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Physical therapy students' willingness to report misconduct to protect the patient's interests
  1. Abraham Mansbach1,
  2. Yaacov G Bachner2,
  3. Itzik Melzer3
  1. 1Department of Philosophy and Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel
  2. 2Department of Sociology of Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
  3. 3Physical Therapy Department, Ben-Gurion University of the Negev, Beer-Sheva, Israel
  1. Correspondence to Dr Abraham Mansbach, Department of Philosophy, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel; mansbach{at}bgu.ac.il

Abstract

This article presents a study on the ethical dilemma of whistleblowing in physical therapy, and suggests some lines for further research on this topic as well as ways for integrating it in the physical therapy curriculum. The study examines the self-reported willingness of physical therapy students to report misconduct, whether internally or externally, to protect the patient's interests. Internal disclosure entails reporting the wrongdoing to an authority within the organisation. External disclosure entails reporting the offence to an outside agency, such as the police, professional organisation, or press. The findings indicate that the students view the acts that are detrimental or cause injustice to the patient in a very serious light. In dilemma situations such as these, the students reported a willingness to act. The students also report considerably greater likelihood of whistleblowing internally than externally. The pattern reveals a desire to correct the misconduct coupled with a marked decline in the willingness to blow the whistle as this act moved from the workplace to an external authority.

  • Applied and professional ethics
  • education/programmes
  • ethical dilemma
  • misconduct
  • physical therapy
  • professional misconduct
  • truth disclosure
  • whistleblowing

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People face a difficult dilemma when they contemplate ‘blowing the whistle’ on potentially harmful actions performed by other people working within their organisation. These individuals must choose between the public good and their loyalty to colleagues, supervisors and/or their employer. Whistleblowing is also complex given the question of power involved in the act, which can affect the whistleblower. Although there are some cases in which employers have rewarded whistleblowers for their efforts, the typical response is harassment and mistreatment. In the civil service, whistleblowers are often transferred to inferior positions, or to locations where they are cut off from their colleagues.1 In the private sector, most whistleblowers end up unemployed, either because they are fired or because their work environment becomes so intolerable that they are forced to leave.2

The dilemma becomes even more complex in the healthcare professions, in which the damaged party is the patient. If physicians, nurses and other healthcare workers decide to do nothing to stop a colleague's or supervisor's harmful conduct, they may be violating their basic professional commitment to promote and protect patients' health and welfare and, in fact, undermining the very raison d'etre of the profession and their service within it.

The issue of whistleblowing has been identified as being exceedingly important to the profession of physical therapy. Both the study by Guccione3 in 1980, which surveyed 450 members of the American Association of Physical Therapists in New England, and that of Triezenber4 in 1996, which relied on the Delphi technique of a panel of experts, pointed to the duty of physical therapists to report colleagues' misconduct as one of the key ethical issues facing the profession, now and in the future. Despite the topic's importance, no studies have been conducted on whistleblowing in physical therapy since John D Banja5 published his article on ‘Whistleblowing and physical therapy’ in 1985, in which he examined situations in which whistleblowing was needed in the profession as well as the benefits and liabilities of taking such action.

Given both the significance of the issue and its many complexities, the lack of any in-depth discussion or research is a serious omission. It is important to understand the scope of whistleblowing dilemmas facing physical therapists. What do they actually do when confronted by the harm a patient has experienced at the hands of a colleague or healthcare institution? At the pedagogical level, the topic should not simply remain part of the ‘hidden curriculum’ that exists in medical education at the present.6 Physical therapists needed to be equipped with the appropriate tools to address such situations; to achieve this, we need to determine how to integrate whistleblowing into the physical therapy curriculum. Should it be included in a regular course on the ethics of physical therapy or as an aspect of practical training? Here, it would be particularly relevant to examine what position(s) physical therapy students hold with regard to whistleblowing.

