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Negotiating the TensionBetween Policy andReality: Exploring Nurses'Communication AboutOrganizational WrongdoingMark P. Orbe & Granville KingPublished online: 10 Dec 2009.

To cite this article: Mark P. Orbe & Granville King (2000) Negotiating the TensionBetween Policy and Reality: Exploring Nurses' Communication About OrganizationalWrongdoing, Health Communication, 12:1, 41-61, DOI: 10.1207/S15327027HC1201_03

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Negotiating the Tension BetweenPolicy and Reality: Exploring Nurses’Communication About Organizational

Wrongdoing

Mark P. OrbeDepartment of CommunicationWestern Michigan University

Granville King, IIIDepartment of CommunicationIndiana University Southeast

This article explores the ways in which registered nurses communicate about organi-zational wrongdoing. Critical incidents were gathered from over 200 registerednurses. Through the phenomenological process of description, reduction, and inter-pretation, 5 themes emerged as central to responses of policy violations and personalethics in the workplace: (a) perceptions of wrongdoing, (b) upholding the ideals of theprofession, (c) clarity and evidence of wrongdoing, (d) consequences of reporting,and (e) workplace dynamics. The interpretative findings focus on how these themesare united by a tension that nurses face in terms of adhering to policy while attemptingto manage the realities of their everyday professional lives. A discussion of these find-ings, including how they relate to existing and future research and practice, is offered.

Nurses confront issues of inappropriate behavior by other nurses on a daily basis.Responses to these incidents, which can involve acts of incompetence, negligence,or human error, can take a variety of forms. Left unattended, such events maythreaten the lives of numerous patients, the well-being of employees, as well as theintegrity of the health care facility.

Various settings (e.g., corporations, educational, and so on) have been used toenhance our understanding of internal disclosure of organizational wrongdoingsby employees. Currently, a majority of the research has focused on coworker retal-iation (Miceli & Near, 1994), situational variables (Miceli & Near, 1992b), and in-terpersonal closeness (King, 1997) as factors that may affect the reporting of

HEALTH COMMUNICATION, 12(1), 41–61Copyright © 2000, Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to Mark P. Orbe, Department of Communication, Western Mich-igan University, Kalamazoo, MI 49008–3899. E-mail: orbe@wmich.edu

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organizational wrongdoings. Additionally, we must investigate other factors thatperform a key role in the process by which individuals perceive, process, and re-spond to instances of organizational wrongdoing. In this article, we explore onearea: the communicative responses of those aware of organizational wrongdoingsthat have received little attention in the literature.

Communication performs a central role in the process by which individuals re-spond to organizational wrongdoing in the workplace. How, where, and if awrongdoing is reported within the organization is affected by—and subsequentlyaffects—the culture of that organizational setting. Stewart (1980), for example,noted that organizations that provide clear and proper channels for the disclosureof internal wrongdoings encourage employees to use those channels. Along thosesame lines, Trevino and Victor (1992) noted that internal channels create an ethicalatmosphere within the organization that may prompt other acts of wrongdoing tobe reported. On the other hand, an individual who anonymously reports a wrong-doing to a colleague or a member of upper management may not be taken seriously(Elliston, 1982), thus allowing the wrongdoing to go unanswered.

Reports of wrongdoing among registered nurses are growing in ethics and nurs-ing journals (Bower & Rubin, 1996; King, 1997). The nursing profession, likeother health care professions, faces a number of special ethical challenges in thedaily operations. These may encompass a number of personal and professional is-sues, including decisions to confront a colleague who may be incompetent (Anon-ymous, 1989; Cerrato, 1988; Rozovsky & Rozovsky, 1990), performing under theinfluence (Alexander & O’Quinn-Larson, 1990; Beck & Buckley, 1983; Fowler,1986; Guy, 1986; Patrick, 1984), or abusing a patient (Carlisle, 1993; Castledine,1994; Eaton, 1993; LaRocco, 1985). Although a nurse may observe these andother incidents of wrongdoing, a number of related issues (i.e., professional loy-alty, organizational norms, or personal relationships) may directly impact the up-ward communication of a perceived wrongdoing by a nurse (Greenlaw, 1982;O’Connor, 1992). Although various scholars have addressed issues such as patientabuse (Castledine, 1994; Eaton, 1993; LaRocco, 1985), nurse impairment (Alex-ander & O’Quinn-Larson, 1990; Patrick, 1984), threats (Frapwell, 1986), unethi-cal and unsafe practices (Dupre, 1984; King, 1991), and ethics and thephysician–nurse relationship (Friedman, 1990; Stanley, 1990; Wilson, 1983), weknow of no specific examination of the ways in which nurses communicate aboutorganizational wrongdoing. The purpose of this study, therefore, was to examinehow nurses communicate about wrongdoings within their organizations. In orderto facilitate a process of discovery that focuses on the lived experiences of nursesfrom their own particular standpoint, a phenomenological methodology was em-ployed. Ultimately, we believe that the insight generated from this project willcontribute to the existing literature on organizational wrongdoing in general, aswell as that which specifically pertains to the communication of health care profes-sionals. As a means to these objectives, this study posed two research questions:

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(a) How do nurses communicate regarding organizational communication?, and(b) What are the primary factors that govern their reactions to organizationalwrongdoing? In order to understand how these “essential” questions were createdand explored, a brief description of phenomenology is warranted.

