Analysis

Should I say sorry? How to handle complaints – and how to learn from them

While patient feedback can be difficult to hear, showing empathy may help resolve issues

While negative feedback may be difficult to hear, an empathetic approach can often prevent complaints escalating

  • Nurses are often the first point of contact for angry or upset patients and relatives
  • Empathy, good listening skills and a willingness to apologise can often de-escalate a situation and may be what the patient is seeking
  • Tips, advice and tools for dealing with complaints and learning from negative feedback, even during the COVID-19 pandemic

The NHS in England received more than 208,000 written complaints in 2018-19 an average of 572 a day.

Figures from NHS Digital show that most related to inpatient care, with poor communication

...

While negative feedback may be difficult to hear, an empathetic approach can often prevent complaints escalating

  • Nurses are often the first point of contact for angry or upset patients and relatives
  • Empathy, good listening skills and a willingness to apologise can often de-escalate a situation – and may be what the patient is seeking
  • Tips, advice and tools for dealing with complaints and learning from negative feedback, even during the COVID-19 pandemic
Illustration showing a nurse sitting with a woman, taking notes as the speaks
Picture: iStock

The NHS in England received more than 208,000 written complaints in 2018-19 – an average of 572 a day.

Figures from NHS Digital show that most related to inpatient care, with poor communication being the most common cause for complaint. Where profession was mentioned, medical staff were the group most complained about (41%), but nursing featured in nearly a quarter (23%) of complaints.

Could some complaints be resolved at an early stage?

Separate research by NHS Resolution looked at why some of those who make a complaint go further and claim for clinical negligence.

208,000

written complaints were made about the NHS in England in 2018-19

Source: NHS Digital

A common finding was that after an incident, claimants felt staff had failed to provide an adequate or appropriate explanation and did not say sorry for mistakes.

So how should nursing staff handle an initial complaint from a patient or their relative?

And should they apologise, as complainants appear to wish they would, or is doing so an admission of liability?

The implications of saying sorry

The Patients Association chair Lucy Watson is in no doubt: ‘Patients just want people to say sorry, but there’s still some difficulty around professionals apologising. They worry they’re going to be opening themselves up to litigation.’

But saying sorry does not mean taking the blame, she argues.

And that position is backed by NHS Resolution, as its Saying Sorry leaflet for healthcare staff makes clear.

Apologising, the leaflet says, is:

  • Always the right thing to do.
  • Not an admission of liability.
  • Acknowledges that something could have gone better.

Saying sorry is also ‘the first step to learning from what happened and preventing it recurring’, the leaflet adds.

An apology is only one part of dealing with complaints

Illustration showing two hands holding up a sign saying 'sorry'
‘It’s the first step in learning from mistakes,’ says NHS Resolution
Picture: iStock

But Ms Watson, a nurse by background, suggests there’s more to handling complaints than apologising. Truly empathising with the patient or relative who is making the complaint is also key.

‘It’s about putting yourself in that person’s shoes,’ she says.

A nurse working on a hospital ward, for example, will be familiar with the usual sights, sounds and smells of that environment. But to a patient or relative these things can be strange and unsettling – frightening, even. This can cause the person to seem cross or aggressive when in fact they are feeling anxious.

‘If you’re understanding, and show that you want to listen, that can deflate any anger the person might have started off with,’ Ms Watson says.

‘When people raise concerns with nurses on the ward, that’s a really great opportunity to sort out the issues. You can resolve things at the time. And that’s what most people want.’

Early action can prevent escalation

Sarah Harrison, who heads the complaints and patient advice and liaison service (PALS) at Lancashire and South Cumbria NHS Foundation Trust, agrees. But she acknowledges that finding time to listen properly to a concern can be challenging for nurses.

As a result, difficult conversations frequently take place in a rush, in corridors and other unsuitable settings.

But time invested early pays dividends and can prevent a problem escalating.

