Introduction

"It [whistleblowing] is a position no one should be in... It has consumed my life for two years."(Barry Adams, RN, whistleblower, 11/3/98)

Given the move toward managed care, the increased competition amongst health care organizations, and the need to cut costs in order to remain competitive, one can anticipate that the conditions which give rise to typical instances of whistleblowing will continue to get worse. In this paper we begin with an account of a recent case of whistleblowing which occurred in a sub-acute care unit of a New England hospital. We then provide an analysis of the phenomenon of whistleblowing, including a discussion of its principal features, a discussion of its grounding in a clash of values, and an argument that, in the final analysis, instances of whistleblowing in health care organizations (HCOs) are indicative of a failure at the organizational level. Acknowledging that both professional organizations and accrediting agencies address standards for individual and organizational behavior, we inquire whether the American Nurses Association (ANA) Code for Nurses or the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards provide mechanisms to overcome the need for whistleblowing. We find that neither provides protective mechanisms in their current form, but argue that JCAHO, given its accrediting function, is in a unique position to require that HCOs both articulate their organizational values and address perceived lapses in ethical behavior which may adversely affect patient care or professional conduct. In support of our argument we address issues relating to organizational ethics and, finally, we provide recommendations which we believe will reduce the need to resort to whistleblowing behavior in the defense of patient welfare and professional conduct.

Case Study

In 1996, Barry Adams, a registered nurse (RN) working on a sub-acute care unit in a New England hospital, blew the whistle on unsafe health care practices that he observed in his work setting. Adams became increasingly concerned about the quality, safety, and dignity of patient care as the hospital implemented staffing cuts and cost containment measures. He carefully documented unsafe practices and correlated these with inadequate staffing and a lack of adequate supervision of inexperienced nurses. There was an increased incidence of patient falls, instances where patients were left to lie in their own urine and feces, treatments not being completed, and serious medication errors. These incidents resulted from a substantial increase in the nurses' patient assignments.

For three months, Adams and other nurses followed precisely the process outlined by the organization to communicate concerns to hospital administrators. He soon realized that the administrators were not interested in using the information he provided to correct the situation; in fact, he was harshly criticized for collecting this information. He then decided to proceed with a variation of the traditional saying: "If it's not documented, it's not done" and, instead, adopted the approach: "If it's not done, document it!" Also, at one point he refused to take narcotic orders from a technician working for a physician, citing that this was against the Nurse Practice Act.

Adams was threatened with the loss of his job and, in spite of previous performance reviews that were excellent, he was eventually fired. He sued and won his case (his attorney was an RN). The hospital appealed and lost again. Five units of the hospital have since closed "for financial reasons."

Whistleblowing and the Whistleblower

In an ethically responsible HCO, whistleblowing should not have to occur because there would be internal procedures to address staff concerns. We believe that whistleblowing is a moral action of last resort and that, under certain circumstances, it is not only appropriate, but necessary. According to Dougherty (1995), whistleblowing "refers to a warning issued by a member or former member of an organization to the public about a serious wrongdoing or danger created or concealed within the organization" (p. 2552). We would add to this definition that a genuine case of whistleblowing requires the whistleblower to have utilized, unsuccessfully, all appropriate channels within the organization to right a wrong. Some would disagree with our account. Nielsen (1997), for example, identified 12 ways that an individual could blow or threaten to blow the whistle, and he uses the term "whistleblowing" regardless of whether the revelation occurred internal or external to the organization. Our definition is in keeping with a study conducted by Sellin (1995) on patient advocacy within organizations that distinguished whistleblowing from reporting. According to Sellin, participants tended to view whistleblowing as an external action to an unresponsive organization and reporting "more as an internal process, done through organizational channels" (p. 23). Such was the situation with Barry Adams. He had unsuccessfully exhausted all the internal channels of communication regarding unsafe patient care and dangerously low staffing levels before "going public."