PHENOMENOLOGY

Grounded in the works of Husserl (1964) and Merleau-Ponty (1962, 1964, 1968),phenomenology represents a human science approach that seeks to explore the con-scious experiences of how people understand the world in which they livepre-reflectively rather than as they conceptualize or theorize it. As described by Eu-ropean (Husserl, 1962; Merleau-Ponty, 1962) and American scholars (Deetz,1981; Lanigan, 1979; Nelson, 1989; van Manen, 1990), phenomenological inquiryinvolves a rigorous science where analysis focuses on conscious experience ratherthan hypothetical constructs.Phenomenologyis an inductive approach that seeks togain understanding by consciously setting aside preconceived ideas so that the fo-cus is on the descriptions of lived experiences provided by respondents.Phenomenologists work to reveal the experiences of persons who are seen as com-plex beings from a particular social, cultural, and historical life circumstance (vanManen, 1990).1 Specifically, phenomenological inquiry involves three stages: (a)gathering descriptions of lived experiences (description), (b) reviewing these de-scriptions in order to reveal essential themes (reduction), and (c) discovering howthe essential themes collectively reflect the quintessence of the phenomenon (inter-pretation). One method to gather phenomenological descriptions is through thecritical incident technique (Flanagan, 1954), where persons are asked to articulatetheir experiences in writing (Leslie, 1997; Orbe, 1994; van Manen, 1990). For thepurposes of this study, critical incidents were gathered as a means to gain access tothe experiences of how nurses perceive and respond to organizational wrongdoing.

Step One: Gathering Descriptions of Lived Experiences

This study is part of a larger research project on how nurses respond to instances oforganizational wrongdoing. A random sample of 1,900 active (vs. retired) regis-tered nurses, provided by a state board of nursing located in the midwest, were ad-ministered surveys. As part of this survey,2 respondents were asked two “critical in-cident” questions: (A) Describe in as much detail as possible a past or present

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1Specific phenomenological techniques include bracketing (Nelson, 1989), self-reflexitivity (Erni,1989), and imaginative free variation (Lanigan, 1979).

2This survey was designed to gain information from the nurses on a number of topical areas relatedto their perceptions of unethical behavior within their organization (i.e., observances of wrongdoingand upward communication, perceptions of intentional vs. unintentional wrongdoing, communication,and co-worker wrongdoing).

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incident of wrongdoing that you have observed or have knowledge of within yourorganization, and (B) Was this incident reported to officials within the organiza-tion? Why or Why not?3 Of the 1,900 surveys sent directly to the nurses, 372 werereturned anonymously via postal mail over a 3-month period (20% general re-sponse rate). These 372 returned surveys included a total of 202 critical incidents(or 11% of the total 1,900 distributed), most between one and three paragraphs inlength.4 These data, once typed into uniform fashion, resulted in 32 single-spacedpages that offered descriptions of how organizational wrongdoing was perceivedby a group of diverse nurses. In this regard, respondents were overwhelmingly fe-male (93%), who worked both full- (71%) and part-time (21%) in a variety of posi-tions: hospital nurse (36%), head nurse/manager (5%), educator (7%), home healthcare nurse (7%), and staff nurse (11%). Most were employed in a hospital (58%),but others worked in a college setting (5%), home health (6%), HMO (3%), or nurs-ing home (4%). The descriptions of nurses’ perceptions of organizational wrongdo-ing on their jobs, based on the critical incidents representing a wide diversity ofnursing experiences, provided the impetus of the phenomenological process.

Step Two: Facilitating The Reduction Process

The ultimate goal of a phenomenological reduction, according to Lanigan (1979),is to determine which parts of the descriptions of lived experiences are essential andwhich are not. Van Manen (1990) characterizes this process as one that attempts togive “shape to the shapeless” (p. 88). To facilitate the emergence of themes eachcritical incident was read, reviewed, and then mentally and physically put aside, sothat other transcripts could undergo the same process.5 The descriptions of organi-zational wrongdoing—including the reasoning behind why each incident was han-dled the way that it was—were transcribed, read, bracketed, reviewed, and subse-quently reduced into potential themes. The consequence of this process was theemergence of five themes (explicated in subsequent sections within this article)that reflect the essence of nurses’ communicative experiences in regard to organi-zational wrongdoing.

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3Other research has been reported that presents empirical analysis of these questions. The focus ofthis article is on presenting the phenomenological review and interpretation of responses to these twocritical incident open-ended questions.

4The expense of this massive mailing was financed through a research grant from Indiana Univer-sity, Southeast. However, due to the large cost, follow-up letters could not be sent out after the initialmailing.

5The thematic reduction process involved a number of steps by the primary researchers. First, eachresearcher worked independently in reviewing, and subsequently thematizing the descriptions of livedexperiences provided by co-researchers. Second, the primary researchers worked collaboratively in or-der to facilitate the identification of primary themes. Finally, a third review of all possible themes wascompleted in order to facilitate the emergence of five essential themes. For a detailed description of thephenomenological reduction process, see van Manen (1990), chapter 4.

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Step Three: Interpretations Via a Hyper-Reflective Lens

A phenomenological interpretation simultaneously begins while the researchersare involved in the reduction process. An interpretation of themes involves a con-stant reflection of essential themes and how they relate to one another including in-sight that was not immediately apparent in earlier steps (Orbe, 1994).

