The Power of Apology

This is article twenty-eight in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

John is sweating; he feels unwell, and his blood pressure is so high that he can hear his heartbeat in his ears. Anxiously rubbing his hands together, he approaches the office of the clinical director. He softly knocks on the door and asks, "Hi Lisa, could I please have some advice?... I've really messed up!"

Regardless of the industry or profession, 'to err is human.' This means that occasionally, despite our best efforts and intentions, we all make mistakes.

John explains to Lisa that when he admitted Mrs Smith's prize show cat, Esmerelda, to be spayed, he assured her that he would keep clipping to a minimum and use a midline approach to reduce the chances of a patch of hair growing back in a different colour on the flank. However, he had not mentioned the need to place an intravenous catheter for induction or asked the nurses to be sparing when they clipped for IV placement. When Mrs Smith arrived to collect Esmerelda, she shrieked in horror upon noticing a patch of fur missing from her cat's front leg. The nurse discharging Esmerelda had asked John if he would go and speak to Mrs Smith. He hoped Lisa would be able to offer him some ideas on what he could say to resolve the situation.

When mistakes are made, it is sometimes difficult to know what to say, and there is often confusion over whether empathising and offering an apology is viewed as an admission of wrongdoing. However, saying "sorry that this happened" will show empathy and go a long way in helping to ease the situation. Shame, guilt, anger, fear, and humiliation are all commonly recognized as feelings that prevent apologies from being made, and blame cultures perpetuate a fear of failure.¹ It may seem easier not to say anything at all.

Staying silent

Rather than saying the wrong thing, we often choose to remain silent, feeling more comfortable passing the management of concerns or complaints to insurers. However, not apologising can also have consequences. For our clients, a lack of timely communication can raise suspicion and concern, and may lead to a perception that the practice team does not care. The RCVS Codes of Professional Conduct state that veterinary surgeons and nurses must respond "promptly, fully, and courteously to clients' complaints and criticism."^2,3

For those receiving a complaint or criticism, a lack of opportunity to empathise and offer an apology can have profound effects on their emotional and physical well-being, as feelings of remorse, shame, and guilt eat away at them and cause them to socially disconnect.

"When we develop the courage to admit we are wrong and work past our resistance to apologising, we develop a deep sense of self-respect."⁴

"Oh gosh, John, that does sound tricky. I would advise you to start with an apology…"

When performed effectively, an apology is a powerful aid in:

• Rebuilding trust
• Restoring balance
• Showing empathy
• Enhancing resolution
• Reconnecting and restoring relationships

When receiving an apology, we no longer see the person making the apology as a threat. This enables us to overcome our anger and opens the door to forgiveness.⁴ Offering an apology can also help the wrongdoer overcome some of the feelings of shame and guilt they might feel. Since apologising usually causes us to feel humiliated, it can also act as a deterrent, reminding us not to repeat the act.⁴

Lisa advised John to follow six simple steps…

1. Talk to the person who has been upset as soon as possible after the event. Ensure that where possible, the team member involved or a senior team member offers the apology.
2. Don't rush. It's important to recognise that to be effective, an apology should not be rushed. It is vital that when making an apology, we make time to listen, empathise and fully understand what we are apologising for.
3. Offer to come back to the conversation when the person is ready if they are very emotional. If the person is returning on another day, it might be appropriate to offer, "I'm sorry you have had to come in and talk about this today."
4. Don't say BUT! When you say "I'm sorry," the word that follows is often "but." This should be avoided as it undermines the sincerity of the apology.
5. Make sure you offer a "why," a "because," and an "and." According to Jahan Kalantar ⁵, a perfect apology should have three parts: start with "why" you are sorry, move onto "because" to accept and acknowledge what has happened, and finish with an "and" to show you recognise the impact and the consequences.

In this example, John might offer the following apology:

"I am sorry for not explaining that we would need to clip a patch of fur on Esmerelda's leg for her anaesthetic. I understand that you are very upset and concerned that the fur on Esmerelda's leg will grow back a different colour and because it might affect her show status."

Ensure that the apology is received and accepted. Consider what needs to be done to resolve the situation. In some instances, this may be explaining why your actions were necessary, while in others, it might be reassuring the person who feels wronged that the team will discuss what happened and put steps in place so the same mistake is not made in the future.

Lisa also suggested that they have a debrief later in the day and schedule a team Significant Event Audit (SEA) to consider what systems or processes could be put in place to avoid this type of error happening again.

