SEARCH

SEARCH BY CITATION

Keywords:

  • narrative enquiry;
  • nurses;
  • patient advocacy;
  • whistle blower;
  • whistleblowing

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

jackson d., peters k., andrew s., edenborough m., halcomb e., luck l., salamonson y. & wilkes l. (2010) Understanding whistleblowing: qualitative insights from nurse whistleblowers. Journal of Advanced Nursing66(10), 2194–2201.

Abstract

Aim.  This paper is a report of a study conducted to explore the reasons behind the decision to blow the whistle and provide insights into nurses’ experiences of being whistleblowers.

Background.  Whistleblowing is a stigmatized and hidden activity that carries considerable ramifications to all concerned. In the health sector, when episodes of poor practice or service provision are identified, it is frequently nurses who are the whistleblowers. Despite this, there is remarkably limited literature that explores nurses’ experiences of whistleblowing.

Methods.  Qualitative narrative inquiry design. Data were collected in 2008 from 11 nurse whistleblowers using in-depth semi-structured interviews.

Findings.  Participants were drawn from a range of general and specialty clinical areas and experienced whistleblowing as highly stressful. The findings were clustered into three main themes, namely: (i) Reasons for whistleblowing: I just couldn’t advocate, (ii) Feeling silenced: Nobody speaks out, and (iii) Climate of fear: You are just not safe.

Conclusion.  The whistleblowing nurses believed they were acting in accordance with a duty of care. There is a need for greater clarity about the role nurses have as patient advocates. Furthermore, there is need to develop clear guidelines that create opportunities for nurses to voice concerns and to ensure that healthcare systems respond in a timely and appropriate manner, and a need to foster a safe environment in which to raise issues of concern.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References
  •  Nurses believe that patient advocacy is part of their role and therefore are frequent whistleblowers in the healthcare sector.
  •  Whistleblowing is a stigmatized activity that carries considerable ramifications to individuals and organizations.
  •  The professional and personal effects of being a whistleblower are documented to a limited extent in the literature.

What this paper adds

  •  Nurses ‘blow the whistle’ as a last resort in order to advocate for patients and promote patient safety.
  •  Some health organizations promote a culture of silence when dealing with complaints about patient safety.
  •  Insights into the lived experiences of whistleblowing in the healthcare sector from the perspectives of whistleblowers themselves.

Implications for practice and/or policy

  •  Organizational change is essential to ensure that complaints made by staff are dealt with in an appropriate and timely manner.
  •  Greater support for nurses and healthcare professionals is necessary at all levels for those involved in whistleblowing incidences to augment personal safety and job security.
  •  Opportunities need to be created for nurses and healthcare professionals to voice concerns as a team related to issues of patient safety or organizational wrongdoing.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Although whistleblowing is addressed in the international nursing literature, much of the published material is discussion papers (Firtko & Jackson 2005, Johnstone & Kanitsaki 2006), with relatively few empirical research studies conducted (Vinten & Gavin 2005), particularly in the last 10 years. The predominant method applied in empirical studies has been structured (quantitative) surveys (McDonald & Ahern 2000, Burrows 2001, King 2001, Ahern & McDonald 2002, McDonald & Ahern 2002, Firth-Cozens et al. 2003), although some have included open-ended questions (Burrows 2001, Firth-Cozens et al. 2003). However, rather than drawing on participants’ lived experiences, many of these studies have tended to use hypothetical scenarios or items where the participants are asked to indicate what they, as nurses, think they would do if confronted with an unethical situation (King 2001) or if they had concerns about practice standards (Burrows 2001, Beckstead 2005, Attree 2007). A limited number of studies have used qualitative methodology (Orbe & King 2000, Kingston et al. 2004, Attree 2007, Ohnishi et al. 2008) and very few papers published in the last 10 years have used face-to-face data collection methods (Kingston et al. 2004, Attree 2007, Ohnishi et al. 2008). There is no widely accepted theoretical framework for whistleblowing in the healthcare sector although researchers have proposed virtue-ethics as a foundation (Faunce 2004, 2007, Bolsin et al. 2005).

