and professional authorities. The doctors were charged with murder and acquitted later (Court of Appeals of the State of California, 1983; Superior Court of the State of C alifornia for the County of Los Angeles, 1983). Ms. Bardenilla, on the other hand, received no support from the profession and had difficulty finding employment as a result of her actions (Fry). These scenarios are not uncommon; in fact, they have occurred with remarkable frequency since the 1970s (Harris, 1981; Robbins, 1978).
negligence, abuses, or dangers that threaten
Whistle-Blowing Defined
the public welfare.
Whistle-blowers are people who apply their expertise or knowledge about the organization in which they work to expose negligence, abuses, or dangers that threaten the public welfare (Bok, 1980).Besides protecting the public, one may engage in whistle-blowing to expose personal victimization, as in cases of sexual or personal harassment, discrimination, and the unjustified denial of tenure or promotion (Theodore, 1986). Whistle-blowing is not ordinarily the first recourse in drawing attention to a problem; all sources for problem resolution should first be exhausted within the employing agency (Petersen & Farrell, 1986).When the administration is nonresponsive, engages in cover-up, or attempts to silence or discredit the employee, and when harm to others or self is imminent, the individual makes a public disclosure of the situation (Ghiselin, 1989)."Going public" includes disclosing the facts and dangers to groups such as the professional association, the union, and the media. Resolution of the problem from within the organization would be the most logical and appropriate response; unfortunately some employers ignore the 6
warnings of their employees. As Ewing (1978)explains,
. . . not only are they not to be heard, but also not to be seen. It is as if the voices of criticism-the whistle-blowers-were the Sirens of Greek mythology, and top executives were the sailors of Ulysses who, in order to pass by without being seduced, stopped one another's ears with wool (p. 11).
Whistle-blowers are people who apply their expertise or knowledge about the organization in which they work to expose
Elements of Whistle-Blowing Bok (1989a) contends that there are three elements that, when combined, account for the negative reactions toward the whistle-blower: dissent, breach of loyalty, and accusation. Dissent is a form of public disagreement; in whistle-blowing, however, dissent is narrower in scope. It includes challenging authority or majority opinion, alerting the public to a risk, and assigning responsibility for that risk (Bok). In other words, one is not merely stating disagreement with others on a subject or a position; one is pointing out dangers and detailing the inadequacies that led to the dangers. This is precisely what Dr. Stockmann, Ms. Silkwood, and Ms. Bardenilla did. Corrective action may entail considerable expense; it may disrupt the status quo and damage the reputation of an organization and its employees. A mature and morally responsible administration will, nevertheless, respond with an impartial and objective factNursing Forum
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finding inquiry. This type of agency invites problem identification and suggestions for improvement, for it recognizes that The true organizational loyalists . . . are not the people who pretend they do not see anything wrong, but rather those who shout the defects from every rooftop while trying to pull together a team to eliminate them (Kanter, 1983, p. 143). An organization lacking in the necessary qualities will respond defensively, exhibiting a posture of thinly disguised contempt toward the ethical employee (Brown-Stewart, 1987). It will invest its energies in a concerted effort to dismiss or cover up the problem and to silence the whistle-blower. The alarm sounded by whistle-blowers is regarded as a breach ufluyalty; like calling a foul on one’s own team (Bok, 1989). Administrators and colleagues perceive the whistle-blower’s actions as a form of betrayal of the agency, the profession, and friends. For the whistle-blower, loyalty to colleagues and the organization conflicts with loyalty to the public welfare. The conflict is strongest for those who take seriously their responsibilities to the public, yet also have close bonds of allegiance and commitment to the profession, to colleagues, and to the organization (Bok, 1989; Petersen & Farrell, 1986). The element of accusation arouses the strongest reaction from within the organization or profession. Here, the whistle-blower tries to identify who is/was responsible for the negligence or abuses that threaten public welfare (Bok, 1989a).The charge may be one of unethical or unlawful conduct by colleagues or superiors. This will arouse alarm, hostility, and a scrambling to cover u p inadequacies and protect professional reputations. The whistle-blower may find that the administration and colleagues attempt to discredit her as a way of attacking the credibility of her findings (Robbins, 1978). Isolation, persuasion, modified interrogation tactics, brainwashing, and harassment are techniques Nursing Forum
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that have been employed to control and silence dissident employees (Andersen, 1990; Bok, 1989b; Theodore, 1986). The whistle-blower faces being discharged and may even find future employment difficult as a result of blacklisting within the professional community (Schaefer, 1990; Theodore, 1986). These measures are shocking but not uncommon. Bureaucratic settings employ them quite often to achieve conformity and compliance (Grosman, 1989; Robbins, 1978). Thomas Stockmann lost his job and was harassed in his home, Sandra Bardenilla had difficulty finding employment, and Karen Silkwood lost her life trying to protect others. In view of the severe repercussions that a whistle-blower experiences, it is worth investigating what leads an individual to choose such action in the first place.
