Continuing Education Institutional Betrayal and Gaslighting Why Whistle-Blowers Are So Traumatized

DOI: 10.1097/JPN.0000000000000306 Continuing Education C 2018 Wolters Kluwer Health, Inc. All rights reserved. J Perinat Neonat Nurs r Volume 32 Number 1, 59–65 r Copyright  Institutional Betrayal and Gaslighting Why Whistle-Blowers Are So Traumatized Kathy Ahern, PhD, RN ABSTRACT Despite whistle-blower protection legislation and healthcare codes of conduct, retaliation against nurses who report misconduct is common, as are outcomes of sadness, anxiety, and a pervasive loss of sense of worth in the whistle-blower. Literature in the field of institutional betrayal and intimate partner violence describes processes of abuse strikingly similar to those experienced by whistle-blowers. The literature supports the argument that although whistle-blowers suffer reprisals, they are traumatized by the emotional manipulation many employers routinely use to discredit and punish employees who report misconduct. “Whistle-blower gaslighting” creates a situation where the whistle-blower doubts her perceptions, competence, and mental state. These outcomes are accomplished when the institution enables reprisals, explains them away, and then pronounces that the whistle-blower is irrationally overreacting to normal everyday interactions. Over time, these strategies trap the whistle-blower in a maze of enforced helplessness. Ways to avoid being a victim of whistle-blower gaslighting, and possible sources of support for victims of whistle-blower gaslighting are provided. Key Words: gaslighting, institutional betrayal, reprisals, whistle-blower N urses who report concerns about illegal or unethical behavior are often subjected to reprisals that include denigration and Author Affiliation: Visitor, University of New South Wales, Kensington, New South Wales, Australia. Disclosure: The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding Author: Kathy Ahern, PhD, RN, Visitor, University of New South Wales, Kensington, NSW 2052, Australia K.Ahern@unsw.edu.au. Submitted for publication: July 4, 2017; accepted for publication: November 1, 2017. The Journal of Perinatal & Neonatal Nursing marginalization. As a result of these reprisals, whistleblowers often experience severe emotional trauma that seems out of proportion to “normal” reactions to workplace bullying. The purpose of this article is to apply the research literature to explain the psychological processes involved in whistle-blower reprisals, which result in severe emotional trauma to whistle-blowers. “Whistle-blower gaslighting” is the term that most accurately describes the processes mirroring the psychological abuse that commonly occurs in intimate partner violence. BACKGROUND On a YouTube clip,1 a game is described in which a woman is given a map of house to memorize. She is then blindfolded and given 30 seconds to find the kitchen door or she will get slapped. According to her mental map, the individual finds herself where the door should be, but it is not there. As the woman frantically searches for the missing door, she gets slapped. Then she is ordered to find the bedroom or get another slap. After several rounds of the “blind-maze game,” the woman becomes disheartened, confused, exhausted, anxious, and paranoid. Then a new rule is added. The woman is not allowed to say that the map she was given is false, or she will receive an even harsher punishment. The blindfolded individual is trapped. She was given a faulty map, set up to fail, was punished for failing, and forced to keep using a faulty map. The video clip describes the situation of people who have been caught up in abusive “love fraud”–type situations with sociopathic individuals. However, the blind-maze metaphor reflects many of the experiences of individuals who report misconduct at work. The thesis of this article is that the “blind-maze game” that traumatizes romantic partners in abusive “gaslighting” relationships is the same process by which whistleblowers are inordinately traumatized when they report www.jpnnjournal.com Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 59 misconduct. Traumatized whistle-blowers are using a faulty “mental map” in which they erroneously believe their allegations will be investigated and that they will be protected. WHISTLE-BLOWING The term “whistle-blowing” has several definitions. Peters2(p2908) defines it as “a situation where a party or parties take matters that would normally be held as confidential to an