Afraid to Apologise?

Care Opinion (CO) is a two-way feedback system which allows health service users to share feedback and subsequently receive a direct response from organisations. This has not only helped to make innumerable improvements in NHS medical practice and infrastructure, but also provided a safe space for users to share stories anonymously, process their experiences, and feel acknowledged by those involved in their care.

While over 75% of stories posted on the website are of a positive nature, expressing deep gratitude and praise, there is also a significant minority of complaints, emphasising inadequacies in service quality at the point of use. Common themes raised in critical feedback include poor communication, concerns with medical treatment, and a perceived lack of respect for the service user. These stories are understandably upsetting to share, which makes it all the more important that organisations provide a genuine response, as complainants have often lost trust in services and could carry these negative feelings throughout their healthcare journey if not addressed.

This short post will explore the key aspects of an apology, examples of good and bad apology responses on CO, and fundamentally, why medical professionals are afraid to ‘say sorry’. 

An apology is a written or spoken expression of one’s regret, remorse or sorrow for having wronged another. Studies suggest that apologies often fall into two main categories: (1) sincere apologies which take accountability for wrongdoings, and offers ways to rectify or prevent the same errors, and (2) instrumental apologies which serve a personal goal of avoiding punishment or rejection by others.

A thoughtful CO blog post by Anne Cooper titled ‘Weasel Words and No-Apology Apologies’ explores this idea, that many apologies lack sincerity and avoid acknowledging what actually occurred, opting to use the old-time phrase of ‘I’m sorry you felt that way’. This suggests that the patient is somehow choosing to see the events in a negative light, and fails to express any personal accountability.

In order to further explore the apology responses seen on CO, I created a new search with the following filters:

• Stories with criticality greater than or equal to 3 (moderate to severe)
• Responses including the term ‘apology’

 

This produced a total of 143 stories, of which only 12% were marked as ‘helpful’ by the respective authors.

On analysis of the stories and responses, there was a clear trend which appeared: for severe criticality stories, authors had almost always written extremely detailed accounts of a negative event (or series of events) which caused them great distress and invariably affected their ability to function after the encounter. Despite this, a large majority of these stories only received a short, automated message from the Feedback or Patient Advice and Liaison Service (PALS) teams of the organisation, requesting them to contact another email or phone number to discuss their complaint further. This is then often followed by another frustrated reply from the author as they share their difficulties with contacting the team, or not receiving any acknowledgement hence turning to platforms like CO for help. This is evidently a vicious circle, exacerbating the author’s upset and further reducing their trust in the organisation and the NHS as a whole.

In contrast, when reading the ‘helpful’ responses, there was a vast difference in the approach and tone of apology. Four key elements that made these responses more sincere included, (1) validation of the author’s experiences and feelings, (2) expression of remorse for what had happened, (3) explaining why the error may have occurred and (4) an active commitment to change. These sentiments helped the author feel heard and put greater emphasis on transparency and improvement. Furthermore, responses were perceived as more genuine when the responder was a specific member from the team/department to whom the story was addressed. This is important as it allows them to better understand the nuances of the issue, including the working environment and staff dynamics, and offer more practical solutions in light of the feedback.

The wide spectrum of apology responses seen on CO raises another important question: why are some medical organisations reluctant to apologise? Some laws permit the use of apology messages as part of medical lawsuits, arguing an admission of guilt from the staff members involved. This can lead to permanent suspension and defamation of affected individuals, as well as instilling shame and distrust from colleagues and patients.

This may be the main deterrent to apology, and signifies a deep-rooted issue within the healthcare sector. In addition, another reason why clinicians may be uncomfortable giving a genuine apology is due to a lack of education on how to approach such situations. Throughout medical training, junior doctors are taught to ‘break bad news’ by remaining calm and objective, pausing to allow the patient to process the information and nodding sympathetically.

However, it can be argued that this lacks the true empathy and understanding required in such a scenario. Mistakes are often presented as collective shortcomings and compounded problems beyond anyone’s control, leaving the patient feeling helpless and unable to seek closure. As mentioned earlier, it is vital that responders show accountability and find the courage to admit personal errors; patients are more receptive when matters are seen from their perspective and specific concerns are addressed as opposed to blanket statements of regret.

As a medical student myself, I understand the unease of approaching a foreign situation without a framework or model (as we are so often taught), and it can be daunting to show weakness in a profession where every action could potentially change the course of a person’s life, for better or worse. However, once we understand the limits of our competence, this can allow us to see the bigger picture and ensure that mistakes do not define us, but rather refine our future practice and improve patient outcomes.

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Written by Emma Johnson, 3rd year medical student at Sheffield University as part of a Social Accountability SSC placement (December 2023).