When whistleblowing occurs in the way we have defined it, we believe it is a morally courageous action. When all is said and done, the whistleblower must blow the whistle for the right moral reason and reasoning.

When all is said and done, the whistleblower must blow the whistle for the right moral reason and reasoning.

It follows, therefore, that the whistleblower him or herself must be carefully scrutinized. What are the personal and the professional reputations of the whistleblower? What is the motive driving the whistleblower? Is it to benefit the client or the organization, or is it a need for attention or revenge? Is the whistleblower's cause seen as legitimate and significant by trustworthy colleagues and friends? Is the whistleblower aware of the potential consequences of blowing the whistle and still willing to accept responsibility for actions taken? In our case, Adams' personal and professional reputation were above reproach (21 persons attested to his high integrity during the suit over his termination), and he blew the whistle out of a concern for patient safety and staffing inadequacies. He was aware of the consequences of his actions and willing to assume responsibility for them.

As Adams discovered, blowing the whistle can be a life-altering experience '” either for better or for worse. The whistleblower who stops an unethical practice in his/her organization and gets rewarded for the behavior can feel a sense of deep accomplishment. However, the whistleblower who attempts to stop an unethical practice in her/his organization and gets punished for it may have to live through many harrowing experiences, including, as Barry Adams experienced, the loss of his job and difficult court proceedings.

Even if one does not lose one's position, Hunt (1995a, pp. 155-158) describes other troubling experiences such as broken promises to do something about the unethical practice, isolation and humiliation, formation of an "anti-you" group, organizational stonewalling, questioning of one's mental health, unusually close observations of what one does and says, vindictive tactics to make one's work more difficult or insignificant, talk about so-called generous severance packages, assassination of one's character, disciplinary hearings before one has had a chance to address one's concerns, and possible suspension. Adams experienced virtually all of the preceding tactics. Not noted by Hunt, but most tragic of all, are those persons who commit suicide because they tried to do what was morally right but could not survive the harassment and threats to their selves. The preceding tactics and situations are the result of an organization that has profoundly lost its moral compass and has been ethically tainted to its core. We shall return later to the concept of whistleblowing as a failure of organizational ethics.

Whistleblowing and Clashes of Values

What makes whistleblowing so difficult for all persons involved? Chiefly, it is the clash of values inherent in most cases of whistleblowing. This clash of values may take many forms, for example, loyalty to clients or to one's own integrity versus loyalty to the organization. But what is meant by personal integrity and by loyalty? By personal integrity is meant that one is consistently true to one's moral ideals and value system and is able to demonstrate this consistency in how one lives her/his daily life. By loyalty is meant that one is steadfast in allegiance to others and does not desert or betray others in their time of need. Loyalty also suggests other virtues such as mutual respect, promise keeping, and ability to keep confidences. In addition, one must remember that at times loyalty can be blind or misplaced and, thus, ceases to be a virtue because harm, rather than good, can come from it (Silva & Synder, 1992). In Adams' case, he placed loyalty to safe patient care and his role as patient advocate over the profit motive of the hospital.

Moral Justification for Whistleblowing

Whistleblowing should not be a capricious matter; a person's or an organization's life or death may result from it. Thus, strong moral justification must exist for blowing the whistle and, ideally, the whistleblower should have an established reputation for high integrity lest his or her personal characteristics detract from the issues . The following are considered some necessary conditions that should be established before one undertakes blowing the whistle and Adams met all of them:

1. The reason the whistleblower is blowing the whistle is because he/she sees a grave injustice or wrongdoing occurring in his/her organization that has not been resolved despite using all appropriate channels within the organization;
2. The whistleblower morally justifies his/her course of action by appeals to ethical theories, principles, or other components of ethics, as well as relevant facts;
3. The whistleblower thoroughly investigates the situation and is confident that the facts are as she/he understands them;
4. The whistleblower understands that her/his primary loyalty is to client(s) unless other compelling moral reasons override this loyalty;
5. The whistleblower ascertains that blowing the whistle most likely will cause more good than harm to client(s); that is, clients will not be retaliated against because of the whistleblowing; and
6. The whistleblower understands the seriousness of his/her actions and is ready to assume responsibility for them.