The definitive objective of an interpretation consists of ahyper-reflection(Merleau-Ponty, 1962) that results in the emergence of one central idea from whichinterpretations on the essential themes can be articulated. This process involves acollectivereviewingofeachstep in thephenomenologicalprocesstoreveal the intri-cate mechanism(s) that seemingly connect the themes. The following explicationsof nurses’ communicative experiences regarding organizational wrongdoing cap-ture the ways in which one central idea (policy vs. reality) interconnects the five es-sential themes that emerged through the process of description and reduction.

EXPLICATING NURSES’ COMMUNICATION ABOUTORGANIZATIONAL WRONGDOING

The critical incidents provided by the participants involved in this study provided agreat deal of insight into how nurses communicate about organizational wrongdo-ing. The experiences that they shared include incidents that occurred within bothfull-time and part-time positions in a number of contexts including hospitals, homehealth, schools of nursing, free standing surgery centers, hospices, multihospitalsystems, and nursing homes. Within their narratives, the registered nurses involvedin this phenomenological inquiry described the process by which they becameaware of an instance of wrongdoing and came to some decision as to how theywould respond to this incident. Additionally, some respondents also related theconsequences of their decisions. As the phenomenological reductive process wasengaged, it became clear that the nurses’ descriptions of lived experiences could beclustered into two areas associated with organizational wrongdoing: (a) descrip-tions of how the wrongdoing was handled by the person, and (b) descriptions of rea-sons why a certain response was enacted.

Official Reports

Throughout the description of incidents, the nurses involved in this study describeda variety of responses to their knowledge of organizational wrongdoing. Most ofthe narratives recounted instances when nurses reported the wrongdoing directly tosupervisors, doctors, surgeons, hospital CEOs, or the state board of nursing. Their“reports” were communicated through a variety of means, including written docu-mentation, oral communication, anonymous messages (written or phoned), as wellas formal complaints. However, upon reflection, it is clear that many of the respon-

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dents may have interpreted our question of “reporting” the wrongdoing as referringto official actions. A comment from a 40-year-old female nurse who serves as aneducator in a multihospital system appeared to capture the gist of this line of reason-ing. Her comments were affixed near the second critical incident question thatasked about to whom the wrongdoing was reported.

Actually, you did not specify “report”—I assume you mean a supervi-sor-type person. I would more likely discuss the incident with the individualinitially. If they do not correct the error then I would move up the chain ofcommand.

These remarks provide a possible explanation as to the large number of incidentsthat described a more formal reporting of wrongdoing. However, other nurses ex-plained an assortment of other responses to organizational wrongdoing. These re-sponses can be clustered into two general domains: communicating with peers anddecisions not to report. Decisions not to report the wrongdoing, or in other words,“do nothing,” were described by nurses in a number of situations; these decisionswere made for a variety of reasons (to be explicated in subsequent sections).

Communicating With Peers

Communicating with peers refers to situations when nurses made the decision notto officially report instances of wrongdoing, but instead handle them in a more in-formal manner. Examples of this general form of response include discussing thesituation with co-workers, approaching the person involved in the wrongdoing, orunobtrusively creating instances when others are likely to learn of the wrongdoing.In some circumstances, this form of handling organizational wrongdoing proved tobe more effective than more formal reporting which often times is required by pol-icy. Such was the case for one Assistant Director of Nursing:

[This involved] a doctor’s private nurse getting pain medication out of the pa-tient’s medication cubicle … [This] was reported to the Director of Nursingand to the nurse’s boss. The boss ignored the situation, so the next time it hap-pened, the hospital nurses began lockingall pain meds in the narcotic box.

A final example of peer communication, one that involves a form of “peer disci-pline,” was provided by a hospital nurse:

A co-worker of mine, a[n] RN with her associate degree in nursing, haddrawn up insulin for all her patients who were to receive insulin that morning.She labeled the syringes and put the amount and type of insulin along with thepatient’s name. She then taped the syringes to the top of the medication cart.

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We all agreed that this was not good practice. Another RN decided to “teachher a lesson” and took and discarded the insulin and refilled the syringes withnormal saline … then retaped the syringes as they were left previously. Be-fore giving the “insulin,” the RN was told by a bystander of the contents andredrew the insulin before administering it to the patients.

In short, the registered nurses involved in this study described an assortment of re-sponses to becoming aware of wrongdoings in the work place, including official re-ports and communicating with peers. Although this information provides someinsight into a nurse’s perspective on organizational wrongdoing, the descriptions ofwhynursesrespondedintheways inwhichtheydidyieldssignificantdetailpertainingto the factors that most influence their decision-making processes. The five essentialthemes—(a)perceptionsofwrongdoing,(b)upholdingtheidealsof theprofession,(c)clarityandevidenceofwrongdoing, (d)consequencesof reporting,and(e)workplacedynamics—that emerged from the nurses’ narratives appear to capture the central is-sues inherent in the process by which decisions of reporting are made.

Perceptions of Wrongdoing

One of the central issues that affects the way nurses respond to becoming aware oforganizational wrongdoing involves their perception of the incident. Interestingly,a pattern emerged from the reduction–interpretation process: Many head nursesand nurse managers who provided instances of wrongdoing for our study main-tained that most, if not all, violations of policy are reported via the appropriatechannels. This perception, however, differed somewhat from those of other nursesnot currently in supervisory positions. For instance, throughout the critical inci-dents, nurses described situations that went unreported because they were per-ceived as trivial in relation to the overall care of patients. One hospital nurse relatedan instance when a staff member

crushed a medication that should not be crushed, such as an extended release… [this was] not reported. It was absorbed quickly by the patient, but causedno problem.