organisation outside that organisation.” Other definitions do not specify that an individual reports concerns to an external body. McDonald and Ahern3(p16) define whistle-blowing as a person “who identifies an incompetent, unethical, or illegal situation in the workplace and reports it to someone who may have the power to stop the wrong,” indicating that internal reporting of concerns constitutes whistle-blowing. Rehg and colleagues4 suggest that it is not necessarily the reporting of concerns that create a whistle-blower; rather, reporting opens the door to reprisals, which are the defining characteristic of whistle-blowing. In practice this means that a nurse who reports suspected malfeasance to her employer is simply being a good employee who is adhering to her professional code of conduct. It is only when the nurse experiences subsequent punitive reprisals that the she belatedly realizes that she has been morphed from “good employee” to despicable whistle-blower. Rothschild describes how whistle-blowers in their study were: . . . almost to a person, extremely devoted to the organization’s purpose, and they worried that the misconduct they observed would undermine that purpose, and potentially, bring down the whole organization. Typically, they saw their boss as the perpetrator of the problem, and they believed that if senior management knew what was going on, they would surely correct the situation. Thus, they tend to go, first, to their boss’s boss with the information. Only when they see that the boss is either complicit or inert do they consider going outside the organization, to either the media or to a legal authority. At this stage, they see themselves as being without a real choice: Indeed, in 79% of our cases, the individual whistleblower values the purposes of the organization and their own integrity so highly, that they see no alternative to disclosure. In very few cases in our sample did the whistle-blower anticipate or prepare for the retaliation that was about to come their way.5(p891) Retaliation against whistle-blowers is common and severe and includes negative job performance evaluations, micromanagement, isolation, loss of job, and blacklisting.3,5 Whistle-blowers are framed as deviant and stripped of their respectability.6 60 www.jpnnjournal.com According to Peters et al,2 the effects of whistleblower reprisals on nurses include overwhelming sadness and distress, akin to the grief associated with the death of a loved one. Anxiety is felt for years, to the extent that it interferes with normal enjoyment of life. Other outcomes include intrusive thoughts and nightmares, and constant hypervigilance—looking for and anticipating possible danger in previously unproblematic activities. All nurse whistle-blowers in the Peters et al study reported experiencing a level of emotional distress that negatively influenced their health, ability to work, and their private lives. These disabling posttraumatic stress disorder (PTSD) symptoms first started with self-doubt and then escalated in a spiral to a loss of sense of coherence, dignity, and self-worth.2 GASLIGHTING The “blind-maze game” phenomenon is reported in diverse areas of environmental disasters,7 sexual harassment and assault,8 and intimate partner violence.9 The common threads in these reports are the way in which trauma is created and exacerbated through the betrayal of trust. When what should happen is the opposite of what is happening, cognitive dissonance is created, which undermines the individual’s sense of reality, confidence, and their mental health. When a romantic partner uses these strategies, it is called “gaslighting.” When institutions apply these strategies, it is a sign of institutional betrayal.10 There is mounting evidence that the trauma experienced by whistle-blowers is exacerbated by the cognitive dissonance resulting from a real-life version of the blind-maze game. Prior to their disclosures, whistleblowers are generally high-achieving, respected, exceptionally committed members of their employing organization.5 They have no reason to believe that their organization will not be as troubled at the reported malfeasance as they are. The mental map that the majority of whistle-blowers are working from is that the organization will investigate allegations of misconduct. Codes of conduct and mission statements all acclaim the organization’s integrity and foremost concern for patients. Nurse whistleblowers only discover that their mental map is faulty when they experience