When a nurse encounters patient abuse or neglect she can select a course of action from three basic options: exit, voice, and loyalty.
Antecedents to Whistle-Blowing
The Emergence of Moral Distress When a nurse encounters patient abuse or neglect she can select a course of action from three basic options: exit, voice, and loyalty (Hirschman, 1970). She may leave the organization, confront the problem by speaking out about it, or remain silent, placing self-interest or loyalty to the organization above patient accountability. Patient advocates choose voice, thereby making a moral decision to take action. However, in nonresponsive or defensive organizations, institutional constraints are applied that obstruct the nurse’s ability to act on her decision (Crisham, 1981).These constraints may be either overt or covert, consisting, for example, of punishments, 7
Patient Advocac and Whistle-Blowing in Nursing: Help For the He pers
K
verbal threats, or the ”silent treatment” (Nader, Petkas, & Blackwell, 1972). Institutional constraints generate moral distress, which is a product of the dissonance that arises when one cannot carry out the desired actions to implement a moral decision (Jameton, 1984).The distress a proactive nurse experiences may be manifested in many ways: feelings of anger, depression, isolation, alienation, loss of self-worth, weeping, palpitations, headaches, diarrhea, guilt, sleep disturbances, and concerns of being a burden to support persons (Wilkinson, 1987/88). In order to protect the patient and subsequently relieve the moral distress, the nurse seeks assistance through the administrative hierarchy, progressing methodically through the channels of command from head nurse to chief executive officer. The belief that surely someone in administration will take action on the problem once its existence is known compels the advocate to continue up the hierarchy, fighting resistance at each level, in search of a responsive administrator (Whyte, 1957). As time passes and the problem remains unresolved, concerns for patient welfare as well as the discomfort of moral distress are heightened by a sense of urgency. Nevertheless, the nurse has hope and conviction that an administrator, at some level, will address the problem (Maccoby, 1988). Whistle-blowing is not yet entertained as a possible course of action; one still believes that ultimately the system will work properly. Advancing up the administrative ladder conveying concerns about patient care will successively expose the deficiencies and nonresponsiveness of employees throughout all echelons (Kanter, 1983). The result is additive: The higher one goes the greater the scope and number of those implicated, directly or indirectly, in the patient abuse or neglect. As a result, the advocate will encounter anger directed from personnel in several levels of the organization. She becomes socially ostracized and avoided even by those not implicated in the abuse or neglect. The closer one gets to the executive level of the hierarchy, the more it becomes apparent that administrators, managers, and staff are equally defensive and 8
dismissive in response to the advocate’s concerns. Kantrow (1984) articulates the circular reasoning used to legitimize dismissal of the advocate’s complaints: What exists in the present is the distilled product of long experience, examination, and challenge and is, therefore, probably the right way for things to be. If something were grossly wrong with those arrangements, they would never have survived intact as long as they have. The mere fact that they exist is compelling evidence that what exists is right (p. 74). This is what Bernstein and Rozen (1989) call “dinosaur brain thinking,” and it is represented in Kanter ’s (1968, 1972, 1983) concepts of organizational commitment and immortality. When this belief prevails in an agency, patient advocacy is interpreted as nonconforming or aberrant behavior that represents a threat to the status quo (Mann, 1977). The system then breaks down into adversarial factions of good guys (us) versus bad guys (anyone not like us), and the thrust of loyalists is then directed at driving the deviant from the system (Bernstein & Rozen, 1989; Russell, 1958).Slater (1990) calls this the operationalization of the ”Toilet Assumption-the notion that unwanted matter, unwanted difficulties, unwanted complexities and obstacles will disappear if they’re removed from our immediate field of vision” (p. 19).