Our underlying premise is that when whistleblowing occurs there is an institutional failure. We agree with Hunt (1995b) that whistleblowing represents a "multi-layered breakdown in accountability" (p. xvii). Since the common welfare of citizens, particularly in matters of health, is a goal of the health care professions, whistleblowing affects health care institutions, corporations, providers, and clients profoundly. At the core of the whistleblowing issue lies accountability--public and private organizational accountability, health care professional organizational accountability, health care worker accountability, and consumer/client accountability. We begin the remaining sections of our paper by examining whether professional codes and accrediting agencies can provide the accountability that HCOs need.

Professional Codes of Ethics for Nurses and Other Health Care Providers

What do the current professional codes of ethics tell us about the responsibilities of nurses and other health care providers in relation to the practice of whistleblowing in HCOs? It seems reasonable to expect these codes to provide important guidance in this matter. Thus, professional codes for nurses and guidelines outlined by JCAHO are discussed here to identify important parameters of these documents in terms of whistleblowing and to propose ways in which they may be used more effectively.

Professional Codes for Nurses

The earliest code for nurses is generally thought to be that written in 1893 by Lystra Gretter, principal of the Farrand Training School for Nurses in Detroit (Fowler, 1992). This code was patterned after the Hippocratic Oath for medicine; Gretter called it the "Florence Nightingale Pledge." It was not until 1950 that the American Nurses Association (ANA) House of Delegates adopted an official code of ethics, the Code for Professional Nurses. Early codes, including the 1953 Code of Nursing Ethics formulated by the International Council of Nurses (ICN), emphasized, as reported by Hull (1980), the nurse's duty to carry out the doctor's orders faithfully and with intelligence. Professional codes gradually evolved to adapt to the changing social context of nursing. References to carrying out physicians' orders were eliminated and a new self-concept of nursing emerged: no longer was the nurse seen as a passive employee of an organization and an instrument of the physician, but rather, as an active professional relating to physicians and other health professionals as an independent practitioner whose primary duty is to the patient.

The Code for Nurses with Interpretive Statements formulated by the ANA in 1985 serves as the profession's public expression of the ethical values and duties of nurses. Although the Code does not set forth step-by-step ethical actions that a nurse should employ, it does embody a deep concern for ethical principles of nonmaleficence, beneficence, fidelity, veracity, social justice, and respect for the autonomy of the patient and the nurse. The Code specifically calls for nurses to be accountable to prevent or remedy any potential harm that might come to a patient: "The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person" (American Nurses Association, 1985, p. 1).

The Code of Professional Conduct composed by the United Kingdom Central Council (1992) sets forth a similar expectation for accountability:

As a registered nurse, midwife or health visitor, you are personally accountable for your practice and, in the exercise of your professional accountability, must act always in such a manner as to promote and safeguard the interests and well-being of patients and clients. (p. 40)

Finally, the Code for Nurses: Ethical Concepts Applied to Nursing formulated by the ICN (1973) states that "the nurse takes appropriate action to safeguard the individual when his care is endangered by a co-worker or any other person" (p. 2).

Nurse Practice Acts also provide important ethical guidelines for nurses, and, in fact, Adams appealed directly to them in defending his refusal to accept instructions on medication from a technician. For the most part, however, neither the professional codes nor the Nurse Practice Acts provides guidance in what ought to occur when the nurse must act to focus on some deficiency that she/he observes in order to safeguard individual clients or the public. Whistleblowing, in itself, may seem repugnant to individuals who have been taught since childhood that it is bad to "snitch" on friends and colleagues. If one follows rigorously the tenets of the Code, how does this affect the nurse's sense of loyalty to colleagues and the organization? How does a nurse's willingness to act in accordance with the Code threaten the welfare of her/his family?

