This guest blog post is contributed by Anne Cooper, writing in a personal capacity.
Back in the mid 80s hospitals organisations didn't usually have 'complaints managers'. In 1988, when I was a fresh-faced staff nurse, the large hospital I worked in just didn't have that sort of role. We did have a hospital administrator and they dealt with all of the handwritten letters that arrived pointing out where people thought we had gone wrong, but these letters were relatively infrequent. I was intrigued even then.
As a young aspirant manager on a management course I focussed my project on understanding why people complained and how satisfied they were with the outcome. As you might expect it was fascinating stuff. I wish I had kept my report and I suspect it would still hold some useful insights even today.
It turned out I happened to be in the right place at the right time as in 1985 the 'Hospital Complaints Procedure Act' was published. By 1989 I had been appointed as the first 'Complaints Manager' for the organisation. It was one of the most fascinating and challenging roles I have ever done and the things I learnt during that time stand me in good stead even today.
My learning included writing skills. I was a child educated in the 1970s when freedom of expression was valued over grammar and as a result it took some coaching from the hospital administrator to brush up my writing skills. Fortunately I was always part of the nursing family and as a result the practices I followed came from that value base. I had a great Director of Nursing, my boss, who never wavered in his belief that patients should receive high quality care. So my philosophy about the rights of patients and carers was strong but I had to learn how to express the outcome of the sometimes complex investigations I had to undertake. Seeking truths was my mission, but what was less easy was how to express those truths on paper.
So learning to 'craft' letters and words was a learning journey and I soon learnt that the blunt facts were not allowed. I became better and better at getting to truths but sometimes I felt I couldn't speak them. What was expected was a form of what I call “weasel words”: apologise without apologising, as this would be an admission of culpability and guilt.
As the pressure on measuring and analysing complaints became greater during the 90s, as part of the evolving management culture, it seemed to me that increasingly the process itself was the matter being measured - rather than the content of what people were telling us, or the quality of our response in the eyes of the person giving feedback. Targets on response times were introduced and closely monitored by our board but there was little emphasis on the quality of our written responses.
Writing weasel words is not easy. Finding ways to express an apology without actually saying you have done anything wrong is an art form. It's not my natural behaviour, so when faced with the most complex cases I sought to meet people face to face. In this way I could continue to use my communication skills driven by my values.
I had one incident where a clinical director resigned as a result of my response to a complainant. Essentially he had been wrong but he didn't know how to apologise and was unhappy when I did, in writing. I wasn't afraid to push things but there is a fine line that I used to walk and the art of words was part of my life. I was mildly chastised by the CEO at the time after the incident. I learnt to understand the rules.
Sadly I believe that weasel words still pervade the system. And strategies for not admitting culpability, for expressing an apology without taking responsibility, can sometimes be seen on Patient Opinion. For example, the "if-apology": “I’m sorry if you felt you had a poor experience when you came to our emergency department.”
I recognise these words and what they mean. I know them intimately. I have used them in the past myself, despite my misgivings.
Even the lawyers these days tell us that an apology is not an admission of guilt, but still NHS organisations sometimes seem fearful of facing the truth when things go wrong. I think it's time to get our act together – and new digital media like Patient Opinion have the potential to help.
Responses that give a bland 'please contact our PALs officer' irritate me too. I have personally received these responses to my own comments on Patient Opinion, even when no confidential issues are at stake. If someone gives feedback on a public site, organisations should have the decency to reply transparently too, and using the excuse of confidentiality doesn't wash for me.
It's time to face the transparent new culture that the digital world is offering us. So let’s #banweaselwords and #makeapologiesreal.
Anne Cooper is Lead Nurse for Informatics at NHS England
Weasel words and no-apology apologiesWeasel words and no-apology apologies https://patientopinion.blob.core.windows.net/profile-pictures/657ea709-7097-4125-bba0-046aa4473e1c.jpeg Care Opinion 0114 281 6256 https://www.careopinion.org.uk /content/uk/images/logos/co-header-logo-2020-default.png
Update from Care Opinion
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Response from Richard Morris on 16 Mar 2015 at 19:34
The same lack of transparency is evident internally as well. At my Trust (I am a volunteer) good stories from PO appear on comms bulletins. Bad stories are never publicised.
Response from James Munro, Chief executive, Care Opinion on 16 Mar 2015 at 21:02
Thanks for sharing your experience and observations on “the art of apology”, or non-apology. I know that writing this has taken honesty and courage.
Your post rings true because we know – and we are told by site users, staff and patients alike – that some responses on Patient Opinion seem less than genuine. There is a suspicion, justified or not, that some organisations are just “going through the motions” on Patient Opinion. Do concerns raised really get addressed? Is feedback really shared with staff? Does sorry really mean sorry?
These are important issues and we have to address them together. If feedback and response is to have any value at all, and not just be a box-ticking exercise, it has to be authentic.
Our own approach at Patient Opinion (and of course, not the only one possible) is to continue to build on the power of transparency and the community of those who care. For example, a while ago we added the ability for users to rate a response as helpful or not. It’s a small thing, but it starts to create a norm of helpfulness. Here, for example, is the “rated most helpful” response on Patient Opinion last month:
We’re still only scratching the surface, though. We need to keep working at new, open, simple approaches to ensure feedback is heard, learned from, acted on, and in ways that everyone can contribute to. We need to keep the NHS honest. To me, that’s part of what “our NHS” means.