The Emergence of Moral Outrage The perception of the advocate as a threat marks a critical turning point in the organizational dynamics and the behaviors of the advocate. Initially the advocate was regarded as a nonconformist, a dissident, or a troublemaker. Social controls such as institutional constraints were applied to pressure the advocate to be silent, to stop ”rocking the boat”, and to conform. Once the patient advocate is seen as a danger to the system, however, the organizational posture becomes Nursing Forum
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more aggressive and invidious in character. The continued denial of and nonresponsiveness to patient abuse and neglect is now compounded by attacks on the credibility, integrity, and emotional stability of the advocate (Bok, 1980). The nurse becomes the focus, and the patient care problem is interpreted by organizational loyalists as a product of the advo-
The perception of the advocate as a threat marks a critical turning point in the organizational dynamics and the behaviors of the advocate.
cate’s magnified or distorted perceptions. The harassment is reinforced in the collective by the administration’s denial or dismissal of the advocate’s requests for intervention on behalf of the patient (Grosman, 1989). Every aspect of the advocate’s performance is now scrutinized for flaws. She may be given more work than she can possibly complete, or may be debased with assignments consisting exclusively of menial tasks (Nader et al., 1972). The personal attacks on the advocate turn the moral distress she has experienced into moral outrage. Moral outrage is a product of the emotional turbulence, pain, incredulity, indignation, and rage that the advocate experiences. It occurs when a logical attempt to solve a moral problem results in denial of the problem and an assault on the nurse’s integrity by those who have sacrificed their integrity and the welfare of patients to preserve the status quo of submarginal performance. The psychobiological remnants of moral distress are then compounded by the experience of moral outrage. When moral outrage occurs, the advocate directs Nursing Forum
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her efforts toward a broader scope of activities. She seeks protection for the patient, verification of the accuracy of her perceptions as a defense against attacks on her credibility, and retribution for the moral injuries she has sustained (Murphy & Hampton, 1988). The hope of problem resolution is abandoned when the advocate discovers that even the chief executive officer is, at best, noncommittal in response to her concerns. As a result, whstle-blowing is then entertained as a viable solution (Schattschneider, 1960), one that will remedy the patient care problem, reaffirm the advocate’s credibility, and relieve the moral outrage. The dynamics that precede whistle-blowing are, in many respects, similar to those that follow disclosure. The primary difference is that the intensity of bureaucratic resistance is often greater when one makes a public disclosure of organizational inefficiency, corruption, or abuse. Moreover, the hardship for the proactive nurse may be even greater after disclosure for she may by now be unemployed. She may have minimal social support and no protection from the professional association (Chalk & von Hippel, 1979). If we are truly committed to patient advocacy, then we must consider ways to ensure that nurses receive support in fulfilling this role, even in its most extreme form-whistle-blowing. Recommendations These may not be the best of times. I doubt that they are the worst of times. What is certain is that they are our times (Neylan, 1989, p. 5). For our times we are encouraged to “avoid committing resources to initiatives that contribute to the status quo” and to use the stresses we experience in practice as springboards for constructive change (Neylan, 1990a, p. 24; 1990b). The following recommendations are offered with the wisdom of this advice in mind. 9
Patient Advocacy and Whistle-Blowing in Nursing: Help For the Helpers
Recommendation #1
Recommendation #4
Petition state and provincial nurses’ associations to introduce guidelines for the resolution of professional practice problems and an RN consultation service, modeled after the Registered Nurses‘ Association of British Columbia (RNABC) prototype.
Petition the International Council of Nurses, national, state, provincial, and district nurses‘ associations to lobby for legislation to protect nurse whistle-blowers who are acting within the scope of professional standards and ethics.