reprisals, which is the real-world equivalent of the blind-maze slap. Basing one’s sincere actions on false assurances,11 and being ambushed by the ferocity of unexpected reprisals, explains a great deal about why whistle-blowers experience long-term PTSD symptoms.2 Repeated false reassurances given by apparently genuinely concerned managers severely undermine the whistle-blower, as experienced by British nurse January/March 2018 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Rodriquez-Noza, who made allegations about the “third world treatment” of patients.12 The hospital’s acting Director of Nursing met with Rodriquez-Noza twice to discuss her concerns, where Rodriquez-Noza was informed her allegations were “taken very seriously but no evidence was found.” Then Rodriquez-Nova was fired from her job. A subsequent review following complaints by patients’ families resulted in 3 nurses from the hospital being charged with willful neglect and falsification of records, indicating (too late) that RodriquezNoza had indeed reported events accurately and that the Director of Nursing had indeed not investigated her allegations. However, by that time, Rodriquez-Noza had already experienced a mental breakdown and become suicidal.12 When the whistle-blower believes what she is told that she is a valued staff member and her concerns are taken seriously, while she experiences actions that portray her as incompetent or mentally unstable, cognitive dissonance is created. Cognitive dissonance leads to confusion and self-doubt. It is a major factor in trauma from intimate partner violence where victims feel trapped in an abusive relationship because of economic dependence; potential judgment from others, beliefs regarding social roles, and the time, effort, and resources they have already committed to the relationship.13 Cognitive dissonance discussed in the intimate partner violence literature highlights the insidious means by which repeated denials of reality undermine a target’s well-being. Such a form of emotional manipulation known as “gaslighting” occurs when the gaslighter tries to induce in her partner the sense that reactions, perceptions, memories, and beliefs are not just mistaken but utterly without grounds. Gaslighting almost always involves multiple incidents that take place over time, frequently involves isolating the target, and often involves multiple parties cooperating with the gaslighter.14 The same gaslighting constellation of isolation and denial of allegations and reprisals is consistently reported in whistle-blower literature.2–4,6,12,15–23 Abramson14 explains that the aim of perpetrating institutions is to destroy the possibility of disagreement by so radically undermining the person that she has nowhere left to stand from which to disagree and no standpoint from which her words might constitute genuine disagreement. Abramson provides the following hypothetical scenario: [Whistle-blower] Liz starts to notice that she’s being left out of important decisions and not invited to major meetings. She hears rumors that clients are being told she doesn’t want to work with them anymore and has recommended that they speak to her new boss The Journal of Perinatal & Neonatal Nursing instead . . . . Finally, Liz confronts her boss, who has a plausible explanation for every incident. “Look,” he says kindly at the end of the meeting. “I think you’re being way too sensitive about all this—maybe even a little paranoid. Would you like a few days off to destress?” Liz feels completely disabled. She knows she’s being sabotaged—but why is she the only one who thinks so?” . . . Also the manipulative threat is clear to the whistle-blower that her job is on the line.14(p4) In whistle-blower gaslighting, the gaslighter creates cognitive dissonance in the whistle-blower by pronouncing that her distress at reprisals and stonewalling are merely irrational responses to minor, isolated bureaucratic irritations. Often, the finding is couched in terms of concern and respect. McDonald and Ahern3 describe an example in which a whistle-blowing nurse received official commendation for reporting misconduct and was simultaneously threatened with legal action. Because whistle-blower gaslighting consists of false reassurances coupled with incongruent actions (see Table 1 for examples), it often takes the whistleblower quite a while to realize that her employer is actually trying to discredit her before she can discredit her employer.5 When intimate partner or whistle-blower