This situation represents a number of instances when persons’ actions violatedwritten policy but were viewed as relatively minor, and thus not reported. In mostcases, nurses shared that many of these cases were self-corrected or monitoredclosely, or both, as illustrated in the narrative following.

A nurse flushed an IV with demerol 100 mgm instead of normal saline … Shedid not report it and neither did I; she monitored the patient very closely andthe patient did fine.

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Clearly,according tosomeof thenurses involved in thisstudy,someviolationsofpolicy are minor enough as to go unreported given that “no harm was done.” In gen-eral, nurses described several examples of these cases of wrongdoing that consis-tently go unreported; these reflect behaviors that are commonly accepted within theworkplace. The two excerpts below illustrate two practices that, although they areclearly examples of violations of organizational policy, are tolerated as acceptable.

Nurses frequently administer to patients doses of narcotics above the pre-scribed dose which [is then] recorded as being “wasted” … No [not reported],it is almost common practice. (Hospital nurse)Staffing is padded when surveyors are coming; [This is] not reported—theyknow it, they do it. (Head nurse)

Although some instances of wrongdoing were perceived as minor enough to gounreported, when the effects of wrongdoing posed a threat to self or others, someaction was warranted to rectify the situation. For many nurses, practices that jeop-ardize the quality of patient care represent such instances. Mistakes in treatmentthat “could have caused harm to the patient,” “caused patients severe pain,” or“could have caused a patient’s death” are instances of wrongdoing that are not gen-erally tolerated. A significant number of nurses described instances of alcohol ornarcotic abuse by doctors and nurses; these incidents also were generally per-ceived as serious enough to warrant some response. Some nurses felt thatwrongdoings that had the potential for harmful effects—as seen with the use of“could have’s” in the previous examples—dictated some action, even when nurseswere able to monitor the situation in which a wrongdoing had the potential to causea patient’s harm. This is seen in the following description, one that had no signifi-cant effect on the patient, but had the potential for great harm.

[thirty-two] week gestation pregnant patient in preterm labor [was] beingcontrolled with magnesium sulfate for steroid treatment to try to mature fetallungs … 6am dose was not given. Yes, [this was] reported to nurse man-ager—that one injectioncould makethe difference in an infant’s lungs beingmature!

Within these descriptions, it is also important to note that nurses’ perceptions ofthe same incident of wrongdoing might be different. For instance, among the criti-cal incidents shared with us, respondents discussed instances of “frequent failure[of staff] to wash hands each time between patients.” A pattern emerged wherenurses described that this violation of policy “occurs too frequently” and that theyare “too busy to report it every time it happens.” Other nurses, however, reportedthis wrongdoing since it increased the likelihood of spreading viruses from patientto patient. For some registered nurses, any violation of policy, including some-

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thing as “minor” as health care professionals not washing their hands, needs to bereported because it compromises the integrity of the nursing profession.

Upholding the Ideals of the Profession

Regardless of the perceived seriousness of the organizational wrongdoing in ques-tion, some nurses felt obligated to report all policy violations. The judgment ofthese nurses revolved around the ideals of the nursing profession that are built uponquality patient care for all. Organizational policy is established to ensure this pur-pose, therefore, violations of policy—albeit sometimes in small ways—jeopardizequality patient care. Within their descriptions of why they reported wrongdoings intheir work environment, nurses most often offered the rationale that explained thatthe instances “compromised patient care and safety,” or were “not within the stan-dards of our nursing guidelines.” One hospital nurse described her response to awrongdoing perceived by some as minor:

I respect my job and my patients. I would never leave them unattended. I alsoknow my job and its duties; I only expect the same of others.

For many respondents, an ethical responsibility was assumed when they de-cided to enter the ranks of the nursing profession. This responsibility was some-thing taken very seriously for some nurses who were likely to guarantee qualitycare at all costs, including the risk of personal or professional reprisals. One homehealth care nurse articulated her ideology in terms of a basic humanitarian ap-proach to others:

[I] haven’t seen wrongdoing but would not tolerate these actions. No oneshould be in the hands of someone that doesn’t care. I wouldn’t want to betreated wrong, therefore I would not watch someone else be done wrong.

Another respondent, who serves as the Director of student health services, de-scribed her rationale behind reporting organizational wrongdoing in a similar man-ner. This can be seen from her comments regarding the lack of documentation ofcontrolled substances in her facility.

Yes, [it was] reported because the actions or lack of actions of one person canputall licensedpersonsat risk,andIpersonallyamnotwillingto takethat risk.

The risk of compromising the ideals of the profession was one factor that promptedsome nurses to respond to organizational wrongdoing and other cases of incompe-tence in clear and direct ways.

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Clarity and Evidence of Wrongdoing

In many instances, respondents described their decisions to report wrongdoingsbased on official policy and procedure. This practice is required “because policystates all incidents are reported to the supervisor and [an] incident report filed.” Al-though some nurses reasoned that their responses to instances of organizationalwrongdoing were enacted to comply with policy, others felt compelled to report allincidents because many could result in “legal issues.” Although written policyseems to exist in terms of just about any case scenario, the interpretation of certainpractices remain as “gray area.” One such issue involves euthanasia, as describedby a 42-year-old head nurse:

The most questionable ethics concern is when to stop putting patientsthrough painful—costly procedures when they are terminal (within 48hours). [These instances are] not reported; it’s a controversy.