‘Someone might say ‘so-and-so was really rude’. But once you’ve spent time listening, you realise that what they’re really upset about is that their child isn’t getting any better, for example’

Sarah Harrison, head of the patient advice and liaison service (PALS), Lancashire and South Cumbria NHS Foundation Trust

‘The sooner you listen to someone’s concerns or distress the less angry those people become,’ Ms Harrison says.

RCN professional lead for community and end of life care Carolyn Doyle supports that view.

‘Quite often, there is a quick solution. If you sit and listen to the concerns you can deal with the situation before it progresses.’

Duty of candour: what’s expected when things go wrong

The Nursing and Midwifery Council and the General Medical Council published joint guidance on the professional duty of candour and being open and honest when things go wrong.

The guidance includes this advice on what patients expect to be told as part of an apology:

  • What happened
  • What can be done to deal with any harm caused
  • What will be done to prevent someone else being harmed

The guidance discourages a ‘formulaic approach’ to apologising and says an apology ‘only has value if it is genuine’.

Take time to listen to the person and get the whole picture

Ms Harrison recommends that, where possible, nurses should find a private space where a conversation can be held in comfort. Take brief notes and use open questions, such as ‘Tell me what happened’, to encourage a full picture to emerge.

‘What we find is that someone might say ‘so-and-so was really rude’. But once you’ve spent five or ten minutes listening, you realise that what they’re really upset about is that their child isn’t getting any better or they’re desperately worried that you can’t fix their problem.

41.3%

of complaints in which profession was mentioned related to medical staff

Source: NHS Digital

‘They focus on a little thing because it distracts them from what they’re really worrying about. So give them the opportunity to let it all out.’

There’s no need to respond immediately – the important thing is simply to listen and get the facts, Ms Harrison suggests.

Then you can explain that you need to go and have a conversation with your manager, and perhaps other staff too, and to reflect on what’s been said before fixing a time to speak again to the person making the complaint.

‘Sometimes when we’re listening to people, we’re practising our answer before we even know what the question is. And if you’re doing that, you’re not actually listening ’

Carolyn Doyle, RCN professional lead for community and end of life care

Ms Doyle adds that as long as you explain your reasons it’s also fine to put off the initial conversation if you are in the middle of something else important that cannot wait.

She suggests a suitable form of words in such circumstances might be: ‘I’m really sorry, I don’t have time to talk about it at this moment but can we make a time so that I can understand the whole context of the issues you have?’

Consider how you would deal with a complaint

When it comes to handling complaints, there’s a huge variation in nurses’ abilities and skills, Ms Harrison says. ‘Some are clearly gifted in dealing with difficult situations and others don’t necessarily respond in the most appropriate way – not because they don’t care, but because they don’t know how.’

And although some staff may feel they don’t have ‘permission’ to respond to feedback about a person’s care, Ms Harrison recommends that front-line nurses be encouraged to ‘own’ any complaint that is made to them and seek to address it.

Sarah Harrison, head of PALS, Lancashire and South Cumbria NHS Foundation Trust
Sarah Harrison: ‘Give them the opportunity just to let it all out’

‘But if they can’t sort it out it’s better they hand it on to someone who can.’

It’s easy to feel intimidated by an angry patient or relative intent on voicing a complaint in the middle of a busy ward. But a cornerstone of good nursing is communication, so if appropriate skills are applied, there should be no need to feel unsettled.

The RCN’s Ms Doyle emphasises the importance of being truly attentive, even if the person complaining is furious.

‘Sometimes when we’re listening to people, we’re practising our answer before we even know what the question is.

‘And if you’re doing that, you’re not actually listening because your brain is so busy trying to construct a response.’

Ms Harrison advises that individuals’ anger in these circumstances is best met with quiet courtesy.

‘It’s really hard to keep shouting at someone who’s politely nodding, not necessarily agreeing but just taking in what the person is saying.