In order to begin to answer these questions, in this study we wanted to find out whether students of physical therapy feel ready to take any action to stop a colleague's or a manager's misconduct in order to protect the patient's interest. We also sought to determine the level of students' willingness to disclose the wrongdoing. Were they only willing to report it to authorities within the organisation or were they willing to take the next step and report it to an external authority?

Methods

Sample and procedure

A total of 112 undergraduate students in the department of physical therapy at Ben-Gurion University participated in the study.

The questionnaire was administered by an experienced research assistant at the beginning of a mandatory course on statistics. The distribution and presentation of the questionnaire were identical for all respondents. All prospective students were informed that the questionnaire was a part of a survey on ethics, that the gathered data would be used for research purposes only, and that participation was voluntary and anonymous. The administration of the questionnaire lasted for approximately 15–20 min. The response rate was very high (90%).

Instrument

The questionnaire consisted of multiple-choice questions regarding sociodemographic details and two vignettes (case stories) describing ethical dilemmas that were likely to arise in the workplace. The sociodemographic section collected information about age, gender, marital status, country of origin and level of religiosity.

The case stories were first presented to five physiotherapy students to receive their preliminary input. Their responses were then used to finalise the questionnaire. The questionnaire presented two vignettes describing situations in which the respondents were required to make a decision that involved whistleblowing. One vignette described an ethical dilemma in which the respondent had to choose between responsibility to a patient and loyalty to a colleague. The other vignette presented a dilemma in which the respondent had to choose between responsibility to a patient and loyalty to management.

The case stories were designed to replicate specific characteristics seen in acts of whistleblowing, as well as to mark the internal/external divide. Each vignette contained five questions: Question 1 asked the respondent to rate the severity of the misconduct; question 2 referred to the likelihood of taking action by confronting the person (colleague or director) responsible for the wrongdoing and persuading him or her to repair the harm done; question 3 dealt with internal whistleblowing; and questions 4 and 5 with external whistleblowing. All the questions were rated on a five-point Likert scale. The answer to the first question ranged from ‘not serious at all’ to ‘very serious’, while the answers to the other questions ranged from ‘not likely at all’ to ‘very likely’.

Case stories

Dilemma 1: Protecting the patient's interests versus being loyal to a colleague

You are a physical therapist in a rehabilitation centre. Hana, a colleague of yours, is teaching an elderly patient how to climb the stairs on crutches after hip surgery. While you watch them, Hana leaves the patient for a moment to go and answer the telephone and unfortunately the patient falls. Hana quickly returns and helps the patient to stand up, and leads him/her back to bed. Contrary to the regulations, she does not report this incident, but makes sure that the patient is fully conscious and feels good. You know that Hana's behaviour violates the regulations and could harm the patient.

  1. How serious do you consider your colleague's behaviour?

  2. How likely is that you will talk to your colleague and try to persuade her to report the incident to her superiors?

  3. If you decide not to talk to your colleague, or if you have talked to her about the matter and not succeeded in getting her to report the incident, how likely is it that you will go to someone at the centre who has the power to intervene, such as the head of the physiotherapy ward or the ethics committee, if there is one at the rehabilitation centre?

  4. If you decide not to approach anyone at the centre, or if you do talk to someone and he or she does nothing to intervene, how likely is it that you will turn to the Physical Therapists' Association, an external body?

  5. If you decide not to talk to the Physical Therapists' Association, or if you do talk to them and they do nothing, how likely is it that you will report the matter to the media?

The internal reliability of the questionnaire (questions 1–5) was satisfactory (α=0.75).

Dilemma 2: Protecting the patient's interests versus being loyal to management

You are a physical therapist in a municipally run centre for victims of violence. It has recently come to your attention that the director of the physiotherapy section intends to use money budgeted for modern physiotherapy equipment to buy luxury fittings for her own office. You know that the director's decision was not approved by the appropriate authority and that the lack of the equipment will significantly delay the recovery of those who are cared for by the centre.