gaslighting works well, the target ends up feeling a worthless “nobody” in a major depression. Factors contributing to such an outcome include grief at the loss of many intangible but significant things: the loss of an independent perspective, the loss of the ability to form and maintain one’s own perceptions, and the loss of trusted relationships.14 In whistle-blower gaslighting, there is also grief at the knowledge that the whistle-blower has brought the situation upon herself by reporting misconduct in the first place. INSTITUTIONAL BETRAYAL The trust individuals have in institutions is based on expectations that the institution will fulfill an important role in their lives. Examples include a religious institution providing a place of worship and community, an educational institution providing an environment conducive to learning, and a healthcare institution providing safe and effective care. There is an implicit expectation of support by members of many institutions, including between employees and their organization, church members and their clergy, and soldiers and the Department of Defense. When individuals trust or depend on an institution, there is potential for betrayal. When these expectations are violated, institutional betrayal has occurred.29 The concept of institutional betrayal arises from Betrayal Trauma Theory (BTT), expanding the scope of www.jpnnjournal.com Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 61 Table 1. Red flags of whistle-blower gaslighting 1. The workplace environment makes misconduct/reprisals seem normal.24 – 26 2. Proactive steps to prevent misconduct/reprisals are not undertaken.24,25,27 3. The response to allegations of misconduct/reprisals is inadequate.27 Examples include stonewalling, willful blindness, and deliberate ignorance of events, evidence, and policies.25 4. Misconduct/reprisals are covered up.25,27 5. Your case is mishandled.27 For example, mediation is not an appropriate strategy to deal with alleged reprisals, as it does not address the imbalance of power central to bullying, nor does it redress wrongs.28 6. Delaying tactics.25 For example, lack of time/resources is provided as an explanation for not properly investigating your allegations; lengthy processes inevitably mean that the case becomes “too old” to merit investigation. 7. Organizational action is inconsistent.27 The organization is inexplicably incompetent in investigating your allegations but is extraordinary meticulous in holding you accountable. 8. It is unnecessarily difficult to report misconduct/reprisals.29 9. Your experience is denied in some way,8,25 such as calling unfair treatment a “personality clash,” or allegations of reprisals a “gray area” or “miscommunication.” You are advised by an apparently supportive person in the institution to “put this behind you” and “get on with your life.” 10. An environment is created where you no longer feel like a valued member of the team.27 11. You are reprimanded after you made allegations of misconduct/reprisals24 when there were no problems with your work prior to your allegations. 12. Your supervisor approves, acquiesces, or fails to intervene in retaliatory actions.4 13. You are referred for psychiatric evaluation or advised to take stress leave following destabilizing reprisals and denials.3,5,14 14. Hypocrisy: You are praised for reporting misconduct but no steps are taken to protect you from reprisals.3 personal betrayal to acknowledge that institutions are often trusted or depended on in much the same way as individuals. According to BTT, traumas that are perpetrated in the context of a relationship in which the victim trusts and/or depends on the perpetrator will be remembered and processed differently than other traumas. Familial rape, childhood physical abuse perpetrated by a caregiver, and domestic violence are examples of betrayal traumas.29 So are reprisals against employees who report misconduct that harms members or clients of the institution. Institutional betrayal can happen through acts of commission in which the institution takes action that harms its members. This occurred for 2 Texas nurses who were criminally indicted for misuse of official information when they reported a physician to the Texas Medical Board after the hospital administration failed to take action on their concerns.22 Institutional betrayal can also occur through acts of omission, in which the organization fails to take actions that could protect members, as in Rodriquez-Noza’s case,12 where