This paper is based on a larger study in which we sought to describe the experiences of whistleblowing from the perspectives of whistleblowers, bystanders to whistleblowing events and subjects of whistleblowing complaints. In this current paper, we present findings on the reasons the nurses decided to become whistleblowers, and insights into nurses’ experiences of being whistleblowers.

Background

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Patient advocacy is a crucial element identified in the literature influencing why nurses blow the whistle (Davis & Konishi 2007). In some cases, nurses believe that their duties as advocate leave them with little option but to blow the whistle on perceived deviant organizations or individuals, in order to protect patients, and improve quality of care (Ahern & McDonald 2002). A major United kingdom (UK) whistleblowing survey found that 445 (86·7%) of nurses indicated that they had occasion to have raised concerns about a serious patient safety risk in their workplace (Public Concern at Work 2008). Internationally, in recent years there have been several high profile cases reported in the media that have involved nurse whistleblowers (Faunce et al. 2004, Johnstone 2004, 2009, Tammelleo 2006). Central to these cases has been the concern for patient safety (Faunce et al. 2004, Johnstone 2004, 2009, Tammelleo 2006).

Attree (2007) conducted a grounded theory study of the factors that influenced 142 nurses’ decisions to raise their concerns about standards of practice in three Acute NHS Trusts in England. The possibility of retribution, repercussion, labelling and prediction of no action to address the situation, were presented as reasons for not raising concerns. Similarly in an Australian study, Kingston et al. (2004) found that the disincentives for reporting were perceptions of potential risks, lack of value in the process, and cultural norms. Nurses were found to be much more likely to report wrongdoing involving a patient than doctors (Kingston et al. 2004) which is in accordance with previous findings (Firth-Cozens et al. 2003). Orbe and King (2000) included two critical incident scenarios with their quantitative survey of US nurses in the Midwest. Using a phenomenological methodology to analyse the data they identified five themes; perceptions of wrongdoing; upholding the ideal of the profession; clarity and evidence of wrongdoing; consequences of reporting and workplace dynamics.

The impact of being a whistleblower can be divided into professional effects; physical and emotional effects, and effects on the whistleblower’s personal life. The professional effects include loss of reputation, reprisals, and loss of job security (McDonald & Ahern 2000, Kingston et al. 2004, Attree 2007, Ohnishi et al. 2008). While there may be positive outcomes for blowing the whistle, McDonald and Ahern (2000) found that they were overshadowed by the negative outcomes which could include being referred to a psychiatrist or demoted, suspended or transferred from their usual place of work. Being a whistleblower may impact on personal life and cause physical and emotional symptoms (McDonald & Ahern 2002, Firth-Cozens et al. 2003, Kingston et al. 2004, Calcraft 2005).

In recognition of the vulnerability of whistleblowers, there have been major developments in legislation aimed at protecting whistleblowers over the last 15 years in Australia (Department of Parliamentary Services 2005), UK (Vinten & Gavin 2005) and United States of America (Faunce 2007). Among the protective strategies are the establishment of authorities designed to investigate whistleblower complaints, requirements for whistleblowers to indicate that information is disclosed in good faith, and the protection of anonymity and protection against retaliation and reprisal. However, it is not known whether these protective measures have altered the experience of nurse whistleblowers. Furthermore, the contextual issues surrounding nurse whistleblowing are not fully understood.

The study

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Aim

This paper is a report of a study conducted to explore the reasons behind the decision to blow the whistle and insights into nurses’ experiences of being whistleblowers.

Design

The study had a qualitative narrative inquiry design. The autobiographical stories were detailed descriptions of the participants’ experiences of whistleblowing. Consistent with narrative inquiry, temporality, meaning and the social aspects of whistleblowing were explored during the interviews (Elliot 2005, Carter 2008).

Participants

The study was advertised in a professional magazine circulated by a large industrial nursing organization. Information sheets providing additional details about the study and consent forms were mailed to the potential participants following contact from them. Inclusion criteria required that participants be Registered or Enrolled Nurses with direct experience of being a whistleblower. Recruitment continued until data saturation was achieved, and following procedures of informed consent, 11 people meeting the inclusion criteria were recruited into the study from several Australian states.