Although this example involves a case of great magnitude, nurses are confronteddailywith lessseveresituations that involve judgmentcalls.Wrongdoings thatwereclearviolationsofpolicyandprocedure—intheeyesof thenursesinvolved—shouldbe reported. However, the ability to prove that a wrongdoing occurred, including in-stances when another’s judgment is called into question, appears to impact thenurses’ decision of how to respond to the situation. Accusations of wrongdoing thatwere supported with clear, undisputed evidence appear to be more likely reported;those cases that were more difficult to prove may be handled in different ways.

From the perspective of staff nurses, making an allegation against co-workerscontains a great deal of risk. This appears to be the case for younger nurses espe-cially, as demonstrated in the narrative following:

I worked in an ER where I noticed all of the Toradol was missing … At first Iblamed the Pharmacy … after a few times, it occurred to me that a particularnurse was working on the nights that the shortage occurred … I did not reportit because I was not sure and fairly new on the job. I did not wish to accusesomeone falsely [nurse eventually admitted it to others].

Even when the circumstances are readily apparent and nurses are relatively certainthat policy has been violated, the possibility, however slim, of falsely accusing oth-ers remains a salient issue in their decision to report organizational wrongdoing.This is especially the case when the allegations involve a person with a great deal ofcredibility in the unit. The following narrative, offered by a male anesthetist, illus-trates the difficulty of such situations:

I once observed a co-worker under the influence of narcotics (there was abso-lutelynodoubt). However, since I was a new employee and this person was a

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valuable, long-term employee of the organization, I would have felt like anidiot had I reported it and been wrong … [It was] not reported due to fear ofbeing wrong and subsequent embarrassment as a new employee.

The nurse who provided this critical incident was concerned about the conse-quences associated with falsely accusing another co-worker. Although this con-sideration affected some nurses, many more nurses were fearful that makingallegations—even those that were supported by clear evidence—againstco-workers would result in negative repercussions in the work environment.

A patient had surgery with general anesthesia, our discharge instructionsstate the patient may not drive a car for 24 hours. My nurse manager allowedthe patient to drive 90 miles after signing an “against medical advise” form.Our discharge instructions also say do not sign any legal documents for 24hours. The patient should not have been allowed by law or policy to drive.[This was] not reported; I feared what my manager would say to me … andhow she would treat me.

Consequences of Reporting

As described earlier, some nurses work to uphold the ideals of the nursing pro-fession and strive to guarantee quality patient care at all costs. These personstypically take the appropriate steps to ensure that organizational wrongdoingsare corrected. However, other nurses involved in this study explained that theirresponses to instances of wrongdoing were impacted by the possibility of nega-tive effects on their personal, social, or professional lives. For these women andmen, their responses to becoming aware of policy violations were not handled“by the book.” Instead, a number of considerations were contemplated, includ-ing the possibility of negative repercussions for blowing the whistle on policyviolations or unethical behavior.

Depending on the specific organization, the consequences for nurses who re-port policy violations can vary greatly. Some may be regarded as heroes or martyrsfor highlighting practices that, if left unattended, jeopardize the safety of others.However, for others, breaking the silence on instances of organizational wrongdo-ing can have any number of negative repercussions, including social isolation,peer retaliation, managerial reprisals, personal attacks, and being labeled as not ateam player. For the nurses involved in this study, some of the most difficult deci-sions on how to handle wrongdoings occurred when they perceived their optionsas being dictated by the fact that they had little organizational power or clout. Inother words, when the wrongdoings involved staff with more hierarchical power,their options involved remaining silent and employed (“going along to get along”)

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or breaking the silence and risking their current job status. Some nurses, like thestaff nurse’s following comments, were quite straightforward in explaining whythey remain silent:

I am a surgical nurse. Sexist language is used by some personnel during casesin which patient is sedated … I know patients hear this language subcon-sciously … No, [I haven’t] reported this … I am a coward.

Although only a small number of nurses involved in the study described the riskof social isolation from peers as a consequential danger, a clear pattern emerged ofinstances when the power and credibility of others (supervisors, doctors, and ad-ministrators) caused nurses to overlook some policy violations. Some felt “forcedto stand by and even support” decisions that they knew to be erroneous, as depictedby one staff nurse who discovered that a

… nurse manager was using [her] position as a means to acquire new prod-ucts from a sales representative who she had a relationship with … New prod-ucts were obviously inferior to current product … I did notdirectlyreport thisincident due to the risk it would have created in my position. I was forced tostand by and support the evaluation which later failed.

When policy violations involve those persons in supervisory and administrativepositions, nurses may feel as if they have no clear direction to proceed without jeop-ardizing their work relationships with others. One nurse shared that she has becomeaware that the “administration of the hospital has [literally] pulled out guns to visi-tors.” When responding to the second critical incident question, “Did you reportit?,” she wrote “report to whom???”