Every act of patient advocacy is a potential whistleblowing incident and nurses have not been prepared to address the latter. The RNABC has established guidelines for the resolution of professional practice problems and a consultation service that RNs may contact for advice.
The United States has passed legislation to protect whistle-blowers employed in government sectors (Government Accountability Project, 1977). Yet no such legislation exists to protect nurse whistle-blowers acting in agreement with standards or professional practice and the code of ethics for nursing. Recommendation #5
~
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Every act of patient advocacy is a potential whistle-blowing incident and nurses have not been prepared to address the latter. Recommendation #2
Establish local and regional mentor networks of former nurse whistle-blowers under the auspices of the professional association for the purpose of providing support, networking, and guidance to those engaged in whistle-blowing. The manifestations of moral distress and moral outrage, and the harassment and ostracism whistleblowers experience can have devastating effects on proactive nurses. Yet there is no formal support service in existence for the whistle-blower.
Petition the bargaining agent for nurses (either union or professional association) to negotiate a contract clause granting union officials the right to specih and monitor criteria for working conditions to alleviate the harassment and ostracism of whistle-blowers. Grosman (1989)cautions, ”It is all very well to pass legislation to protect whistle-blowers, but the whistleblower must survive in a hostile environment long after the deed is done” (pp. 35-36). Presently, there is no protection for the nurse who blows the whistle and chooses continued employment in the accused agency. Recommendation #6
Recommendation #3
Apply censure with public disclosure to healthcare agencies that fail to support professional nursing conduct or engage in the abuse of RNs in all levels of the hierarchy. Further, institute a process of commendation to alert nurses to supportive work environments; conduct these processes under the auspices of the professional nurses association.
Empower students in nursing-education programs by instructing them in all aspects of patient advocacy, including whistle-blowing. In addition, urge faculty to role model, rather than discuss, advocacy behaviors that are in agreement with the Code of Ethics for Nurse Educators (Rosenkoetter, 1983). Advise students about current sources of support for whistle-blowers as a matter of course.
Journals and newsletters provide public disclosure to employers of nurses who have received warnings, licensure suspensions, revocations, and reinstatements. Yet until recently no parallel mechanism has existed to warn nurses seeking employment of agencies that sanction RNs for behavior illustrating professional role enactment (e.g., patient advocacy). In April, 1989, the Ontario Nurses’ Association intro-
10
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duced censure against one Toronto hospital for the employer’s attempt to “deal(s) with its employees in an unfair manner” (BCNU, 1990, p.4). In addition, there is no mechanism to protect nurse administrators who are dismissed for supporting proactive behaviors among their nursing staff. Last, no forum exists to advise nurses of environments that support the professional role. The American Association of University Professors (AAUP) imposes censure on universities that impede professorial role enactment. Censure is publicly disclosed by journal and newsletter, monitored, and removed only by the AAUP. Universities are eager to obtain AAUP reinstatement and do so by improving the treatment of their faculty, because the disclosure of censure limits their ability to attract desirable faculty. Recommendation #7
Integrate research efforts to clarih the incidence, patterns, and effects of whistle-blowing among nurses. In addition, encourage research initiatives to include path analysis and time series designs to explore the phenomenon and effects of whistle-blowing over time. Wilkinson‘s (1987/88) research confirmed that moral distress occurred at a frequency of not less than once weekly for RNs. Aside from this report, there are no statistics on the incidence of moral distress and moral outrage among nurses. There are no figures on the frequency of whistle-blowing, nor have we many data on the patterns or effects of such proactjvity. Grosman (1989) points out that “A trust betrayed is not easily resuscitated” (p. xiii). In other fields, betrayed trust and continued harassment post-whistle-blowing have driven public advocates out of their chosen professions into marginal jobs (Ewing, 1978). Do nurses who have engaged in whistle-blowing remain in the profession, or have we driven them out to preserve a status quo of submarginal performance? Recommendation #8