  1. How serious do you rate the director's behaviour?

  2. How likely is it that you will try to persuade the director not to use the money for her own office, but to purchase the needed equipment?

  3. If you decide not to talk to the director, or if you have talked to her and not been able to change her mind, how likely is it that you will report the director's intentions to someone at the centre who has the power to intervene, such as the centre's general director or the ethics committee, if there is one at the centre?

  4. If you do not refer the matter to an authority at the centre, or if you do and he or she does not intervene in the director's decision, how likely is it that you will turn to the Physical Therapists' Association, an external authority?

  5. If you decide not to report the matter to the Physical Therapists' Association, or if you do talk to them and they do nothing, how likely is it that you will report the matter to the media?

The internal reliability of the questionnaire (questions 1–5) was high (α=0.81).

Statistical analysis

The mean differences between the groups were assessed using the paired Student's t test or analysis of variance repeated measures test according to the number of groups in the analysis. The significance level was set at p<0.05 for all analyses. The data were analysed using SPSS statistical software, PC version 16.0.

Results

The response rate was very high (90%, 112 of 124). The respondents' average age was 25.2 years (SD 2.01, range 21–35). Ninety (80.4%) were women, which is in accordance with and reflects the predominance of women in the physical therapy profession.7 One hundred and nine (97.3%) were single and 99 (88.4%) were born in Israel. Seventy-nine (70.5%) ranked themselves as secular, 13 (11.6%) as conservative and 19 (17%) as orthodox Jews.

A comparison of the average scores for the severity of the misconduct, the likelihood of taking action by turning to the person responsible for the damage done, and the indices of internal and external whistleblowing for the two vignettes is presented in table 1.

Table 1

Comparison between the respondents' scores for the two vignettes regarding the severity of the misconduct, the likelihood of taking action to change the situation and the indices of internal and external whistleblowing.

The respondents gave the professional misconduct in both vignettes a very high score on the scale's possible range of 1 to 5. The director's misconduct was rated higher than the colleague's, and the difference between the two scores was statistically significant. Relatively high scores were also given to the respondents' likelihood of taking action by asking the person involved to report his or her own misconduct. The likelihood was higher in the case of the director but the difference between the scores did not reach statistical significance. The scores of the questions of internal and external whistleblowing were significantly higher for the director's misconduct than those for the colleague's misconduct.

Table 2 presents a comparison between the average scores of the respondents' likelihood of reporting the misconduct to someone in the workplace, to the Physical Therapists' Association and to the media in the two case stories. For both, the average score of reporting the misconduct to someone in the workplace was found to be significantly higher than the average score of reporting the misconduct externally to the Physical Therapists' Association or to the media. Furthermore, the average score of reporting the misconduct to the Physical Therapists' Association was significantly higher than that of reporting it to the media. Therefore, there was a marked decline in the respondents' willingness to blow the whistle as this act moved from the workplace to the Physical Therapists' Association and finally to the media.

Table 2

Comparison between the respondents' scores for the two vignettes on the likelihood of reporting the misconduct to a superior in the workplace, to the Physical Therapists' Association and to the media (n=112)

Discussion and conclusions

The findings of the study indicate that the students viewed acts that are detrimental or cause injustice to the patient as being very serious. In problematical situations such as these, the students reported a willingness to act; this willingness was greater in the case of a manager's misconduct than in that of a colleague. The students also reported a considerably higher likelihood of blowing the whistle internally rather than externally.

Among the many cases of whistleblowing discussed in the literature, whistleblowers seem to follow a distinct pattern. Usually, they first report the case to their superiors, and it is only after the internal disclosure has failed to put a stop to the wrongdoing that they sometimes decide to disclose the behaviour to an external authority.8 In fact, most scholars agree that this two-step procedure is the most prudent for would-be whistleblowers, for both strategic and ethical reasons.9 First, it allows employees to remain loyal to the organisation even as they try to put a stop to its harmful activities. Second, it proves that they are free of ulterior motives and provides them with the moral justification for taking their case to an external authority, if necessary.

