It is sometimes said that the hardest things to do reap the most benefit. Is this true for the practice of apology and disclosure in healthcare? And if so, to whom do the benefits accrue? Pamela Popp, executive vice president/chief risk officer for Western Litigation, offers her perspective.
Disclosure and apology in healthcare includes the intention to share information with the patient regarding all aspects of their treatment, even if there has been an error in the rendering of that treatment. The error does not have to be intentional, nor does it actually have to harm the patient, but is important information to share with the patient. While studies have confirmed that disclosure is beneficial, it’s important to understand the psychology involved in this benefit.
Our society places significant value on the act of apologizing when one person is impacted by another. Children are taught to apologize when they do something wrong and adults are expected to apologize when actions warrant: bumping into a stranger on the street, hurting someone’s feelings with a comment or causing an accident, for example. When one of these situations occurs, the injured (or wronged) party has an expectation—created through these societal norms—of receiving an apology.
An apology should include three basic components: the statement of regret for what happened, a clear “I’m sorry” statement and a request for forgiveness. It is even stronger when it acknowledges the feelings of the recipient and addresses the prevention of a future reoccurrence. The purpose of the apology is to restore the dignity of the ‘victim’ and the standing of the transgressor.
When one doesn’t occur, the person is caught in cognitive dissonance—the disconnect between what they believe to be true (“I will now receive an apology”) and what is actually true (“I am not hearing an apology”). This disconnect causes frustration which can manifest in disappointment, anger or even violence in the person who feels cheated of the expected apology.
In addition, insincere apologies can do more harm than good, since the receiver will be able to sense the lack of sincerity and feel even more insulted or harmed than before the artificial apology.
For the discloser (usually a provider of care), the benefit may come in the form of release from the obligation to hold the error as a secret. Some individuals find the concept of rendering an apology to be impossible, where the act of recognizing the event and its result is simply too hard. It was reported in a recent article in Psychology Today (Why Some People Refuse to Apologise) that those who are unable to give an apology are often trying to protect their ‘fragile sense of self’—or simply cannot recognize a flaw in their own performance or behavior.
In their minds, it is safer to distance themselves from the other person’s expectations than to try to reconcile the vulnerability necessary to render a sincere apology. They may believe that by apologizing they will have assumed full responsibility for the event, including relieving the other party of any involvement in the outcome.
This aspect of apology is important to appreciate when the individual looking to apologize is a healthcare provider, and the event is the outcome or consequence of their care. Physicians, in particular, succeed in healthcare when they have developed complex coping skills that allow them to maintain distance from their patients in order to objectively diagnose and treat the condition without emotional attachment. This distancing can be perceived by the patient as indifference, callousness or even arrogance.
To the person who has erred, their professional actions have become intertwined with their character so if someone then criticizes their behavior, they are essentially criticizing the person as well. This can be incredibly threatening to an individual whose definition of self is wrapped up in his or her professional successes and interactions.
This can be called “ego” and is often described in common vernacular as “his ego got in the way” when in fact, it was his fears, emotions and insecurities that prevented him from doing what would have been expected by society (ie, rendering an apology). When added to the situation where an apology is needed, these factors cause the emotions to become much more complex than may otherwise be viewed by an outsider.
An article entitled Apologies and Settlement in Court Review (Volume 45, Robbennolt) looked at the nature of apology in legal cases, and found that statements of fault acceptance had more impact than apologies that simply stated sympathy without responsibility.
How does the healthcare sector address this disconnect—the expectation of the patient to have someone take responsibility and say “I’m sorry” when there is an unanticipated outcome or error, and the provider’s reluctance to make a statement of responsibility and apology inconsistent with their world view of what they need to do in order to survive?
That remains the challenge. Resources are becoming more widely available that allow providers to feel more comfortable with the expression of emotion. It is important that this be considered a skill needing to be learned, including the appreciation of the other person’s feelings, their expectation of the apology, and the need for that apology to be sincere and heartfelt. Much like learning effective negotiation strategies, the parties need to understand before they are confronted with the event how to assess the situation, determine what is needed for success and how to deal with their own emotions before, during and after the conversation to remain comfortable.
Using adult learning techniques, providers can be shown the effectiveness of a sincere apology through education, role-playing and actual involvement. Like other language skills, apologizing is easier once an individual has had experiences in various forums, and with varying results, in order to feel comfortable with his or her approach.
It is crucial that the providers understand that the act of apologizing does not mean admitting inferiority, unworthiness, weakness or submission. It is simply the act of witnessing the other human being—of actively seeing their pain, frustration or distress, and giving those emotions value. One study—Are You Big Enough to Apologize, in Psychology Today—defines apology as the ability to say “I see you were harmed by my action and that matters to me.”
Creating a mentor or support system for the providers is also a key component to developing a successful disclosure/apology program. Within these colleague conversations, the providers can share their difficulties with the emotions that arise for them, and can learn how to best balance their need for distance with the ability to engage in emotion when needed.
It is also important for providers to understand how a statement of apology could be utilized should litigation result from the error or outcome. The majority of states have enacted legislation meant to encourage the honest dialogue between provider and patient, including the use of the phrase “I’m sorry”.
More importantly, the research in Are You Big Enough to Apologize has indicated that if an apology is given, the receiving individuals “felt that settlement offers were more adequate, felt less need to punish the other party and were more willing to forgive than were participants who did not receive apologies”.
Why would this be the case? Because the act of apologizing sincerely, and having that apology accepted, brings both individuals back to a level playing field, emphasizing their humanness. When appropriate, the apology can also include a promise to prevent recurrence in the future as well as a form of compensation (monetary or otherwise).
These components are best received once the baseline of the relationship is restored, so that the wronged party can feel recognized and witnessed by the transgressor, and see the offerings as between equals rather than as an act of dominance or demanded submission. This equality is known as the ‘norm of reciprocity’—meaning that there is a repayment of sorts to bring the parties back to a status equal to that which existed before the underlying event.
Finally, it is important for the provider to remember that the issue of apology and admissibility in court applies only in situations where the event actually makes it to litigation, and then to trial. Fortunately this percentage remains very small, with less than 5 percent of filed medical malpractice cases reaching courtrooms for trial, and an even smaller amount continuing to actual verdict.
It is in the majority of situations, where a conversation is being held with the patient or family after an event, before litigation is contemplated, that a sincere apology is most effective. When it is effective in that moment, there will be no need to worry about how it will be perceived by a jury, but instead a focus on how to make the patient feel witnessed, cared for and acknowledged.
Disclosure, apology, Pamela Popp, Western Litigation