Target research efforts to examine the phenomena of Nursing Forum
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learned helplessness, instrumental passivity, and their efects on proactive nursing behaviors such as patient advocacy. In Hutchinson’s (1990) study of responsible subversion (rule bending), the findings confirmed a decrease in patient advocacy behaviors in RNs who had been punished for bending bureaucratic rules to protect patients. Wilkinson (1987/88) and Andersen (in press) cite futility in past actions as contributing to moral distress and a decline in patient advocacy. According to the theories of learned helplessness and instrumental passivity, helplessness and passivity replace assertiveness and control-taking behaviors when the environment reinforces the latter and ignores or punishes proactive behaviors (Baltes, 1982; Baltes & Skinner, 1983; Braden, 1990; Raps, Peterson, Jonas, & Seligman, 1982; Seligman, 1975).What we do not know is the extent to which sanctions for proactive behaviors contribute to learned helplessness, instrumental passivity, failure to fulfill the patient advocate role, or support the proactive behaviors of one’s peers. Simply reversing the roles of the oppressor and the oppressed will not achieve a healthy outcome. Recommendations such as censure are offered not with retribution in mind, but rather as a means of initiating improvements for entrenched systems. Conclusions It is the hardest thing in the world to maintain an individual dissident opinion, as a member of a group. . . (Those who are able to d o so) are few. Very few. On them depends the health, the vitality of all our institutions (Lessing, 1986, p. 50,54). We need to be sensitized to the fact that whistleblowers in nursing are not enemies of the people. They are our patient advocates; the watchdogs of our practice and the guardians of professional excellence. Our task is to ensure that these men and women receive the support they need to fulfill the advocacy role. Our responsibility as professionals is to ensure that our colleagues never stand alone again. 11
Patient Advocacy and Whistle-Blowing in Nursing: Help For the Helpers
References Andersen, S. (1990).Nonconformity and personal harassment ofuniversity faculty. Unpublished manuscript. Andersen, S. (in press). Student preceptorships: Do they affect moral reasoning? Nurse Educator. Baltes, M. (1982). Environmental factors in dependency among nursing home residents: A social ecology analysis. In T Wills (Ed.), Basic processes in helping relationships (pp. 405-425). New York Academic Press. Baltes, M., & Skinner, E. (1983). Cognitive performance deficits and hospitalization: Learned helplessness, instrumental passivity, or what? Comment on Raps, Peterson, Jonas, and Seligman. Journal of Personality and Social Psychology, 45(10), 1013-1016. Bernstein, A., & Rozen, S. (1989). Dinosaur brains: Dealing with all those impossible people at work. New York: Wiley. Bok, S. (1989a). Secrets: On the ethics of concealment and revelation. New York: Vintage Books. Bok, S. (1989b). Lying: Moral choice in public and private life. New York: Vintage Books. Bok, S. (1980).Whistleblowing and professional responsibility New York University Education Quarterly, 11(4),2-10, Braden, C. (1990). Learned self-help response to chronic illness experience: A test of three alternative theories. Scholarly Inquiry for Nursing Practice: A n International Journal, 4(1), 23-41. British Columbia Nurses’ Union. (1990). Blacklisting still in effect at Toronto General Hospital. BCNU Reports, 9(3), p.4. Brown-Stewart, P. (1987). Thinly disguised contempt: A barrier to excellence.journal of Nursing Administration, 17(4),22-26. Chalk, R., & von Hippel, F. (1979). Due process for dissenting whistleblowers. Technology Review, 81,48-55. Court of Appeals of the State of California. (1983). 2d Appellate District, Division 2. Barber and Nejdl v. Sup. Ct., 2 Civil 69350, 69351, Ct. of App. 2d dist., Div. 2, Oct. 12, 1983; Barber v.