Data collection

Data were collected in 2008 via semi-structured interviews, which were conducted either by telephone or face-to-face in a mutually agreed setting. In order to ensure consistency in the data collection process, a decision was taken that all the data should be collected by a single interviewer, and so an experienced, skilled narrative researcher from the team conducted all interviews. Following collection of demographic data, participants were initially asked a trigger question; tell me about your experience with whistleblowing, to elicit their stories. Probing and clarifying questions were used as necessary during the encounter. Interviews were digitally recorded and transcribed verbatim.

Data analysis

Data were analysed to reveal the human experience of whistleblowing, reflected in language, and reconstituted in the social world (Holloway & Freshwater 2007a). A code based analysis of the narratives was undertaken, focusing on the narrative content to reveal common themes (Lee & Fielding 2004). Categorical content analysis was undertaken on the raw data (Williams & Keady 2008). The verbatim transcripts were de-indentified by the interviewing researcher. The de-identified manuscripts were then read and re-read by two members of the research team. The data were reorganized according to content and patterns, and recurrent information were coded into sections. Codes were reduced and the data was reconceptualized into themes. Thus, social conventions surrounding whistleblowing, contextualized to the social world of nursing, were revealed (Chase 2005, Holloway & Freshwater 2007a).

Ethical considerations

Ethical approval was granted by the relevant Human Research Ethics Committee. Given the sensitivity and stigmatization surrounding whistleblowing, confidentiality and justice were crucial ethical principles (Holloway & Freshwater 2007b). Following Carter’s (2008) advice, during all phases of this study, we embodied the ethical principle of justice by sensitively and morally re-constructing the participants’ stories, avoiding sensationalism, and ensuring all findings were de-identified. Following receipt of the participant information, and subsequent contact with the interviewer, the participants returned a written, voluntary consent form. Interviews were conducted outside workplace environments in a setting that ensured confidentiality. We also provided the contact details of an independent counselling service for the participants for any additional emotional support they may have required, thus acknowledging the participants’ vulnerability. The team also provided emotional support to the interviewing researcher through regular informal debriefing.

Rigor

The interviews were undertaken by a skilled narrative researcher and initial data analysis was undertaken independently by the interviewing researcher and the principal researcher. Findings were then discussed until agreement on the themes was mutual. These strategies support the dependability and credibility of the study (Holloway & Freshwater 2007a). Throughout the study, an audit trail of the processes and research reflections was documented adding to the confirmability of the study (Polit & Beck 2008). Authenticity and confirmability is further enacted by supporting findings with verbatim excerpts from the narratives of participants.

Findings

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

All participants were women, and worked in a range of general and speciality areas in nursing such as medical/surgical, aged care, operating theatre, mental health, coronary care, midwifery, emergency, intensive care and in the community. They were employed as enrolled nurses, registered nurses, and clinical nurse specialists and had between 2 and 40 years of nursing experience. Participants had varying levels of qualifications, with the highest level attained being a Masters degree.

Findings have been clustered into three main themes, namely: (i) Reasons for whistleblowing: I just couldn’t advocate, (ii) Feeling silenced: Nobody speaks out, and (iii) Climate of fear: You are just not safe.

Reasons for whistleblowing: I just couldn’t advocate

At the time they blew the whistle, the whistleblowers believed that they were taking steps to promote patient safety, and act as best they could to ensure optimal clinical practice and patient management. Their narratives frequently revealed a tension in their perception of themselves as patient advocates – advocacy being a valued and widely accepted role of nurses, and whistleblowers – a role that is stigmatized and looked upon negatively:

People think it’s a bad thing to be a whistleblower. But all it is, ultimately when you’re a whistleblower you’re standing up for a patient’s rights. You’re being patient advocate which is 90% of a nurse’s job. Why is it such a bad thing or seen as such a bad innuendo to be a whistleblower?

