Gaslighting as a Governance Failure in Healthcare

Why suppression of truth signals is a patient-safety risk, not a cultural issue

Co Authors:

Assoc. Prof. Nainaben Dhana DCRT (London), HDRT( South Africa) Grad Cert EBP ( Monash) , ACA registered Counsellor

RT Education and Quality Lead, Adjunct Industry Associate Professor of RMIT, AUSCEP participant (2025-26) &

Dr Alwin Tan, GAICD, MBBS, FRACS, EMBA (Melbourne Business School)

Senior Surgeon | Governance Leader | HealthTech Co-founder
Harvard Medical School — AI in Healthcare
Australian Institute of Company Directors — GAICD graduate
University of Oxford — Sustainable Enterprise

Institute for Systems Integrity (ISI)

Executive Summary

Gaslighting in healthcare is commonly framed as an interpersonal or cultural issue. This framing is insufficient.

This paper argues that gaslighting is better understood as a governance failure mode that disrupts organisational control loops, suppresses safety signals, and increases the probability of patient harm. When concerns are reframed, dismissed, or redirected toward the individual raising them, the system ceases to self-correct.

Drawing on patient safety literature, organisational behaviour research, and governance theory, this paper outlines:

• how gaslighting emerges structurally in healthcare systems
• why it persists under operational and reputational pressure
• how it degrades safety, learning, and accountability
• what boards and executives must do to restore integrity

The central thesis is clear:

Gaslighting is not a communication failure. It is a signal suppression mechanism that converts manageable risk into systemic harm.

1. Introduction

Healthcare systems are complex, high-risk environments that rely on continuous feedback to maintain safety (Reason, 2000). Errors, near misses, and concerns raised by staff are not anomalies but essential signals that enable system learning.

However, in many healthcare organisations, these signals are not consistently processed. Instead, they are:

• minimised
• reframed
• delayed
• or redirected toward the individual raising the concern

This phenomenon, commonly described as gaslighting, undermines the very mechanisms that sustain safe care.

While the term originates in psychology, its organisational expression requires a governance-based analysis.

2. From Behaviour to System Failure

Gaslighting is often mischaracterised as:

• manipulation by individuals
• poor communication
• or toxic leadership behaviour

In healthcare systems, it more commonly emerges as a patterned organisational response under pressure.

Contributing conditions include:

• reputational risk management
• legal defensiveness
• hierarchical authority gradients
• production pressure (efficiency, throughput, KPIs)
• normalisation of deviance (Vaughan, 1996)

Under these conditions, organisations may prioritise narrative stability over truth accuracy.

This creates an environment where:

the appearance of control is maintained while underlying risk accumulates.

3. The Control Loop Model of Healthcare Governance

Effective healthcare governance can be understood as a control loop:

Signals → Oversight → Decision → Correction → Learning

• Signals: incident reports, complaints, whistleblower disclosures
• Oversight: clinical governance, audit, board visibility
• Decision: investigation outcomes, accountability
• Correction: system redesign, remediation
• Learning: policy, training, cultural reinforcement

Gaslighting disrupts this loop at the signal–oversight interface.

Instead of triggering escalation, signals are:

• reinterpreted as interpersonal issues
• downgraded in significance
• contained within conflicted structures
• or delayed until urgency dissipates

The loop remains formally intact but functionally disabled.

4. The Gaslighting Failure Sequence

Empirical observations across healthcare settings reveal a recurring sequence:

1. Signal emergence
   A clinician, nurse, or patient raises a concern.
2. Reframing
   The issue is recast as misunderstanding, attitude, or isolated error.
3. Messenger challenge
   Credibility or intent of the reporter is questioned.
4. Containment
   Review processes remain internal and non-independent.
5. Delay
   Timelines extend, reducing visibility and urgency.
6. Dissipation
   The issue fails to reach decision-making levels.
7. Recurrence
   The same or escalated harm reappears.

This sequence aligns with findings from patient safety research on failure to escalate concerns and hierarchical suppression of voice (Edmondson, 1999; Okuyama, Wagner and Bijnen, 2014).

5. Consequences for Patient Safety

Gaslighting has direct and indirect impacts on patient safety.