Clearly, some nurses fear that their jobs might be at stake should they decideto report organizational practices that are violations of policy, but generallyoverlooked by members of the organization. The following case of patient ne-glect, recounted by a male hospital nurse, describes how reporting wrongdo-ing—especially those that are consciously overlooked by others—can result inloss of job security:

Patient … left on bedpan and forgotten for 1 hour; [another] patient left up inwheelchair and not assisted to bed … most of these problems were due tostaff being cut by 1/3 and patient load being doubled. In our organization ifyou want to keep your job the less said the better.

In this instance, the nurse’s response to an instance of patient care that fell below thestandards as set forth by written policy was governed more by informal policy en-acted by members of the unit.

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Workplace Dynamics

The aforementioned narrative is an excellent portrayal of how many of the five es-sential themes explicated in this section closely relate to one another. In fact, theworkplace dynamics of an organization not only affect the potentiality of negativeconsequences, but they also have a great influence on how nurses negotiate otheressential themes (that is, perceptions of wrongdoing, upholding the ideals of theprofession, and so on). For instance, even for those nurses who strive to maintainthe integrity of their profession, the bureaucratic nature of workplace dynamicsmay cause some to take a “defeated stance.” One hospital nurse described

[The] quality of care [is] very low due to the hospital trying to save money …cut staff, and working nursestoomany hours (dangerous) … No, [this is] notreported—it’s a losing battle—from CEO on down … these people need towork in the hospital to realize the problem—instead, they sit behind a desk!

In some organizational units, past instances of nurses reporting wrongdoingsaffect the ways the staff handles current policy violations. For example, nurseswho are aware of past cases where whistle-blowers suffered personal, social, orprofessional repercussions will take this into consideration as they decide how tohandle instances of organizational wrongdoing. Episodes that include nurses re-porting policy violations—and subsequently putting themselves at risk—but hav-ing the problem continue with no corrective attention are seen as evidence that theorganization is not interested in addressing the issue. As one hospital nurse ex-plained, “I reported it once,” referring to a nurse who recorded bogus vital signs,but “not after that because nothing was done about it.” Without question, the risksof reporting allegations of wrongdoing are not warranted in organizations that thendo nothing. In response to viewing an instance of patient abuse and neglect, onepart-time hospital nurse candidly explained her frustration:

Yes, I reported it to the MD and Director of Nursing, but no discipline wasgiven to the nurse … [it] does no good to report problems when you know thatnothing is going to be done. Our meds [medical doctors] depend on the Direc-tor of Nurses to handle these situations and they usually don’t.

Clearly, this nurse has assumed, by their perceived lack of action, that the mem-bers of her workplace did not value reports of policy violations. Within the de-scriptions of wrongdoing provided by the registered nurses involved in this study,several respondents described instances that they reported via the appropriatechannels. However, in several cases, the nurses who initiated the allegations wereunaware of any action on their grievances. Although their organizations partici-pate in the rhetoric of “let’s hold every employee accountable in making this orga-

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nization the best it can be,” their actions (or lack thereof) tell a different story. Forinstance, a series of incidents alleging that an RN was stealing narcotics were

… reported [by more than 1 person] to [the] department director, the physi-cian directly responsible for [the] unit, and the new CEO of [the] hospitalwho said, “I will get to the bottom of this.” Nothing has been done. This hasbeen going on for more than one year.

In contrast, workplace dynamics that reinforce the rhetoric of their organiza-tional credo with clearly visible actions strengthen the tendency for nurses to con-front organizational wrongdoing within the policy guidelines. The following casescenario, as described by a clinical nurse specialist, was a positive experience thatincreased the likelihood that she would report other wrongdoings in the future.

[The situation] involved a nurse abusing ETOH [alcohol] on a substanceabuse unit. We did a team confrontation—a report was made bymultidisciplinary team—nurse went into treatment and has returned to work.It was a meaningful experience for everyone involved … well-planned, exe-cuted, and had excellent results.

In summary, the five essential themes—(a) perceptions of wrongdoing, (b) up-holding the ideals of the profession, (c) clarity and evidence of wrongdoing, (d)consequences of reporting, and (e) workplace dynamics—explicated within thissection emerged from the nurses’ lived experiences as central to their experiencesin communicating about organizational wrongdoing. Descriptions of these themesappear to work toward capturing the central issues inherent in the process by whichnurses respond to policy violations in the workplace.

NEGOTIATING THE TENSION BETWEENPOLICY AND REALITY

Phenomenological inquiry works to generate the emergence of a central idea fromwhich interpretations of the essential themes can be articulated. For the lived expe-riences of nurses in a variety of organizational settings, the essential issue that ap-pears to capture the ways that they respond to wrongdoing can be seen through anexplication of the tension betweenpolicy–reality.As alluded to in the descriptionsof nurses who labor to uphold the high standards of their profession,policyrefers tothe official existing procedures that were created to ensure quality care for all pa-tients in a productive, safe work environment. Ideally, nurses and others’ commu-nicative behaviors within the workplace are governed by policy and proceduresthat encompass all possible case scenarios (albeit sometimes in generic form). Inthe reality that nurses confront on a day-to-day basis however, policy does not al-

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ways seem effortlessly clear. In some instances, adhering to official policy and pro-cedures is not perceived as possible or necessarily appropriate.