One participant felt very strongly against a particular practice that was in place in her employing hospital, and experienced a sense of failure as she felt unable to effectively advocate for her patients. This participant’s efforts ultimately resulted in her becoming caught up in a very high profile case, involving police investigations and major media coverage. She was not happy that she gained the level of notoriety that she did, but felt that she could not ignore the practice issues confronting her. Despite raising her concerns in a number of ways with numerous senior staff in the workplace, and professional bodies, she was unable to effect change until the media became involved:

There was just nothing I could do. I really prided myself in being able to be a good patient advocate, and I think that’s what a nurse should be; they need to be a good patient advocate, but I just couldn’t advocate and haven’t been able to advocate for anybody, not due to any fault of mine because I tried.

Participants described becoming whistleblowers because they had been unable to gain support for their concerns any other way. One participant had major concerns over one of her colleague’s fitness to practise. She was aware that there had been a long history of concern about the practice of this individual, and was frustrated because she knew that, despite concerns having been raised previously, little progress had been made in resolving these issues. This participant felt that her advocacy role required her to act, in order to protect patients from the risk of harm:

I knew that the NUM [nurse unit manager] was aware, the educator was aware of it, the Director of Nursing was aware of it, that previous wards have documented many times, and it just didn’t seem to be getting anywhere…So yeah, it started to take a toll on me. I’d wake up at night and worry …I thought, well it can’t continue really. We’re an advocate for the patient.

Feeling silenced: nobody speaks out

Participants felt that the systems and organizations which they worked within conspired to create and enforce a culture of silence. They revealed a perception that when individuals had concerns it was not easy for them to speak up:

Nobody speaks out, because they’ve seen that you can lose your job. Everybody’s insecure. It’s a terrible way to be employed, because nobody – there’s this culture of fear, so just everybody’s silent. Nobody says anything, because they’ve seen what can happen.

Reflecting on a situation involving an inappropriate sexual relationship between a doctor and patient, one participant despaired of the organizational culture that silenced the very people who should have been able to better protect the patient. This participant ultimately blew the whistle on the situation, and became marginalized by colleagues who felt that she should have not got involved. Her colleagues positioned the perpetrator as the victim of an interfering complainant. Reflecting on her experience as a whistleblower, this participant felt that the dangers and stressors involved in speaking out meant that she would be unlikely to do so again:

I keep my mouth shut these days. I’m a different person now. I don’t know. In hindsight I wouldn’t have said anything … I wouldn’t have because it caused so much stress and it wasn’t worth it really, like emotionally. It was really tough going to work for so long… you’re just, you know, dreading going to work.

Participants reported their working lives becoming unbearable following the whistleblowing episode. An interviewee felt that her previous experience as a whistleblower had effectively silenced her:

I’ll just never speak out again. I’ll never speak up, because I can’t afford not to work. I can’t and it’s a terrible situation to be in.

Climate of fear: you are just not safe

Many participants talked about the climate of fear that permeates some organizational cultures. Fear was a factor in deciding whether or not to blow the whistle. An interviewee described discussing her concerns with colleagues before making the decision to become a whistleblower. A colleague’s husband was fearful of repercussions to her family and herself, and in response to his fear, the participants’ colleague instead chose to turn a blind eye to the poor practice issues:

She (colleague) had discussed it with her husband and her husband had said look, I don’t want you to do it. It would put our family at risk. You could be at risk. There was also possibly personality issues there with the person involved because he could be very short tempered. He could act irrationally sometimes and we just didn’t quite know if there was something mentally wrong with him or what might happen should he be provoked.

Having made the decision to become a whistleblower, she was initially fearful for her own wellbeing, as well of that of her children:

There was probably a month or two where I was very concerned for my welfare or my children’s welfare. I thought even if he hasn’t got the guts to come after me maybe he’ll go after my children. … There was a bit of concern there for a while.

One participant had experienced being both a whistleblower and the subject of a whistleblowing complaint. In speaking of her experiences as a whistleblower, she disclosed feeling unsafe in the work environment as a result of her whistleblowing activities:

I’m just so unsafe there, because I’m not the kind of person who can turn a blind eye when things are going wrong … You are just not safe. There is nothing you can do [to protect yourself].

One participant had become a whistleblower over an incident that had occurred between herself and a male colleague. This had resulted in the participant becoming fearful that she might become the target of violence from this man:

Males at work really are almost refusing to work with me because I’m a whistleblower… one said that I’m PD [personality disorder] attention seeking … It doesn’t bother me, the mudslinging that’s going on. It’s just whether he [subject of whistleblowing complaint] would get violent with me that does bother me.