5.1 Signal suppression

When staff perceive that raising concerns leads to dismissal or risk, reporting decreases (Edmondson, 1999).

5.2 Loss of learning

Unreported or minimised events prevent root cause analysis and system improvement (Reason, 2000).

5.3 Normalisation of deviance

Unsafe practices become accepted over time (Vaughan, 1996).

5.4 Moral injury and workforce attrition

Clinicians experience distress when unable to act on known risks, contributing to burnout and exit (Dzeng and Curtis, 2018).

5.5 Escalation to external failure

Suppressed risks eventually surface through litigation, regulatory intervention, or public inquiry.

In aggregate, gaslighting transforms early warning signals into late-stage crises.

In oncology settings, gaslighting may occur when symptoms such as pain, fatigue, or treatment side effects are minimised. It can also affect staff, where concerns raised by junior clinicians are dismissed, contributing to burnout and moral injury. Addressing gaslighting is therefore critical to maintaining patient safety, staff wellbeing, and effective clinical governance.

6. Why Gaslighting Persists

Despite its risks, gaslighting persists due to short-term organisational incentives:

• avoidance of reputational damage
• reduction in reportable incidents
• containment of legal exposure
• preservation of leadership authority
• maintenance of operational flow
• Accountability and learning

These incentives create a paradox:

Systems that appear stable in the short term may be accumulating the highest long-term risk.

This dynamic reflects broader governance failures where metrics of control replace reality of control.

7. The Boundary Condition: Truth with Integrity Controls

Unstructured disclosure carries risks:

• reputational harm from unverified claims
• breach of confidentiality
• escalation of conflict
• legal exposure

Therefore, the objective is not unrestricted truth-telling but integrity-controlled signal processing.

Effective systems distinguish between:

• allegation
• evidence
• finding
• corrective action

Gaslighting systems collapse these distinctions by preventing progression beyond allegation.

8. Governance Implications for Boards and Executives

Boards must treat gaslighting as a design risk, not a cultural anomaly.

Key oversight questions include:

• Where do safety and integrity signals enter the system?
• Are reporting pathways independent and protected?
• What proportion of concerns lead to systemic change?
• How are repeat signals tracked and escalated?
• What data is excluded from board-level reporting?
• How are delays explained and monitored?

Boards should also monitor:

• psychological safety indicators
• whistleblower utilisation rates
• incident recurrence patterns
• staff turnover in high-risk areas

These are not cultural metrics.
They are integrity indicators.

9. Restoring the Control Loop

To counter gaslighting, healthcare systems must re-establish functional control loops:

Structural interventions

• independent reporting channels
• mandatory escalation protocols
• separation of legal defence from safety investigation

Process interventions

• time-bound investigations
• transparent outcome reporting
• cross-functional review mechanisms

Governance interventions

• explicit board ownership of safety signals
• integration of integrity metrics into oversight
• protection of individuals raising concerns

The objective is not to eliminate conflict, but to ensure that truth can enter the system without distortion.

10. Conclusion

Gaslighting in healthcare is not a matter of interpersonal dysfunction.

It is a system-level governance failure that suppresses critical signals, disables corrective mechanisms, and increases the likelihood of patient harm.

Healthcare systems do not fail because truth is spoken.
They fail because systems are structured to prevent it from being heard.

For boards and leaders, the task is clear:

Design systems where truth is not punished —
but required for safe operation.

References (Harvard)

Dzeng, E. and Curtis, J.R. (2018) ‘Understanding ethical climate, moral distress, and burnout: a novel tool and a conceptual framework’, BMJ Quality & Safety, 27(10), pp. 766–770.

Edmondson, A. (1999) ‘Psychological safety and learning behavior in work teams’, Administrative Science Quarterly, 44(2), pp. 350–383.

Institute of Medicine (2000) To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press.

Okuyama, A., Wagner, C. and Bijnen, B. (2014) ‘Speaking up for patient safety by hospital-based health care professionals: a literature review’, BMC Health Services Research, 14, p. 61.

Reason, J. (2000) ‘Human error: models and management’, BMJ, 320(7237), pp. 768–770.

Vaughan, D. (1996) The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago: University of Chicago Press.