As reflected in the Adams case study, if nurses adhere strictly to the Code's directives they are often called upon to make personal and professional sacrifices, including loss of employment. The Code calls for nurses to be accountable professionals, yet fails to acknowledge that, in reality, nurses have little power within the health care system. As Barry Adams noted, "Why should nurses have to choose between carrying out the behaviors called for in the [ANA] Code (trying to ensure safe, quality, and dignified care for their patients) and providing for their families?"

Are situations like this the fault of the Code itself? Hunt (1992) argues that if there is a clash between specific codes for conduct and reality, we need to find a way to change reality, not the code. An organization that does not provide an adequate support system for nurses who carry out the expectations of the Code is not functioning as an ethically responsive organization. In effect, without adequate support systems, nurses may be called upon to act in a supererogatory manner simply to uphold the basic principles, such as "safeguarding clients and the public," encompassed in the Code. Thus, changes are needed within the organization to develop and maintain an ethical climate. This climate would ensure that nurses and other health care professionals who file complaints or express concerns about unethical practices within the organization can expect both that these will be taken seriously and that procedures will be in place to arbitrate an issue.

In summary, the very expectation inherent in professional codes of conduct that exhorts nurses to act to protect patients and the public from unprofessional conduct, may, in fact, put unreasonable burdens on nurses if there are not effective support networks within the organization. Organizations must explore options for formulating professional codes in a way that will provide the support critical for raising the organization's awareness of problems that may bring potential or actual harm to patients and the public. One possible source of assistance in developing organizational codes of ethics for HCOs is JCAHO.

JCAHO Requirements

JCAHO accredits 90% of the hospitals in the United States and 30% of the nursing homes (Fletcher & Spencer, 1997). Consequently, JCAHO is in a unique position to demand ethical behavior by HCOs and to insist that personnel who act appropriately on behalf of patients' rights be protected. Since 1991 JCAHO has required all HCOs to have in place procedures and resources to deal with ethical issues arising out of patient care. The standards on patient rights (RI) were followed in 1995 with the requirement that HCOs address issues relating to organizational ethics. By organizational ethics, the joint commission means to ensure that HCOs conduct "business relationships with patients and the public in an ethical manner" (JCAHO, 1997, p. RI - 1).

In themselves the standards are admirable. The patient rights standards not only require that HCOs respect a patient's rights to adequate, respectful care, confidentiality and informed consent, but also insist that HCOs educate their patients and staff members about patient rights and the mechanisms in place for the patient or the patient's proxy to obtain relief if the HCO fails to live up to its responsibility to the patient.

Among the key standards of patient rights are the following (Joint Commission, 1997):

• The hospital addresses ethical issues in providing patient care. (p. RI.1)
• Patients are involved in all aspects of their care. (p. RI.1.2)
• Informed consent is obtained. (p. RI. 1.2.1)
• Patients are involved in resolving dilemmas about care decisions. (p. RI. 1.2.3)
• The hospital demonstrates respect for the following patient needs: confidentiality, privacy, security, resolution of complaints, pastoral care, communication. (pp. RI. 1.3;1.3.1-1.3.6)
• The hospital protects patients and respects their rights during research, investigations, and clinical trials involving subjects. (p. RI. 3)

The standards are sweeping in their scope, though they do not speak directly to the role and responsibilities of professional staff members in carrying out the provisions of the standards. The Joint Commissions' explanation of the intent of RI.1 provides some clarification, though still leaves ambiguous the extent to which professional and other staff would be expected to intervene in the defense of a patient's rights. The Joint Commission (1997) states:

...a hospital demonstrates its support of patient rights through the processes by which staff members interact with and care for patients. These day-to-day interactions reflect a fundamental concern with and respect for patients' rights. All staff members are aware of the ethical issues surrounding patient care, the hospital's policies governing these issues, and the structures available to support ethical decision making. The hospital establishes and maintains structures to support patient rights, and does so in a collaborative manner that involves the hospital's leaders and others. ( p. RI-6)

In an effort to provide HCOs the freedom to determine which policies and structures are most appropriate for the HCO's size and organization, the Joint Commission has missed an opportunity to require due process and other protection for professional staff members who intervene on behalf of patients under their care.