an investigation of her allegations was claimed to have occurred, when it fact it had not. Institutional betrayal can be systemic but made to appear to be isolated incidents. For example, one employee might receive a curt e-mail in response to the reporting of a concern, and this appears to be an isolated incident of a concern being summarily dismissed. However, if all complaints receive the same curt response,29 this indicates that the institution’s deliberate but unspoken policy is to routinely ignore 62 www.jpnnjournal.com employee concerns. The person who has made the complaint is left wondering how the manager could be so incompetent in handling the allegations, when in fact the manager is simply enacting the institution’s unspoken policy of ignoring and minimizing complaints. Every time the whistle-blower takes the matter up the chain of command to a higher manager, she is met with similar inexplicable incompetence, which is, in reality, a well-choreographed systemic institutional betrayal. Institutional betrayal often occurs when the reputation of the institution is valued over the well-being of members or clients. For example, during the investigation into child abuse at Penn State, it was determined that allegations had been buried for a period spanning 14 years.25 During this period, the University’s leaders had made a series of decisions that prioritized Penn State’s good name over all else.8 Institutional betrayal is associated with complex outcomes similar to those associated with interpersonal betrayal. Empirical evidence of the impact of institutional betrayal includes psychological distress, anxiety, dissociation, and suicide attempts.29 When measured directly, the exacerbating effects of institutional betrayal on psychological well-being are clear and consistent with BTT: higher rates of dissociation, anxiety, and other traumarelated outcomes.8 Wright et al30 used BTT to explain how betrayal of trust by an institution exacerbates posttraumatic symptoms. Using an augmented version of the Institution Betrayal Questionnaire, they sampled undergraduate students at a Northwest university who had participated in January/March 2018 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. study-abroad program. Of the students who reported a traumatic experience, more than one-third (35.44%) also reported experiencing at least one form of institutional betrayal, such as minimization or cover-up of the traumatic event. In 4 of 6 subtypes of study-abroad traumatic events, institutional betrayal contributed to posttraumatic distress. Another study of institutional betrayal of female university students who reported unwanted sexual advances10 found that almost half (46%) of victims reported experiencing at least one form of institutional betrayal, including 21.5% of participants who reported that the institution responded as if their experience was no big deal. A further 9% reported that the institution made it difficult to report the experience, 12.5% of participants said the experience was covered up, and 2.1% reported they were punished in some way. The authors concluded that the added institutional betrayal surrounding sexual assault exacerbated what was already a traumatic experience.10 Likewise, the institutional betrayal of whistle-blowers would exacerbate the trauma of reprisals. Institutional betrayal can even occur at a community level. Beamish7 presents a case analysis of the Guadalupe Dunes oil spill in California. Community members not only reacted to the immediate event but also experienced a more encompassing breach of trust by corporate and governmental regulators. Community members felt betrayed and angry because they believed the spill was not “accidental” but was the outcome of systemic disregard. Once the spill was “discovered,” local Unocal mangers denied it and state and federal regulators were slow to push for resolution. The pattern of a unified front of denial in the face of objective evidence is typical of systemic institutional betrayal, and trauma is exacerbated when regulatory watchdogs play a part in the betrayal, as occurred with the Bernie Madoff Ponzi scheme,31 for example. SUMMARY The similarity of gaslighting behaviors of sociopathic individuals who abuse romantic partners, institutions that betray their members, and workplaces that systematically undermine the credibility and mental health of whistle-blowers is striking. For whistle-blowers, the processes and effects of gaslighting have not been specifically