‘In the main, people can’t keep on shouting. And if they do, it’s fine to say, “I’m not sure we’re making any progress in this conversation. What if you take some time to write down what you’re really angry about and we’ll meet again?”.’

She adds: ‘That’s a good way of taking the sting out.’

23%

of complaints in which profession was mentioned related to nursing staff

Source: NHS Digital

Avoid challenging the person’s version of events

Keep the conversation neutral if you can, and avoid challenging the person’s version of what happened.

For example, responding with an immediate denial to a complaint about someone’s alleged rudeness may be antagonistic. It can make the person who is complaining feel they are being considered a liar.

‘What’s important is to put yourself in the other person’s shoes and realise that even if you think you didn’t speak with that tone of voice that’s how it sounded to them,’ Ms Watson says.

NHS Education for Scotland has produced useful advice, using the mnemonic CALM, to help build confidence and skills in handling concerns and complaints.

Using CALM in challenging situations

Try these tips when addressing complaints and concerns:

Compose yourself Take a deep breath and adopt a relaxed pose, keeping good eye contact. Think about your body language and show you are ready to respond positively

Attending Give the person your undivided attention. They have chosen to talk to you – and that is a gift that should be valued

Listen Really listen closely and try to identify key words such as ‘angry’, ‘hurt’ and ‘disappointed’. These emotions need to be addressed as much as the situation that gave rise to them

Moving on Respond positively to what the person has said and lay the foundations for moving towards a solution. The first step is to say you are sorry

Adapted from Leading Accountable and Professional Care, published by NHS Education for Scotland

Talk about desired outcomes

Ms Harrison says another useful approach when dealing with complaints is to try to ensure a positive outcome to the conversation.

Although it can come across as defensive and is best asked if a complainant continues to sound angry, you might ask what outcome the person is looking for.

‘Unless you have a clear idea of what they want in terms of an outcome, you’re never going to resolve it. You’re always going to be guessing at what they want.’

Ms Harrison says often, when the person has described the situation that caused the problem, she will ask: ‘What would you have expected it to be like? Describe a positive experience then we can learn what matters to you most.’

Turning a complaint into a learning event

Carolyn Doyle, RCN professional lead for community and end of life care
Carolyn Doyle: ‘Sometimes we learn more from the things that don’t go so well ’

And although it may be forgotten in the heat of the moment when a patient or relative is airing a grievance, learning is fundamental to the process.

As Ms Doyle puts it, complaints are ‘always a learning event’.

‘We’re human beings and things can go wrong. And sometimes we learn more from the things that didn’t go so well because we tend to reflect more on those.’

Even if the complaint is aimed at you, it’s important to take something positive from it, Ms Watson says.

‘It’s really easy to take it personally but see how you can improve your professional practice.

‘If you are involved when someone raises a concern, that’s a really great source of feedback that you can use in your revalidation.’

Complaints and COVID-19

Illustration showing someone writing on a complaints form
Picture: iStock

There was some suspension of complaints procedures at the height of the coronavirus pandemic, including NHS investigations by the Parliamentary and Health Service Ombudsman, but that work has now resumed.

In fact, says RCN professional adviser Carolyn Doyle, the pandemic has changed nothing in the way nursing staff should respond to the initial complaints of patients and relatives.

‘The same rules apply. You still need to make time. And it may be on the telephone or via video conferencing, but you can still indicate that you’re listening even when you’re not face to face with the person.

‘You can still indicate that you care about what’s happening.’

‘Learning as we go’

‘I don’t think COVID-19 has changed anything,’ says Lancashire and South Cumbria NHS Foundation Trust head of complaints Sarah Harrison.

‘As an organisation we took a decision that we weren’t going to stop responding to complaints, partly because learning as we go is important.

‘And if we say we’re not going to answer any complaints, we’re missing the opportunity that the pandemic has given us and the chance to improve.’

The trust’s patient advice and liaison team have been wearing personal protective equipment when on the wards, she says. ‘And it’s not been a barrier for us.’

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