A sincere apology that expresses regret and acknowledges shortcomings can help patients come to terms with something that has gone wrong - and can also help nurses
Dorothy Armstrong, MN, PGCert, BSc, RGN, is nursing adviser to the Scottish Public Services Ombudsman, Edinburgh.
Armstrong D (2009) The power of apology: how saying sorry can leave both patients and nurses feeling better. Nursing Times; 105: 44, early online publication.
Saying sorry to a patient can be a difficult part of nursing practice. But a sincere and prompt apology, using appropriate language and tone, can help those involved come to terms with something that has gone wrong.
Nurses may be concerned that saying sorry will make litigation more likely, but the evidence is that patients are less likely to resort to the courts if they feel they have been listened to and have been offered a “proper” apology that expresses regret and acknowledges fault or shortcoming.
One technique that nurses can use when having to make a difficult apology is to use the three Rs: regret (saying sorry and accepting responsibility); reason (providing a reason for the mistake); and remedy (trying to resolve the mistake as far as possible).
Apologies can be beneficial not only to patients and relatives, but to nurses too.
Keywords: Apology, Feedback, Ombudsman, Litigation
- This article has been double-blind peer reviewed
- Apologising is a key part of our lives – it can be extremely powerful when done well.
- Nurses should be empowered to say sorry, even if they are not directly involved in an incident or problem.
- Use the three Rs: regret, reason and remedy.
- Avoid being vague, passive or conditional.
- It is not easy to apologise, but it is everyone’s business.
The New South Wales Ombudsman (2009) stated: “An apology is the superglue of life. It can repair just about anything.”
As children we are taught to say sorry for our mistakes, but in our working lives as adults many of us find saying sorry a real challenge. But used well, an apology can be extremely powerful for patients and empowering for nurses.
In my work as nursing adviser to the Scottish Public Services Ombudsman, I provide advice to a team of investigators. This work involves the review of nursing records, statements from staff, patients and carers, and notes of meetings. I also meet with nursing staff, patients and relatives to provide an independent and impartial service.
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Often complaints are not upheld: that is, we do not agree with the complainant that there have been failings in the care provided. However, things can and do go wrong. Most complainants are looking for a meaningful apology. They want to be listened to and to be reassured that steps are in place to make sure the same mistake does not happen again. Often I can pinpoint a specific time when an apology given by frontline staff or senior managers would have resulted in a complaint being avoided.
This article provides some useful information about saying sorry, referring to the literature where appropriate. It focuses on a helpful tool that nurses can use to say sorry, called the 3Rs – regret, reason and remedy. Examples of giving a meaningful apology are used throughout the article; nurses can consider, share and hopefully use these in practice.
Why do people complain?
In my role at the ombudsman, it is important to understand why people complain and what it is they are hoping to achieve. The most common reasons complaints occur are:
- To prevent the problem happening again;
- To learn lessons;
- To be given a full explanation and feedback;
- They feel humiliated, betrayed and hurt;
- They want to know what happens next;
- To receive a meaningful apology.
An apology is often one of the most important issues for complainants. They often describe an apology containing the following elements:
- An acknowledgement of the wrong done;
- Confirmation they were right;
- An understanding of why things went wrong;
- An acceptance of responsibility;
- Reassurance that the problem has been addressed and will not happen again;
- A reconciliation of a relationship;
- A restoration of their reputation.
In order to say sorry meaningfully, it is vital to understand the theory and evidence relating to apology, including the definition, reasons, elements, timing and delivery.
What is an apology?
An apology is a way of communicating a message which includes a number of components: a meaningful apology requires all parts to be present. It should first express regret and sympathy as well as an acknowledgement of fault, shortcoming or failing. Omission of one part or the other is only a partial apology and is much less powerful than a complete one. One definition of apology that summarises these two halves is “an encounter between two parties at which one party, the offender, acknowledges responsibility for an offence or grievance and expresses regret or remorse to a second party, the aggrieved” (Scottish Public Services Ombudsman, 2006).
Lazare (2004) pointed out that an apology is more than just saying “sorry”. If, for example, nurses say “I am sorry for the delay”, they are not apologising as there is no acknowledgement of a grievance or acceptance of responsibility. On the other hand, they could say: “I am sorry for the wait. The consultant has been delayed in theatre due to an emergency and his appointments are running late. He has asked a colleague to relieve him and he will see you as soon as possible.” In this example “sorry” is part of the apology as the wrongdoing has been acknowledged and action has been taken.
This quote from a complainant explains this point:
“I am very unhappy with your letter which you seem to be classing as an apology. The terms of the insulting letter are not acceptable to me partly due to the cold and uncaring language. I am at a loss to understand why you would need to query if any distress may have resulted from your actions.”