Specific examples of situations in which adhering to policy was impossible ap-peared throughout the critical incidents provided by nurses. Most often these in-stances involved work environments where nurses were held responsible forgreater patient loads:

With primary care, nurses have triple the work load with the same, or in manyinstances, a great patient load. Some patients get meds late, get treatment [in]3 to 4 hours instead of 2 hours. (Staff nurse)

Several respondentswereadamantabout this issue,one that they felt that thegen-eral public does not readily acknowledge. Expressions of their frustration were seenbycommentsscribbled in themarginsof thecritical incident form.Aftercompletingher response, one hospital nurse interrogated the researchers with an addendum:

P.S. IS THIS THE ONLY THING YOU CAN QUESTION NURSESABOUT? WHAT ABOUT ALL OF THE GOOD THAT THEY DO?? OR[that they]AREOVERWORKED,UNDERSTAFFEDANDUNDERPAID?

Within the perceived tension of policy versus reality, these comments reflect howthe everyday or night realities of health care facilities make it inconceivable to com-ply with established policy and procedures. These regulations, from the perspectiveof some nurses, are created and maintained by persons removed from the daily ac-tivities of the work environment.

The registered nurses involved in this study clearly found that trying to performtheir duties in a less-than-ideal world is difficult. Additionally, nurses acknowl-edged that their personal shortcomings and imperfections also sometimes hin-dered an ideal communicative response to organizational wrongdoing. Personalvendettas against co-workers, fear of becoming isolated on the job, peer pressure,or personality conflicts with others are examples of factors that may influence theircommunication about specific cases. One nurse described how “politics” largelyinfluenced her decision not to report wrongdoings that occurred while visiting rel-atives in a community hospital:

I did not report these incidents because my husband’s father was the patientand my husband is a local nursing administrator. Politically he said he couldnot afford to report this. I know this was not appropriate for two health careprofessionals but we’re by no means perfect people.

Whereas others might have negotiated the tension between policy and reality dif-ferently, the nurse confronted with the previous situation opted to prioritize the

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need to acknowledge potential political ramifications (reality) while compromis-ing the professional responsibility to report the wrongdoing (policy).

The tension between policy and reality is one that appears to affect the experi-ences of nurses as they function in a less-than-perfect world. Each of the essentialthemesexplicated in thepriorsectionof thisarticleareultimatelysituatedwithinne-gotiations of these opposing forces. Official policy clearly outlines the appropriateresponses to organizational wrongdoing; these are in place to ensure quality patientcare in a productive, safe, work environment. However, the day-to-day realties fornurses—including their perceptions concerning instances of wrongdoing and theconsequences of reporting those instances within a specific organizational cul-ture—impact their decisions to comply with official policy. In some instances, thepull toward the importance of following policy takes precedence and wrongdoingsare reported via official channels. In others, the strain of dealing with the diurnal re-ality that nurses face takes precedence and other responses are enacted.

DISCUSSION

In this study we explored two key questions: (a) How do nurses communicate re-garding organizational wrongdoing?, and (b) What are the factors that govern theirreactions to organizational wrongdoing? Using a phenomenological framework, acluster of five essential themes—perceptions of wrongdoing, upholding the idealsof the profession, clarity and evidence of wrongdoing, consequences of reporting,and workplace dynamics—emerged from the narratives of registered nurses as cen-tral to their communicative experiences regarding organizational wrongdoing. Fur-thermore, a central issue of negotiating policy and reality appeared to serve as ameans (hyper-reflection) to interconnect the themes and capture the essence of thephenomena under study.

The research presented in this article represents a methodological innovationfor examining the communication that surrounds those persons aware of organiza-tional wrongdoings. Although the insight that was generated from this project maybe applicable to a variety of health care professionals, it holds great potential tocomplement existing, largely social scientific research and advance our under-standing of how registered nurses respond to violations of policy and ethical stan-dards in the workplace. In this vein, the remainder of the article gives attention tothe research and pragmatic implications of this line of research.

Research Implications

The unique contribution of this article is that it provides descriptive evidence of theways in which nurses respond, via a focus on interpersonal communication pro-cesses, to organizational wrongdoing in the workplace. In many instances the inter-pretative findings from this study complement the existing literature in organiza-

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tional wrongdoing. This is true especially for the findings that point to severalsalient issues central to how organizational members respond to instances of policyviolations or unethical behavior. For instance, our work here clarifies, through theanalysis of actual wrongdoings supplied by nurses, the importance of several fac-tors raised directly and indirectly by existing research: organizational position,clarity of wrongdoing, workplace dynamics, personal and professional code of eth-ics, and perceptions of the severity of the wrongdoing (King, 1997; Miceli & Near,1992a; Miceli, Near, & Schwenk, 1991; Parmerlee, Near, & Jensen, 1982; Victor,Trevino, & Shapiro, 1993). In this regard, we have utilized phenomenological in-quiry to provide support for many of the issues already established in research onorganizational wrongdoing. However, even more significant, this study promotesan insightful vantage point as to the ways that social scientific and humanistic re-search can work collectively to advance our understanding of communication phe-nomena. Space limitations do not allow for an in-depth treatment of all the specificimplications for future research; that notwithstanding, one line of research, asbriefly described later, can serve as a solid illustration as to the potential researchthat our findings might help generate.