identified in the research literature, although complex PTSD outcomes related to whistle-blowing have been described.2,5 CONCLUSIONS Along with the recommendations for research that focuses on the means, processes, and outcomes of The Journal of Perinatal & Neonatal Nursing whistle-blower gaslighting, the following recommendations emerge as having promise in helping nurses who report misconduct to minimize the effects of whistleblower gaslighting. It is important that whistle-blowers who suffer reprisals recognize the reality of their experience.13 First, Miller19 suggests that people who report misconduct should not see themselves as “whistle-blowers” but as “truth tellers.” Second, whistle-blowers who experience reprisals are victims of bullying reprisals and need to be supported as such. Third, depending on the jurisdiction, whistle-blowers could also be victims of a crime when whistle-blower protection legislation is violated. Fourth, whistle-blowers are victims of institutional betrayal when their organization fails to take their allegations of misconduct and reprisals seriously. Finally, organizations that stonewall investigations and deliberately avoid evidence of reprisals to label the whistleblower mistaken, overreacting, or paranoid are perpetrators of whistle-blower gaslighting and need to be held accountable for this psychological abuse as well as the commonly identified workplace bullying acts of reprisal. Research is required on the links between stonewalling investigations of alleged misconduct, reprisals, and adverse outcomes in whistle-blowers that are eerily similar to those reported by victims of domestic violence9 and even torture victims.32 There is a dearth of specialist support geared toward the phenomenon of whistle-blower trauma related to institutional betrayal and whistle-blower gaslighting. Until THE diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases classification systems, workplace policies, and legislation catch up, it appears that one of the most helpful sources of validation for whistle-blower gaslighting victims might very well be Web sites that support victims of abuse. Ways in which long-term whistle-blower trauma can be mitigated include having the individual who witnesses misconduct asking herself about whether her mental map of how the organization will react is accurate. Before reporting misconduct, all employees should take a step back to observe whether there is any evidence that the organization might not be as true to its ideals as it professes. For example, a vaguely formulated code of conduct might suggest that it has merely been established under the pretense of meeting legal and social requirements.33 Clues include the use of “should” or “shall” (instead of “must”) and “guidelines” rather than “procedures.” Words such as “should” mean that policies can be interpreted as suggestions rather than requirements. Also, perhaps there have been examples of other employees being denigrated for reasons that www.jpnnjournal.com Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 63 are difficult to understand with a current mental map that sees the organization as fundamentally ethical and well-meaning. Even if the nurse truly believes the organization will act with integrity, before reporting concerns, she should consider that there is always a possibility that she will be punished, denigrated, and portrayed as mentally ill if she reports misconduct. There are a few alternatives to making a formal allegation of patient-harming misconduct. McDonald and Ahern3 provide a list of alternative activities by nurses who witnessed misconduct but did not report it. These alternatives include speaking directly with the wrongdoer, telling the next shift, quietly doing the right thing, telling a “higher up” in confidence, and using humor or manipulation to change the situation. However, even using these tactics to protect patients from harm, 32% of nurses who used 1 or more of these non–whistle-blowing strategies were ignored or told to “forget” their concerns and one or two others experienced active reprisals. When a whistle-blower experiences reprisals, institutional betrayal, and whistle-blower gaslighting, she has experienced a profound injustice that most other people, including counsellors, might not understand. If required, the most effective mental health intervention is likely to be found with a clinician who has expertise in working with complex trauma survivors. Clinicians who have experience in working with