The organizational ethics standards are an important addition, but unfortunately do not go far enough in ensuring an ethically responsive organization because the standards are too narrowly construed in terms of business practices and external relationships. Without denying the importance of both of these, we believe that the protection of professional and other staff members requires attention both to the general ethical climate of an organization and to internal relationships. The key standards of organizational ethics articulated by the Joint Commission (1997) are as follows:

• The hospital operates according to a code of ethical behavior. (p. RI. 4)
• The code addresses marketing, admission, transfer and discharge, and billing practices. (p. RI. 4.1)
• The code addresses the relationship of the hospital and its staff members to other health care providers, educational institutions, and payers. (p. RI. 4.2)
• The hospital's code of ethical business and professional behavior protects the integrity of clinical decision making, regardless of how the hospital compensates or shares financial risk with its leaders, managers, clinical staff, and licensed independent practitioners. (p. RI. 4.4)

In its statement of intent, the Commission makes it clear that its expectations for the code do not go beyond standard business practices. The Joint Commission (1997) writes: "To support ethical operations and fair treatment of patients a hospital has and operates according to a code of ethical behavior. The code addresses practices regarding marketing, admission, transfer, discharge; and billing, and resolution of conflicts associated with patient billing" (p. RI - 24). The Commission does not restrain an HCO from developing a code that covers far more than business practices, but it does nothing to require, or even encourage, a more extensive code. As the intent explanation makes clear, even standard RI. 4.4, which seems more inclusive by its reference to the "integrity of clinical decision making," is concerned with "policies and procedures that address the relationship between the use of services and financial incentives" (JCAHO, 1997, p. RI - 25). Thus, the standards go a long way towards providing protection for the autonomy and individual rights of patients; however, they are silent on the moral agency of clinicians or on a means to ensure that clinicians may exercise their moral agency.

The management of human resources (HR) standards address professional and moral agency in two ways. First, standard HR. 3 requires that the HCO's leadership ensures the competence of all staff members, while HR. 5 requires that staffs' abilities be assessed. Second, HR. 6 allows a staff member to request not to participate in an aspect of patient care. The statement of intent makes it clear that this standard reflects the variety of cultural, religious, and moral beliefs that staff members have (Joint Commission, 1997, p. HR - 21). However, as the Barry Adams case illustrates, other forms of disagreement arise in clinical settings that are not resolvable by one member of the team asking to withdraw from an aspect of patient care. It is just these types of situations, for example, appropriate staff levels and supervision of inexperienced staff, that may give rise to the need to "blow the whistle," but the standards neither require, nor even urge, that HCOs have procedures and policies in place to address disagreement about clinical practice which ensure the protection and professional integrity of parties to the dispute, especially when the parties to the disagreement are unequal relative to the power structure of the organization.

In sum, as presently formulated, the JCAHO standards work reasonably well for an HCO that is already committed to ethical behavior towards patients and staff; however, they fail to ensure commitment to an ethical climate from HCOs that are only seeking to fulfill the letter of the law. As we discuss below, JCAHO can make a real contribution to patient care by expanding its interpretation of organizational ethics beyond the confines of business practices. The first step is to insist that all HCOs articulate an ethical climate which is based on the protection of patient health and welfare, publicize the key values of the organization, and provide a mechanism to resolve disagreements about the implementation of those values.

Whistleblowing and Organizational Ethics

James Rest (1986) proposes a four-step model for individual ethical decision making. According to Rest, the individual must:

1. recognize a moral issue;
2. make a moral judgment;
3. resolve to place moral concerns ahead of other concerns; and
4. act on the moral concern.