For one participant the fear followed her home, and she disclosed feeling unsafe both at home and at work. Eventually, her fear and anxiety meant that she took extended sick leave, but even while at home she was on edge and frightened:

I was even afraid to be in my own house. I was constantly looking out the back window to see whether somebody was looking over the back fence. You know I was truly just afraid.

Another participant became a registered whistleblower, as defined by the government act in place in her area. Despite the legal protection this afforded her, she was frightened of the consequences to herself personally, legally and financially. She also feared being sued:

I officially became a whistleblower. And that was all in the papers… My name wasn’t mentioned, I was just too scared. I was terrified of the repercussions of any, anything, people might sue me … I became, officially became a whistleblower… but none of them [other colleagues] blew the whistle because they were so scared.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Study limitations

There are limitations that need to be considered in this study. We recruited participants by advertising in a professional magazine of a single industrial nursing organization, which potentially limits the transferability of findings to nurses who are not members of this industrial nursing organization. It can also be argued that volunteers in this study were more likely to be those who have yet to reach closure with regards to their whistleblowing experience. This presupposes there may be others for whom this experience was more ‘positive’, or who have resolved this issue in their lives and have moved forward. If this were the case, our study may have only captured the perspectives of one group of people still affected by their whistleblowing experience, a consequence of volunteer bias. Nevertheless, we have attempted to provide a balanced view. In addition, to ensure consistency in the data collection process, all interviews were conducted by a single member of the team, who was an experienced, skilled narrative researcher.

Effects of whistleblowing

Findings of this study support the literature that suggests whistleblowing has a powerful effect on all those involved, and suggests that despite recognition of the vulnerability of whistleblowers (Department of Parliamentary Services 2005, Vinten & Gavin 2005), and the initiation of supportive measures, whistleblowing remains a highly stressful phenomenon.

In theory, highlighting areas of poor practice should not cause stress, if due process is followed and if the healthcare sectors are genuinely dedicated to improving practice. However, in this study it was evident that there was a pressure to remain silent and to maintain the organizational status quo. In her study of factors influencing nurses to raise concerns about standards of practice, Attree (2007) concluded that in order to achieve an open culture of quality and safety in health care we need to address the current disincentives to reporting concerns about care quality. In addition, organizations should foster cultures which do not blame, but support and welcome open critique and discussion. This is also advocated by Berry (2004), who proposes that whistleblowing could be an opportunity to reflect on and improve the quality of care, rather than causing damage to individuals.

The evidence presented in this study suggests that the whistleblowing nurses believed they were acting in accordance with a duty of care. Similarly, Ahern and McDonald (2002) identified that participants in their study who blew the whistle held the belief that nurses have a primary duty to their patients and must protect them from unethical or incompetent practice. In contrast, those who did not blow the whistle articulated that they felt a shared duty to their patients, medical colleagues and their employer. The participants in this current study articulated the dilemma that they faced in terms of the conflict between their professional duty to expose poor quality care and the potential impact that blowing the whistle would have on their personal and professional life. Other studies have identified similar concerns (Firth-Cozens et al. 2003, Attree 2007).

Implications for practice

It is apparent in some of the findings presented that complaints made by staff to their line managers were not seen to be dealt with in an appropriate manner. Changes from these avoidant leadership styles are necessary in order to promote patient safety (Valentine 2001, Vivar 2006). A more responsive leadership style also has the potential to create an inclusive team environment that encourages nurses and healthcare professionals at all levels to work toward the common goals of patient advocacy and high standards of care (Cook 2001, Oulton 2006, Theofanidis & Dikatpanidou 2006).

Health organizations have a duty to ensure the well-being of their staff as well as their patients and are therefore obliged to provide greater support for staff involved in whistleblowing incidences. Ensuring job security and the personal safety of employees should be paramount for employers, and this in turn has the potential to encourage timely reporting of future concerns related to patient safety.