patients with complex PTSD are able to make sense of perplexing emotional reactions and validate the experience of institutional betrayal.8 Other potential sources of validation of trauma resulting from institutional betrayal and whistle-blower gaslighting can potentially be found in Web sites devoted to survivors of abuse (see, for example, https://lovefraud.com/ and https://www.psychopathfree.com/). People who report misconduct or fraud are often following the policies and procedures required by their job description or code of conduct. Since by some definitions4 whistle-blowing is defined by the occurrence of reprisals, any unusual negative event following the reporting of suspected malfeasance should be viewed as a red flag for the start of reprisals. At this point, the employee should undertake self-protection measures. Such measures include seeking legal advice and mental health support and engaging in emotional hygiene activities such as getting enough sleep and exercise.34,35 It is also recommended that any employee who reports a concern and subsequently experiences an unusual negative workplace event seemingly out of the blue should consider looking for a new job rather than naively trusting that her current employer will do the right thing. 64 www.jpnnjournal.com References 1. Grannon R. The blind maze and the double bind of the narcissistically abusive system. https://www.youtube.com/ watch?v=nCiIh5l F64. Published 2016. Accessed June 17, 2016. 2. Peters K, Luck L, Hutchinson M, Wilkes L, Andrew S, Jackson D. The emotional sequelae of whistle-blowing: findings from a qualitative study. J Clin Nurs. 2011;20(19/20):2907–2914. doi:10.1111/j.1365-2702.2011.03718.x. 3. McDonald S, Ahern K. The professional consequences of whistle-blowing by nurses. J Prof Nurs. 2000;16(6):313–321. 4. Rehg MT, Miceli MP, Near JP, Van Scotter JR. Antecedents and outcomes of retaliation against whistle-blowers: gender differences and power relationships. Organ Sci. 2008;19(2):221– 240. doi:10.1287/orsc.1070.0310. 5. Rothschild J. The fate of whistle-blowers in nonprofit organizations. Nonprofit Volunt Sect Q. 2013;42(5):886–901. doi:0.1177/0899764012472400. 6. Jackson D, Hickman LD, Hutchinson M, et al. Whistleblowing: an integrative literature review of data-based studies involving nurses. Contemp Nurse. 2014;48(2):240–252. 7. Beamish TD. Environmental hazard and institutional betrayal: lay-public perceptions of risk in the San Luis Obispo County oil spill. Organ Environ. 2001;14(1):5–33. 8. Smith CP, Freyd JJ. Institutional betrayal. Am Psychol. 2014;69(6):575–584. doi:10.1037/a0037564. 9. Hayes S, Jeffries S. Romantic terrorism? An auto-ethnographic analysis of gendered psychological and emotional tactics in domestic violence. J Res Gend Stud. 2016;6(2):38–61. 10. Smith CP, Freyd JJ. Dangerous safe havens: institutional betrayal exacerbates sexual trauma. J Trauma Stress. 2013; 26(1):119–124. doi:10.1002/jts.21778. 11. Jones-Berry S. Nurse calls on PM to investigate “dysfunctional whistle-blowing.” Nurs Stand R Coll Nurs G B 1987. 2014;28(31):15. 12. Keogh K. Tribunal told that whistle-blowing nurse’s claims “are without merit.” Nurs Stand R Coll Nurs G B 1987. 2014;28(45):7. doi:10.7748/ns.28.45.7.s2. 13. Nicholson SB, Lutz DJ. The importance of cognitive dissonance in understanding and treating victims of intimate partner violence. J Aggress Maltreat Trauma. 2017;26(5):475–492. doi:10.1080/10926771.2017.1314989. 14. Abramson K. Turning up the lights on gaslighting. Noûs-Suppl Philos Perspect. 2014;28(1):1–30. doi:10.1111/phpe.12046. 15. Bjørkelo B. Workplace bullying after whistle-blowing: future research and implications. J Manag Psychol. 2013;28(3):306– 323. doi:10.1108/02683941311321178. 16. Cleary SR, Doyle KE. Whistle-blowing need not occur if internal voices are heard: from deaf effect to hearer courage: comment on “Cultures of Silence and Cultures of Voice: The Role of Whistle-blowing in Healthcare Organisations.” Int J Health Policy Manag. 2016;5(1):59–61. doi:10.15171/ijhpm.2015.177. 17. Grassley C. Senator. A story of whistle-blower retaliation at the Pentagon. https://www.youtube.com/watch?v=Qamru3 FnVbY. Published April 6, 2016. Accessed June 25, 2017. 18. King G, Scudder JN. Reasons registered nurses report serious wrong doings in a public teaching hospital. Psychol Rep. 2013;112(2):626–636. doi:10.2466/21.13.PR0.112.2.626-636. 19. Miller LA. What you should know before you “blow”: nurses and whistle-blowing in healthcare. J Perinat Neonatal Nurs. 2013;27(3):201–202. doi:10.1097/JPN.0b013e31829c8a90. 