Agents faced with a moral dilemma in health care organizations have the greatest difficulty with the third step of Rest's model. The difficulty comes, in part, from the recognition that agents who "blow the whistle" almost always suffer negative consequences (Seeger, 1997). For this reason, many HCO workers are reluctant to report what they know, especially if the person about whom they would report is a supervisor or someone perceived to have greater standing in what is almost always a hierarchical structure (Walsh-Bowers, Rossiter, & Prilleltensky, 1996). Even when negative consequences are not anticipated, moral agency in health care organizations can be difficult because "medical settings do not encourage understanding and acting upon ethical issues as social and organizational in nature" (Walsh-Bowers, et. al., 1996, p. 332).

Perhaps, as Silva (1998) observes in the lead article of this issue, this is the reason that HCOs have paid insufficient attention to the organizational dimension of ethical issues. While biomedical issues have been a focus of attention for more than 30 years, institutions have exhibited behavior that Silva calls "the cart before the horse" and "the Band-Aid" phenomena. That is, HCOs have tried to solve very difficult moral problems, such as those relating to end of life issues or to distributive justice, before thinking through the moral basis for their actions ("cart before the horse") and by trying to locate responsibility for moral decisions only in a committee or consultant ("the Band-Aid").

While JCAHO has expanded its standards to include organizational ethics, we have already noted that it deals narrowly with business transactions and management aspects of HCOs. The new standard does nothing to influence what one might call the "ethical climate" (Victor & Cullen, 1997) of HCOs. The ethical climate of an organization is the prevailing perception of the organization as reflected in the organization's practices and procedures. Thus, some organizations have an ethical climate that is supportive of conflict resolution, others may encourage aggressive behavior; some are benevolent in character while others are egoistic. If, as we contend, whistleblowing results from a failure of organizational ethics, then it is imperative for HCOs to establish their ethical climates by identifying common values and beliefs so that both employees and patients are able to recognize the organization's core values and to hold the organization accountable for them. This may not be accomplished easily. In large, complex settings the individuals employed by HCOs will hold a variety of moral perspectives, generally reflective of the pluralistic society the HCO serves. We noted previously that whistleblowing results, in part, from a tension of values. Part of that tension may stem from the diversity of moral beliefs held by the staff. For example, while all employees may agree with a hospital's stated value that individuals be treated with dignity, some employees may believe that a policy that allows a surrogate decision maker to remove nutrition and hydration from a person in a persistent vegetative state is inconsistent with that core value. Further, as Liedtka (1991) points out,

the differing educational and socialization experiences of doctors, nurses, and non-medical administrators, coupled with the fact that the primary focus of management has tended to rest on the health of the organization, rather than the individual patient, suggests that the potential for the development of differing value systems between physicians, nurses, and administrators is high. (p. 15)

In the presence of multiple value systems, the occasions for disagreement and misinterpretation are multiplied. Thus, it is the HCO's responsibility to articulate the organization's ethical climate distinct from the individual beliefs held by staff members. In addition, it is important to establish forums and procedures through which individual members of the organization may challenge, in a constructive way, institutional values and decisions made by other members of the organization.

Robert Potter (1996) defines organizational ethics as "the intentional use of values to guide the decisions of a system" (p. 4). One approach to enhance an organization's efforts is for the organization to develop its own code of conduct. It is not enough, however, for organizations to adopt codes. They also must outline specific procedures for how a reported concern will be addressed. There is no point for nurses to report concerns if nothing is done with the information.