Response from ethicsconsult on 17 Mar 2015 at 09:40
Thanks for this blog Anne. I'd like to echo the respect others have expressed for writing with such clarity and honesty about this issue. Your post illustrates how organisational pressures bear down on people trying to 'do the right thing'. Your comments about language also illustrate what a challenging 'moral performance' an apology is. We have few ways to make good after things go wrong in healthcare, and we are expecting apologies to do a lot. We often don't do them well enough, and maybe we expect too much from apologies too. I agree it's important to know how NOT to apologise. It's important to be talking together about how to do it better, too. This is my approach to thinking about how apologies could be improved http://www.clearer-thinking.co.uk/clear_focus/how-to-apologise/
Response from Gina Alexander, Director, Care Opinion Scotland, Care Opinion on 17 Mar 2015 at 09:52
Thank you so much for taking the time to write this. Encouragingly it's been read an amazing 1600 times so far and counting. It is a refreshingly honest, thoughtful and challenging piece for us all to reflect on.
In Scotland, Dr Dorothy Armstrong (@dorothy_DAprof) speaks and writes in a similar vein on the power of apology. Happily she is much in demand! But it's one thing to listen, what matters is how you act. I read yesterday (and can't find the source now!), "never respond to a feeling with a fact". Lots to make me think yesterday..
You guys should get connected if you are not already.
Response from Heather Bain on 20 Mar 2015 at 08:27
I have recently had a response to a letter after my family asked for an enquiry following my father's death from a brain aneurysm. During this hospital admission it was identified that the aneurysm was missed on a CT scan two years previously when he was being investigated for behaviour changes and cognitive impairment. I do appreciate these letters must be hard to write and so much must depend not the persons receiving them and their understanding. In our situation I felt the condolences took over from what the family really wanted to know but there is an admission of error in the letter. I thought it would be useful to include some of the phrases within the letter for people to make their own conclusions:
- unable to provide a definitive answer
- Thanks for you complaint at this difficult time
- offers his condolenses
- offer their sympathies to you
- saddened to learn of death
- this is normal practice
- X is deeply sorry for not recognising the aneurysm was present
- so all staff will learn from the case
- X is very upset about what happened
- Y would not interpret or examine scans directly
- It is likely
- there is the possibility
- discrepancies in reporting
- offer his condolences (again)
- I fully appreciate our conclusions to you will not
- Once again please accept our apologies for the concern caused
After all the non conclusive narrative the medical directorate finally states 'fully acknowledges this and apologises for the fact the aneurysm was not reported'.
Response from jaine297 on 20 Mar 2015 at 12:04
I found this a very interesting article. I work as an NHS Complaints Advocate and can say that the non-apology causes great distress to people and only ever exacerbates the situation. Often what people want is an explanation, an acknowledgement that errors were made (if they were) or that care was not of a good enough standard etc and a sincere apology. It is when they receive the non-apology that they start getting angry and decide to escalate the complaint.
Response from Eunyj9 on 24 Mar 2015 at 14:03
Dear Ann (and all of the above contributors),
I just wanted to add that I do so agree with all you have said. As the 'front-line' responder to most posts in Ayrshire and Arran it is a difficult thing to get the words right every time.
Some staff are still uncomfortable that people can state their story and their feelings openly and yes, they worry about litigation. There is a culture shift to be made and that is where the leadership will be vital. We are fortunate that while there is a lot of work to be done, by endorsing and supporting the use of Patient Opinion, we are on the right path.
Yes, people can take alternative meanings from innocent word. I have heard that some staff on occasion have been not entirely apporoved of some of my responses. Do the staff think I somehow offer the story authenticity and endorse it by saying sorry? (It is not anyone's place to do that other than the author). Do they perceive that I am somehow being unsupportive of the staff by saying sorry? The 'immediately defensive response' may be natural but we need to get beyond that and see that people writing and sharing these stories genuinely feel the way they feel about their experiences of health care and deserve apology at the least.
Maybe I do get it wrong sometimes but one thing I do know, I will not please all the people all the time but my responses come from the heart and I do mean every word. I am here for the Cultural Revolution. I join you in the quest to #banweaselwords and #makeapologiesreal.
Response from RogerWil on 25 Mar 2015 at 09:53
Thank you Ann. That has been very insightful. I have been helping two of our charity members with Ombudsman complaints recently. The original hospital responses to their complaints were full of the language you describe. In one letter the consultant apologises for failing to arrive at a diagnosis when he did diagnose, incorrectly, treated inappropriately and discharged the patient without any follow up plan. In one case the first response from the Ombudsman was just as bad as that from the hospital. Our appeal against that letter was quite forceful. A proper investigation did follow. Both cases have resulted in very critical reports for the hospitals and for named clinicians. The action plans offered however are weak and endeavour to minimise the in-house impact of Ombudsman criticism. That means we now also complain to CQC once we are sure an issue such as patient safety is involved.
Response from AnneC on 14 Apr 2015 at 16:33
Its Anne here. I just wanted to say thank you to everyone who took the time to comment and give feedback. I just felt the blog needed writing and the number of people who have read it means it was a worthwhile thing to do.
Thank you everyone - lets hope we can improve the way we receive and respond to feedback from anyone who has contact with services. Its how we receive it, respond to it and probably most importantly how we use it to do better that really counts.