The answers of the students in our study followed this same pattern. Their desire to correct a colleague's or superior's misconduct was coupled with a progressive retraction as the circle of disclosure widened. There may be several reasons for this retraction. It may reflect the respondents' concerns that external exposure could have negative consequences, not only for the wrong-doer, but also for the healthcare organisation and for the individuals who receive its services. It may also reflect the respondents' awareness of the increasingly serious nature of each level of protest, with them believing external disclosure to hold more risks than internal disclosure. Case studies in the literature, including those in other health and care professions, clearly indicate that the price paid by the whistleblower gets higher when the misconduct is reported externally.10

The main limitation of this study is that the findings reflect the study participants' self-expectations of how likely they would be to report the depicted misconduct, rather than their actual reporting patterns. Their self-assessment does not necessarily indicate what the respondents would actually do if they encountered the unethical behaviour described in the vignettes. The relevant literature repeatedly points to the large discrepancies that exist between an individual's attitudes and his or her actual behaviour.11

This pioneer study was designed as an initial step in examining physical therapy students' willingness to report workplace wrongdoing. Its findings represent a starting point as well an opportunity for future studies. One of the objectives of such studies would be to corroborate whether the principle of the patient's best interest is not pursued to the utmost when it is a senior manager or colleague who is involved in the improper and harmful conduct. If that is indeed the case, then the reasons for this need to be analysed. As the present study showed, there is a progressive retraction in an individual's willingness to blow the whistle as the circle of disclosure widens. Is fear of the possible consequences one of the reasons? As we also observed here, a colleague's unethical behaviour was considered to be less serious than that of a manager. Further studies could examine if this contention is true and, if yes, how an individual's socialisation within the profession relates to and influences it.

We also need to take these questions into account when considering how best to integrate the subject of whistleblowing into the physical therapy curriculum. The objectives in this pursuit would be to broaden the basis of ethical education, provide an additional anchor for the principle of the patient's best interests, and equip prospective physical therapists with the tools to handle similar situations in their future practice. Purtilo,12 13 Guccione,3 Magistro14 and Swisher15 have noted that the increase in physical therapists' clinical autonomy has also brought more complex ethical dilemmas with it. Whistleblowing is certainly one of these. We consequently recommend that, in addition to studying the ethical aspects of reporting wrongdoing, researchers and practitioners also consider whistleblowing as a tool for advocacy and social intervention, as is done in other health professions.16 We also believe that it is important to examine the existing legislation protecting whistleblowers in the given country. Over the past few decades, western democracies have promoted legislation to protect whistleblowers and to encourage whistleblowing.17 In 1989, the Whistleblower Protection Act became law in the USA. A Public Interest Disclosure Act was passed in Australia in 1994 and in the UK in 1998. Similar legislation was passed in New Zealand and in South Africa in 2000. Here in Israel, the Employee Protection Act of 1997 and later amendments were designed to provide such protection.

Finally, the question of how to blow the whistle is no less important than that of whether to blow it or not. Many organisations have created internal channels for reporting misconduct, and our recommendation is to use them when necessary. Such channels have the great advantage of avoiding the damage that public exposure might bring, to the institution and to the whistleblower him/herself. At the same the time, they help strengthen an individual's professional ethics and values. At institutions where internal channels are not available, or where these have not proved effective in stopping the wrongdoing, we would advise the whistleblower who is considering making an external disclosure to seek professional advice beforehand. In most western democracies, voluntary organisations have been established to make whistleblowing in general safer and to support those specific individuals who have decided to take action to stop workplace wrongdoing. It is crucial that students of the practice and ethics of physical therapy be made aware of this information.18–20

References

Footnotes

  • Funding The study was funded by the Israeli Science Foundation (grant no 108/05).

  • Competing interests None declared.

  • Ethics approval This study was conducted with the approval of the curriculum committee of the Physical Therapy Department of Ben-Gurion University.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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