As we noted in the preceding section, JCAHO already requires HCOs to express publicly some of the basic beliefs underlying their organizational culture(s) in the form of mission statements and an articulated patient bill of rights. However, an institution's culture is more than an articulated mission statement. During the Tylenol contamination incident, there was apparently no doubt within the company about what action Johnson & Johnson would undertake. Despite the fact that a recall of the product cost millions of dollars, the corporate culture put doing the right thing above earning profits. This priority of doing right over earning profits was well known to all the employees of Johnson & Johnson. As Sims (1994) states, "the culture not only places constraints upon activities of the organization and its members (cultural prohibitions), it also prescribes what the organization and its members must do (cultural imperatives). In short, the culture guides the activities of the organization and its members" (p. 27). A telling observation by Jackall (1988) is that unethical behavior in modern corporations is traceable more to bureaucratic structures than to individual moral deficiencies.

Since the decision making process in HCOs is increasingly in the hands of non-clinicians, an ethical culture which preserves the priority of patient health over organizational health may be more difficult to find. As Silva (1998) has noted, an HCO must undertake a deliberate process to build an ethics infrastructure. According to Potter (1996), one way to achieve this infrastructure is through the evolution of clinical ethics to organizational ethics. He states, "we will have to learn how to integrate clinical and corporate aspects of bioethics. We must learn how to maintain our skills of analysis of the patient/provider relationship and, at the same time, account for the patient/system relationship" (p. 7). While matters of billing and admission policy are certainly part of this integration, they are only a small part of the ethical climate of an organizational culture. In fact, if an HCO's organizational culture were as well known to its staff as Johnson & Johnson's ethics was known to its employees, statements of principle governing billing and admissions would not be necessary except as information for patients. The importance of an articulated organizational ethics is captured by the analogy which identifies the ethical climate of an organization with the character of an individual and the organizational ethics processes within an organization with the conscience of an individual (Spencer, Mills, Rorty, & Werhane, forthcoming 1999).

As Spencer et al. (1999) point out, effective organizational ethics encompasses diverse ethical perspectives, including business, professional, and clinical imperatives, each of which maintains its traditional stance. To this we would add that the HCO must articulate and disseminate those values which will be predominant so that ambiguities about priorities will be eliminated (Sims, 1994). For example, an HCO might (hopefully) pronounce that meeting patient needs comes before profits. An HCO with an articulated ethical climate and published procedures for resolving ethical disputes can minimize the need for whistleblowing (Bok, 1980). In the next section we will provide some suggestions for establishing an ethical climate and developing procedures to reduce the need for whistleblowing.

Summary Recommendations

As this paper has progressed, a number of recommendations have already emerged from the discussion; these, in turn, direct us to other needs which, if satisfied, will help to strengthen the ethical climates of HCOs. In this section, we reiterate the recommendations that have already emerged and add to them recommendations which address both matters of interpretation and concrete steps that organizations can take to ensure an ethical environment that goes beyond mere compliance (Giblin & Meaney, 1998).

1. Both JCAHO as the accrediting body for HCOs and the ANA as the representative of American nursing professionals should require that an HCO articulate a moral code which goes beyond business practices to clearly identify the basic values which the organization professes.
2. Among the key values for any HCO must be the protection of patient health and welfare.
3. An HCO should publicize the values central to its operation and empower staff to develop interpretive statements which apply the values of the organization in a meaningful way to administrative and clinical practice.
4. HCOs, JCAHO and the ANA should work collaboratively to refine and reaffirm standards of care in the context of a changing health care environment.
5. Every HCO should establish clear procedures for a staff member to follow if she/he believes that current practice is incompatible with the organization's published values and standards of care.
6. JCAHO, the ANA, and other professional organizations should insist that an HCO's reward system be closely correlated to its published values; in particular, the reward system should provide protection for employees who speak out on behalf of patient rights.
7. An HCO should assist staff to understand the difference between personally held values and standards and those which are communally established.
8. JCAHO should initiate a program for ethical challenges to administrative or clinical practice similar to its sentinel event reports. The purpose of the report regarding ethical challenges is to ensure that the issue is addressed and that a satisfactory resolution is achieved. The requirement to report to JCAHO would ensure that an HCO must address such issues. (Effective in 1999, JCAHO will add standards to its Leadership Chapter and its Improving Performance Chapter regarding the management and reporting of sentinel events. Sentinel events are unexpected occurences involving death or serious injury.)
9. HCOs should expand the authority of their ethics committees to include responsibility for concerns relating to organizational ethics.