20. Moore L, McAuliffe E. To report or not to report? Why some nurses are reluctant to whistle-blow. Clin Gov. 2012;17(4):332–342. doi:10.1108/14777271211273215. 21. Osborne K. Nurses feel “impotent, alone and unheard”, whistle-blower tells NHS. Nurs Stand R Coll Nurs G B 1987. 2014;28(41):9. doi:10.7748/ns.28.41.9.s6. January/March 2018 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 22. Thomas MB, Willmann J. Why nurses need whistle-blower protection. J Nurs Regul. 2012;3(3):19–23. doi:10.1016/S21558256(15)30203-9. 23. Wilkes LM, Peters K, Weaver R, Jackson D. Nurses involved in whistle-blowing incidents: sequelae for their families. Collegian. 2011;18(3):101–106. doi:10.1016/j.colegn.2011.05 .001. 24. Houdek P. Professional identity and dishonest behavior. Soc Sci Public Policy. 2017;54:253–260. doi:10.1007/s12115-0170132-y. 25. Klein JL, Tolson D. Wrangling rumors of corruption: institutional neutralization of the Jerry Sandusky scandal at Penn State University. J Hum Behav Soc Environ. 2015;25(5):477– 486. doi:10.1080/10911359.2014.983258. 26. Smith CP, Freyd J. Insult, then injury: interpersonal and institutional betrayal linked to health and dissociation. J Aggress Maltreat Trauma. 2017:1–15. doi:10.1080/10926771 .2017.1322654. 27. Smith CP, Freyd J. Institutional Betrayal Questionnaire (IBQ) and Institutional Betrayal and Support Questionnaire (IBSQ). http://dynamic.uoregon.edu/jjf/institutionalbetrayal/ ibq.html. Published 2015. Accessed June 30, 2017. 28. Kemp V. Antecedents, consequences and interventions for workplace bullying. Curr Opin Psychiatry. 2014;27(5):364– 368. doi:10.1097/YCO.0000000000000084. 29. Gómez JM, Smith CP, Gobin RL, Tang SS, Freyd JJ. Collu- 30. 31. 32. 33. 34. 35. sion, torture, and inequality: understanding the actions of the American Psychological Association as institutional betrayal. J Trauma Dissociation. 2016;17(5):527–544. doi:10.1080/ 15299732.2016.1214436. Wright NM, Smith CP, Freyd JJ. Experience of a lifetime: study abroad, trauma, and institutional betrayal. J Aggress Maltreat Trauma. 2017;26(1):50–68. doi:10.1080/10926771 .2016.1170088. Freshman A. Financial disaster as a risk factor for posttraumatic stress disorder: Internet survey of trauma in victims of the Madoff Ponzi scheme. Health Soc Work. 2012;37(1):39– 48. doi:10.1093/hsw/hls002. Başoǧlu M, Livanou M, Crnobarić C. Torture vs other cruel, inhuman, and degrading treatment: Is the distinction real or apparent? Arch Gen Psychiatry. 2007;64(3):277–285. doi:10.1001/archpsyc.64.3.277. Frost J, Tischer S. Unmasking collective corruption: the dynamics of corrupt routines. Eur Manag Rev. 2014;11(3/4):191–207. doi:10.1111/emre.12034. Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77(9):911–917. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulnessbased stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57(1):35–43. doi:https://doi.org/10. 1016/S0022-3999(03)00573-7. The CE test for this article is available online only. Log onto the journal website, www.jpnnjournal.com, or to www.NursingCenter.com/CE/JPNN to access the test. For more than 135 additional continuing education articles related to professional issues, go to NursingCenter.com\CE. Instructions: r r r r Read the article. The test for this CE activity is to be taken online at www.NursingCenter.com/CE/JPNN. You will need to create (its free!) and login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Professional Development online CE activities for you. There is only one correct answer for each question. A passing score for this test is 11 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost. r Registration Deadline: March 31, 2020 This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749. Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia Board of Nursing, #50-1223, Florida Board of Nursing, #50-1223, and Georgia Board of Nursing, CE Broker #50-1223. Provider Accreditation: Disclosure Statement: For questions, contact Lippincott Professional Development: 1-800-787-8985. Lippincott Professional Development will award 1.0 contact hours for this continuing nursing education activity. Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Journal of Perinatal & Neonatal Nursing The authors and planners have disclosed that they have no financial relationships related to this article. Payment: r The registration fee for this test is $12.95. www.jpnnjournal.com Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 65