Opportunities need to be created for nurses and healthcare professionals to voice any concerns related to patient safety or organizational wrongdoing as a team. This would serve to prevent a single individual being blamed for highlighting poor practice/s, and avoid the ensuing harassment evidenced in the stories of participants in the current study. Working collaboratively in addressing such issues has the potential to produce earlier and more appropriate resolutions that are more readily accepted by the entire healthcare team (Henneman et al. 1995, Burns & Lloyd 2004). Furthermore, encouraging such discussions can serve to disengage healthcare professionals from an existing culture of silence, resulting in a more transparent and supportive working environment.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Our findings suggest that significant changes at both organizational and personal levels are still required if we are to support nurses who have concerns about patient safety. As individual healthcare professionals, it is important that we respond appropriately when concerns about patient safety are raised, and that we avoid the tendency to “shoot the messenger”. Organizations should ensure appropriate channels exist for investigating and responding to staff concerns about practice or safety issues. In this way, individuals working within organizations that foster a culture of silence would have a place to speak in relative safety. Nurses and other healthcare professionals would benefit by being able to collectively reflect on issues of concern, or where there are poor outcomes. Patient care or organizational issues could be raised and dealt with through group processes, thus avoiding the targeting of individuals. Such a strategy has the potential to empower nurses, by destabilizing oppressive organizational cultures that powerfully subjugate them and enlist their silence.

Author contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

DJ, KP, SA & YS were responsible for the study conception and design. KP & YS performed the data collection. DJ & KP performed the data analysis. DJ, KP, SA, ME, EH, LL, YS & LW were responsible for the drafting of the manuscript. DJ, KP, SA, ME, EH, LL, YS & LW made critical revisions to the paper for important intellectual content. DJ obtained funding. ME provided administrative, technical or material support.