We are under no illusion that these recommendations, if followed, will entirely eliminate the need for acts of whistleblowing. There will always be some organizations that are concerned only with mere compliance and, therefore, lack the will to establish an ethical climate such as we have envisioned. The following recommendations address specifically the activity of whistleblowing.

1. Individual nurses should petition their state organizations to work with national nursing and health care organizations to establish policies and procedures for dealing with whistleblowing as an ethical issue.
2. Professional organizations should lobby to obtain legislative protection for health care professionals who have engaged in legitimate acts of whistleblowing.
3. Schools of nursing and staff development programs should provide information about the most important aspects of whistleblowing, including information about conflict resolution.
4. Professional organizations should censure HCOs that fail to provide an appropriate ethical climate and fail to support staff who blow the whistle in a responsible manner.
5. health care researchers should conduct outcomes research on organizations that establish an ethical climate to determine the extent to which the need for whistleblowing has been reduced without sacrificing patient health and welfare.

Authors

James J. Fletcher, PhD

jfletche@gmu.edu

James J. Fletcher received his BA from Iona College, his MA from Marquette University, and his PhD from Indiana University. He is an Associate Professor of Philosophy in the Department of Philosophy and Religious Studies at George Mason University, Fairfax, Virginia. He has been a member of the George Mason faculty since 1972 serving in a variety of teaching and administrative capacities, including 15 years in the Office of the Provost. He teaches courses in ethics, bioethics and philosophy of technology. His current research interests in the area of bioethics include organizational ethics for health care providers and end of life issues. In addition, he has written and presented extensively on higher education issues relating to faculty roles and rewards. He is the Ethics Collaborator in the Office of Health Care Ethics in the College of Nursing and Health Science. He also serves as a community member of the Prince William Health Systems Bioethics Committee for which he provides consultancies and educational programming.

Jeanne M. Sorrell, PhD, RN

jsorrell@gmu.edu

Jeanne Sorrell, PhD, RN is an Associate Professor in the College of Nursing and Health Science at George Mason University. Dr. Sorrell currently serves as Coordinator of the PhD in Nursing program and Coordinator of Special Projects for the Office of Health Care Ethics. She teaches courses in research and writing, as well as courses in the Advanced Clinical Nursing and graduate Nursing Education Certificate programs in the College. She has published articles on a variety of topics related to writing, education, and research and is currently coordinating the production of a videotape on Ethics of the Care of Persons with Alzheimer's Disease. Dr. Sorrell's interest in the ethics of dementia is also reflected in a current funded research project: Ethical Concerns in the Diagnosis and Treatment of Dementia: Stories of Persons with Alzheimer's Disease and their Families.

Mary Cipriano Silva, PhD, RN, FAAN

msilva@gmu.edu

Dr. Silva received her BSN and MS from the Ohio State University, her PhD from the University of Maryland, and her post doctorate in health care ethics from Georgetown University. She is a Professor and Director of the Office of Health Care Ethics, Center for Health Policy and Ethics, College of Nursing and Health Science, George Mason University, Fairfax, Virginia (http://www.gmu.edu/departments/chp/ethics.htm). She currently teaches a doctoral course on "Ethics in Health Care Administration" and is engaged in scholarship and research related to health care ethics. Dr. Silva serves on the ANA Code of Ethics Project Task Force to revise the 1985 ANA Code for Nurses with Interpretive Statements. She is also a member of the American Academy of Nursing Expert Panel on Ethics.

ACKNOWLEDGEMENT

The authors wish to extend their appreciation to Barry Adams, RN, BSN for his generosity and forthrightness in sharing first hand the details of his whistleblowing experience. The case presented here is with the permission of Mr. Adams.

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