As alluded to earlier, existing research clearly indicates that a number of vari-ables correlate to how organizational members act on instances of policy violationand unethical behaviors. Specifically, research has found that the responsibility as-sociated with one’s position (Trevino & Victor, 1992), as well as the perceived se-verity of the wrongdoing (Miceli & Near, 1992a), affect how individualscommunicate about a perceived wrongdoing. Other research reveals that the ac-tions of supervisors and administrators (Barnett, Cochran, & Taylor, 1993) andco-workers (Greenberger, Miceli, & Cohen, 1987; King, 1997; Miceli & Near,1989) also play a crucial role in this process. Although this existing research isvaluable in identifying the specific variables that affect individual’s responses toorganizational wrongdoing, it fails to increase our understanding as to the waysthat these interdependent factors collectively play out in actual instances of whatorganizational stakeholders perceive as organizational wrongdoing. In this regard,future research can explore the extent to which different variables affect responsesto different instances of organizational wrongdoing from the perspective of di-verse standpoints (i.e., professional experience, age, or position). For instance, ourresearch revealed several scenarios in which policy violations were not formallyreported, even though existing research indicates that the observers’ position ofauthority or the severity of the wrongdoing would have warranted blowing thewhistle. The findings of this study, as given evidence through the descriptions oflived experiences supplied by various nurses, lend insight into the complex pro-cess by which several issues are simultaneously negotiated when deciding abouthow to respond to organizational wrongdoing. Drawing from the insights associ-ated with acknowledging the tension that nurses experience between policy and re-ality, future studies can explore RQs that seek understanding into the processes by

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which organizational members weigh some factors more heavily than others in de-cisions on how to respond to organizational wrongdoing. The complexity inherentin this line of research speaks to the important role that both humanistic and socialscientific research must play in order to advance knowledge.

Pragmatic Implications

Inaddition to implications for future research, the interpretative findingsarticulatedin this article can be useful for health care organizations in terms of how they cur-rently manage instances of wrongdoing. This study gave credence to the importantrole that the perceptions of the observer had in defining, and ultimately, communi-cating about organizational wrongdoing. Specific insight was offered in terms ofwhatnursesperceiveasawrongdoing,asopposed towhatbehaviorsmaybeconsid-eredappropriateoracceptable (althoughaviolationofwrittenpolicy).Furthermore,this study gave voice to the ways in which nurses experience the tension betweenwrittenpolicyandtherealisticdemandsoftheirdailyresponsibilities.Healthcareor-ganizations, amidst the perceptions that all administrators are far removed from theconditions that nurses face (as articulated by some of the narratives within this arti-cle), could give attention to how this tension plays out in the daily operations of theirfacilities. In this regard,existingpolicyandprocedurescanbe reviewedwitha focuson acknowledging the real-life experiences of nurses while creating an organiza-tional climate that maintains the high ideal of quality patient care for all.

Ofspecific interest tohealthcareorganizationsmaybe the insightconcerning thevarious methods used by nurses to respond to organizational wrongdoing. Existingresearch appears to focus on how a variety of issues (i.e., personal relationships, se-verity of wrongdoing, organizational climate; Cerrato, 1988; Trevino & Victor,1992) factor intodecisions touse formalchannels to reportorganizationalwrongdo-ing or not. Many of the descriptions that nurses provided for this study gave clear in-dication that responding to policy violations is not necessarily an “either–or”proposition. Instead, nurses gave voice to a number of instances (including thosethatwecharacterizedas“peerdiscipline”6) that theyregardedaseffective,appropri-ateresponsesto instancesoforganizationalwrongdoingbutwerenotconsistentwithexisting policy. Barnett, Cochran, & Taylor (1993) have found that organizationswhose climate is supportive of internal disclosure channels set forth by formal pol-icy increasethe likelihoodthatmemberswillusesuchchannels.Therecognitionthatnurses may very well utilize other channels not guided by formal policy raises an in-

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6Additional insight into the idea of peer discipline, as presented by respondents in this study, can begained through existing work on concertive control (Barker, 1993; Tompkins & Cheney, 1985). Ac-cording to Barker, concertive control involves “a key shift in the locus of control from management tothe workers themselves, who collaborate to develop the means of their own control” (p. 411).

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teresting question: How do health care organizations handle the different avenuesusedtoconfront instancesofpolicyviolations,especially thosethatmaybeeffectivebutarenot recognizednorsupportedbywrittenpolicyandprocedures?Actionsper-formed by management influence how others see their role responsibility within anorganization (Trevino & Victor, 1992). How do health care facilities communicatethis responsibility to their constituents through both formal and informal channels?This issuerepresentswhatwebelieve tobeoneaspectof the largergeneralchallengefor health care organizations as revealed by this study. That is, how do facilities as awhole maintain the ideals of the health profession while functioning amidst theharsh realities of a society that is oriented toward the bottom line?

CONCLUSION

The strength of the insights generated from this scholarly inquiry is significant inthat it provides a foundation of information describing what nurses perceive as or-ganizational wrongdoings as well as the factors that guide their responses to suchinstances. One of the limitations of this study is that it does not propose to representall registered nurses’ or others’ responses to policy violations in the workplace. Theessential themes emerging from this phenomenological inquiry, however, do offervaluable insight into this phenomena. To advance our understanding of how peoplecommunicate about organizational wrongdoing, this insight can be merged withexisting, largely social scientific, research as described earlier. Clearly, the exami-nation of the communicative experiences pertaining to organizational wrongdoingand dissent holds great heuristic and pragmatic value as it relates to those interestedin the areas of health and communication.

ACKNOWLEDGMENT

The research reported here was supported, in part, by a grant from Indiana Univer-sity Southeast.

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