During the debrief, John explained that when he had apologised to Mrs Smith and explained why it had been necessary to clip a patch of fur on Esmerelda's leg, she quickly calmed down and understood. Esmerelda was much loved, and Mrs Smith explained that she would much prefer her to have an IV catheter so that her anaesthetic was safer than risk losing her. Mrs Smith's only request was that other clients be advised to expect the clipped patch on the front leg before the operation so that they didn't get a shock. John was grateful for the opportunity to debrief with Lisa and thanked her for her advice and support, breathing a sigh of relief that they could go home without worrying about the situation and knowing that he had done his very best. During the SEA, the team discussed amending the consent form and pre-operation information to include a sentence about clipping and what to expect.

Checklist: What can you do next?

• Read our previous article in the series 'I made a mistake, what now – how to deal with errors and embed a learning culture?'
• If an error occurs, stop for 5 minutes, check everyone is ok, summarise the case and the things that well - and identifying the opportunities for learning and improvement. By taking these steps we can reduce the likelihood of psychological harm, moral injury, or becoming second victims. Read more in our previous feature 'When it all goes wrong, the importance of debrief'.
• Whilst a hot debrief is a short process that occurs immediately after an incident, a cold debrief takes place days or weeks after the event has occurred, and may take the form of a Significant Event Audit (SEA). An SEA is a process used to analyse an individual case in a systematic and detailed way to find out what can be learned to identify what changes might lead to improvements. Take our free SEA course and use our free resources.
• The RCVS provides free courses on ‘Complaints: Communication, confidence and compassion’ and ‘Resolving complaints in practice’.
• Veterinary Client Mediation Services (VCMS) uses mediation to resolve disputes between veterinary professionals and their clients. Participation in the trial is voluntary, both parties must agree to take part and is free to users. Any concern which falls outside of the RCVS’ remit may be considered by VCMS. 
• The RCVS provides advice to veterinary surgeons, veterinary nurses and the public on what constitutes good professional conduct. Find out more.

References

1. Prothero, M. and Morse, J. (2017) Eliciting the functional processes of apologizing for errors in health care: Developing an explanatory model of apology. Global Qualitative Nursing Research, 4. https://doi.org/10.1177/2333393617696686
2. Code of Professional Conduct for Veterinary Surgeons. 2. Veterinary surgeons and clients [RCVS] [online]. Available from: https://www.rcvs.org.uk/setting-standards/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons/#clients [Accessed 19 June 2023]
3. Code of Professional Conduct for Veterinary Nurses. 2. Veterinary nurses and clients [RCVS] [online]. Available from: https://www.rcvs.org.uk/setting-standards/advice-and-guidance/code-of-professional-conduct-for-veterinary-nurses/#clients [Accessed 19 June 2023]
4. Engel, B. (2002) The power of apology: How to give and receive an apology. And it's worth it, on both ends [Psychology Today] [online]. Available from: https://www.psychologytoday.com/us/articles/200207/the-power-apology
5. Kalantar, J. (2018)  The perfect apology in three steps [TEDXSydney] [online]. Available from: https://tedxsydney.com/talk/a-perfect-apology-in-three-steps-jahan-kalantar/
6. Empathy vs apology [Sorry Works!] [online]. Available from: https://sorryworks.net/empathy-vs-apology

About the author

Helen Silver-MacMahon MSc (Dist) PSCHF Cert VNECC DipAVN(surg) Cert SAN RVN

Helen is a Quality Improvement Clinical Lead at RCVS Knowledge. Helen qualified as an RVN in 2000 and has worked in both first opinion and referral hospitals. Since qualifying, she has gained certificates in ECC and Small Animal Nutrition and the Advanced Diploma in Veterinary Nursing (Surgical).

In 2021, Helen completed a MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh and is currently undertaking a PhD at the University of Lincoln exploring the non-technical skills that veterinary nurses require when monitoring and maintaining anaesthesia. She is also collaborating with the University of Aberdeen to research Incivility in veterinary practice and working towards chartered ergonomist status.

Helen is an RCVS Knowledge Champion for her role in the sustained training and use of a surgical safety checklist within the small animal theatre at the former Animal Health Trust.

Helen is passionate about developing the veterinary profession's understanding of Human Factors as a powerful aid in improving patient safety, enhancing performance, and supporting the wellbeing of the veterinary team. She enjoys designing bespoke coaching, training and speaking on topics that advance the quality of care. She has written articles and co-authored several book chapters on both clinical and of non-clinical aspects practice.