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Superior Court of California, 147 Cal. Appel. 3d, 10006, 195 Cal. Rptr. 484 (1983). Crisham, P. 91981). Measuring moral judgment in nursing dilemmas. Nursing Research, 30(2), 104-110. Ewing, D. (1978). The employee’s right to speak out: The management perspective. Civil Liberties Review, 5(3), 10-49. Fry, S. (1989). Whistle-blowing by nurses: A matter of ethics. Nursing Outlook, 37,56. Ghiselin, M. (1989). Intellectual compromise: The bottom line. New York: Paragon House. Government Accountability Project. (1977). A whistle-blower’s guide to the federal bureaucracy. Washington, DC: Institute for Policy Studies. Grosman, 8 . (1989). Corporate loyalty: A trust betrayed. Toronto, Penguin. Harris, M. (1981). Why nothing works: The anthropology of daily life. New York: Simon & Schuster. Hirschman, A. (1970). Exit, voice, and loyalty. Cambridge, MA: Harvard University Press. Hutchinson, S. (1990). Responsible subversion: A study of rulebending among nurses. Scholarly lnquiryfor Nursing Practice: A n lnternational Journal, 4(1), 3-17. Ibsen, H. (1963). An enemy of the people. In M. Meyer (Trans.), Ibsen’s plays: Two (pp. 107-223). London: Methuen. (Original work published 1882). Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall. Kanter, R. (1983). The change masters: Innovation and entrepreneurship in the American corporation. New York: Simon & Schuster. Kanter, R. (1972). Commitment and community: Communes and utopias in sociological perspective. Cambridge, MA: Harvard University Press. Nursing Forum
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Kanter, R. (1968).Commitment and social organization: A study of commitment mechanisms in utopian communities. American Sociological Review, 33,499-517.
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Kantrow, A. (1984). The constraints of corporate tradition: Doing the correct thing, not just what the past dictates. New York Harper & Row. Lessing, D. (1986). Prisons we choose to live inside. Toronto: CBC Enterprises. Maccoby, M. (1988). W h y work: Motivating and leading the new generation. New York: Simon & Schuster. Mann, D. (1977). Participation, representation, and control. In J. Scribner (Ed.), The Politics of Education (pp. 67-93). Chicago: University of Chicago Press. Moloney, M. (1986). Professionalization of nursing: Current issues and trends. Philadelphia: Lippincott. Murphy, J., & Hampton, J. (1988). Forgiveness and mercy. New York: Cambridge University Press. Nader, R., Petkas, R., & Blackwell, K. (1972). Whistle Blowing. New York Grossman.
Schaefer, W. (1990). Education without compromise: From chaos to coherence in higher education. San Francisco:Jossey-Bass. Schattschneider, E. (1960).The semisovereign people: A realist’s view of democracy in America. New York Holt, Rinehart & Winston. Seligman, M. (1975). Helplessness: On depression, development, and death. San Francisco: Freeman. Slater, P. (Ed.). (1990).The pursuit ofloneliness: American culture at the breaking point (3d ed.). Boston: Beacon. Superior Court of the State of California for the County of Los Angeles. (1983, May 3). People of the State v. Neil Barber and Robert Nejdl. Tentative decision. Theodore, A. (1986). The campus troublemakers: Academic women in protest. Houston: Cap &Gown. Whyte, W. (1957). The organization man. New York Simon & Schuster.
Neylan, M. (1990a). Nurses must bridge the waters between the present and future goals. RNABC News, 22(3), 23-24. Neylan, M. (1990b). President’s message: A new initiative for the 90s. RNABC Nezus, 22(1),5. Neylan, M. (1989). President’s message: Setting sail. R N A B C News, 21(5),5. Petersen, J., & Farrell, D. (1986). Whistleblowing: Ethical and legal issues in expressing dissent. Dubuque, IA: Kendall Hunt. Raps, C., Petersen, C., Jonas, M., & Seligman, M. (1982). Patient behavior in hospitals: Helplessness, reactance, or both? rournal of Personality and Social Psychology, 42, 1036-1041. Robbins, A. (1978). Dissent in the corporate world: When does an employee have the right to speak out? Civil Liberties Keoiew, 5(3),6-10.
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Wilkinson, J. (1987/88). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16-29.
Acknowledgment This paper is dedicated to the Ontario Nurses’ Association in gratitude for its courage in taking a stand to protect its members from unfair treatment by employers.
Notation Dr. Andersen invites nurse whistle-blowers interested in participating in research on this subject to contact her at Kwantlen College, PO Box 9030, Surrey, British Columbia, Canada V3T 5H8. 13