References

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References
  • Ahern K. & McDonald S. (2002) The beliefs of nurses who were involved in a whistleblowing event. Journal of Advanced Nursing 38(3), 303309.
  • Attree M. (2007) Factors influencing nurses’ decisions to raise concerns about care quality. Journal of Nursing Management 15(4), 392402.
  • Beckstead J.W. (2005) Reporting peer wrongdoing in the healthcare profession: the role of incompetence and substance abuse information. International Journal of Nursing Studies 42(3), 325331.
  • Berry B. (2004) Organisational culture: a framework and strategies for facilitating employee whistleblowing. Employee Responsibilities and Rights Journal 16(1), 111.
  • Bolsin S., Faunce T. & Oakley J. (2005) Practical virtue ethics: healthcare whistleblowing and portable digital technology. Journal of Medical Ethics 31(10), 612618.
  • Burns T. & Lloyd H. (2004) Is a team approach based on staff meetings cost effective in the delivery of mental health care? Current Opinion in Psychiatry 17(4), 311314.
  • Burrows J. (2001) Telling tales and saving lives: whistleblowing – the role of professional colleagues in protecting patients from dangerous doctors. Medical Law Review 9(2), 110129.
  • Calcraft R. (2005) Blowing the whistle on abuse. Working with Older People 9(2), 1821.
  • Carter B. (2008) ‘Good’ and ‘bad’ stories: decisive moments, ‘shock’ and ‘awe’ and being moral. Journal of Clinical Nursing 17(8), 10631070.
  • Chase E. (2005) Narrative inquiry. In Handbook of Qualitative Research (DenzinN.K. & LincolnY.S., eds), Thousand Oaks, California, pp. 651679.
  • Cook M.J. (2001) The renaissance of clinical leadership. International Nursing Review 48, 3846.
  • Davis A.J. & Konishi E. (2007) Whistleblowing in Japan. Nursing Ethics 14(2), 194202.
  • Department of Parliamentary Services (2005) Whistleblowing in Australia – transparency, accountability....but above all, the truth, Vol. 31. Parliamentary Library, Canberra.
  • Elliot J. (2005) Using Narrative in Social Research. Sage Publications Ltd, London.
  • Faunce T. (2004) Developing and teaching the virtue ethics foundations of healthcare whistle blowing. Monash Bioethics Review 23(4), 4155.
  • Faunce T.A. (2007) Whistleblowing and scientific misconduct: renewing legal and virtue ethics foundations. Medicine and Law 26(3), 567584.
  • Faunce T., Bolsin S. & Chan W.P. (2004) Supporting whistleblowers in academic medicine: training and respecting the courage of professional conscience. Journal of Medical Ethics 30(1), 4043.
  • Firth-Cozens J., Firth R.A. & Booth S. (2003) Attitudes to and experiences of reporting poor care. Clinical Governance 8(4), 331336.
  • Firtko A. & Jackson D. (2005) Do the ends justify the means? Nursing and the dilemma of whistleblowing. Australian Journal of Advanced Nursing 23(1), 5156.
  • Henneman E., Lee J. & Cohen J. (1995) Collaboration: a concept analysis. Journal of Advanced Nursing 21, 103109.
  • Holloway I. & Freshwater D. (2007a) Vulnerable story telling: narrative research in nursing. Journal of Research in Nursing 12(6), 703711.
  • Holloway I. & Freshwater D. (2007b) Narrative Research in Nursing. Blackwell Publishing Ltd, Oxford.
  • Johnstone M.J. (2004) Patient safety, ethics and whistleblowing: a nursing response to the events at the Campbelltown and Camden Hospitals. Australian Health Review 28(1), 1319.
  • Johnstone M.J. (2009) Bioethics: A Nursing Perspective. Churchill Livingstone Elsevier, Chatswood, NSW.
  • Johnstone M.J. & Kanitsaki O. (2006) The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. International Journal of Nursing Studies 43(3), 367376.
  • King G. III (2001) Perceptions of intentional wrongdoing and peer reporting behavior among registered nurses. Journal of Business Ethics 34(1), 113.
  • Kingston M.J., Evans S.M., Smith B.J. & Berry J.G. (2004) Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Medical Journal of Australia 181(1), 3639.
  • Lee R.M. & Fielding N.G. (2004) Tools for qualitative data analysis. In Handbook of Data Analysis (HardyM. & BrymanA., eds), Sage Publications, London, pp. 529546.
  • McDonald S. & Ahern K. (2002) Physical and emotional effects of whistle blowing. Journal of Psychosocial Nursing & Mental Health Services 40(1), 1427.
  • McDonald S. & Ahern K. (2000) The professional consequences of whistleblowing by nurses. Journal of Professional Nursing 16(6), 313321.
  • Ohnishi K., Hayama Y., Asai A. & Kosugi S. (2008) The process of whistleblowing in a Japanese psychiatric hospital. Nursing Ethics 15(5), 631642.
  • Orbe M.P. & King G. (2000) Negotiating the tension between policy and reality: exploring nurses’ communication about organizational wrongdoing. Health Communication 12(1), 4161.
  • Oulton J. (2006) Nursing management today: an ICN viewpoint. International Hospital Federation Reference Book 2005/2006, 8183.
  • Polit D.F. & Beck C.T. (2008) Nursing Research: Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins, Philadelphia.
  • Public Concern at Work (2008) Public Concern at Work/Nursing Standard Whistleblowing Survey 2008. Retrieved from http://www.pcaw.co.uk/pressrelease_pdf/WBsurvey_summary.pdf on 7 April 2009.
  • Tammelleo A.D. (2006) NY: ‘whistle-blower’ nurse terminated: court fails to find retaliatory termination. Hospital Laws Regan Report 47(1), 3.
  • Theofanidis D. & Dikatpanidou S. (2006) Leadership in nursing. ICU’s and Nursing Web Journal 25, 18.
  • Valentine P. (2001) A gender perspective on conflict management strategies of nurses. Journal of Nursing Scholarship 33(1), 6974.
  • Vinten G. & Gavin T.A. (2005) Whistleblowing on health, welfare and safety: the UK experience. The Journal of the Royal Society for the Promotion of Health 125(1), 2329.
  • Vivar C. (2006) Putting conflict management into practice: a nursing case study. Journal of Nursing Management 14, 201206.
  • Williams S. & Keady J. (2008) Narrative research and analysis. In Nursing Research Designs and Methods (WatsonR., McKennaH., CowmanS. & KeadyJ., eds), Churchill Livingstone, Philadelphia, pp. 331340.