This response is a good example of how a complaint can escalate when the wrong language and tone is used in a written apology. Later in this article, I discuss the importance of using the most appropriate words in a letter and also highlight the use of tone and body language when a verbal apology is given.
Many people find it difficult to apologise. They do not like to admit they were wrong for a number of reasons including hurt, denial, avoidance, fear of rejection and inability to accept responsibility.
Lazare (2004) suggested that women generally apologise more often than men because they have a higher tendency for guilt and culpability, a precursor to apology. There are also cultural differences in the language used and the reasons why people apologise. For example, in German the phrase for apology is ‘entschuldige bitte’. The core of the word ‘schuldig’ means guilty. In Japanese a number of words are used in different types of apology, depending on the context and the relationships.
Fear of litigation
In my experience, another reason why staff do not apologise readily is fear of litigation (Sellar, 2007). There is a strong sense in the nursing community that apologising is, in itself, admitting liability and therefore should not be done. However, there is strong evidence that apology is not linked to higher rates of legal action (Holden, 2009; Leape, 2005; Woods, 2005).
Section 2 of the Compensation Act 2006 (an act of the UK Parliament) says “an apology, an offer of treatment or other redress, shall not of itself amount to an admission of negligence or breach of statutory duty”.
This particular section only applies in England and Wales. When the 2006 act was introduced, the accompanying explanatory notes said section 2 was intended to reflect the existing law. Our understanding is that the law on this point is the same in Scotland as in England and Wales.
Currently there appears to be no written guidance on apology from the NMC or the nursing professional associations.
However, the General Medical Council (2006) provided helpful guidance for doctors: “Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology.”
“The Being Open policy advises healthcare staff to apologise to patients, their families or carers if a mistake or error is made that leads to moderate or severe harm or death, explain clearly what went wrong and what will be done to stop the problem happening again” (NPSA, 2005).
Many nurses think they should not say sorry as they may be sued, but saying sorry does not mean admitting liability in the legal sense. Even in the litigious US, where lawsuits are much more likely to be instigated than in the UK, there are a number of studies which suggest that being open and honest with patients and relatives when things go wrong can reduce the number of claims against staff. In addition, if the quality of the relationship between the doctor and patient is good, and the patient feels their views and values are respected, then the doctor is less likely to be sued (Lazare, 2004).
The New South Wales Ombudsman (2009) provides a powerful example of how a meaningful apology was used and how important being open and honest can be to the relationship between healthcare professionals, patients and relatives.
Eleven patients were given a contaminated solution which had been injected into the heart during cardiac surgery. Five patients died following this error. One of the senior staff recalled the events:
“One of my senior colleagues called all the families together and he and I sat down with the 11 families and said: ‘This is [a] terrible thing that has happened. It is awful. We are truly sorry that this has happened. We are not going to do another operation until we have got these patients out of the woods.’ And we did not. We said: ‘We are going to leave no stone unturned until we find out what the cause was.’ We knew it was an infection, we knew it had occurred somewhere in the processing of that solution, which was beyond our control as individual clinicians. But we said sorry. None of those patients took legal action.”
We know from our work at the Ombudsman’s office that complainants want a meaningful apology, lessons to be learnt and to prevent the same mistake happening again.
Lazare (2004) described the importance of apology for staff as well as complainants. The ability to apologise after something has gone wrong can be powerful for staff, and can help to restore the relationship with a patient or relative and so avoid further damage.
By saying sorry, nurses are helping to restore a balance. An apology recognises that nurses will often be feeling bad too, even if they are not at fault themselves.
Elements of a meaningful apology
Once the decision has been made to accept that things have gone wrong, a meaningful apology can have a powerful effect on both parties. Box 1 shows the elements of a meaningful apology.
Box 1. Elements of a meaningful apology
- An acknowledgement of the wrongdoing. Whether or not it was intentional, an apology must correctly describe the offending action or behaviour. The description must be specific to demonstrate an understanding of the offence. It must also acknowledge the resulting impact on the aggrieved person/people.
- Accepting responsibility for the offence and the harm done. This includes identifying who was responsible.
- A clear explanation about why the offence happened. This should show the offence was not intentional or personal. Although most people will want an explanation, this is not always the case. Also if there is no valid explanation, then one should not be offered. The offender may wish to say there is no excuse for the offending behaviour.
- An expression of sincere regret. This demonstrates that the offender recognises the aggrieved person’s suffering and is sorry. It can be difficult to express sincere regret in writing – face to face can be more powerful.
- An assurance that the offence will not be repeated. This may include a statement of the steps that have been or will be taken to put things right.
Source: Scottish Public Services Ombudsman (2006)
Delivering an apology
How should an apology be delivered? The “devil is in the detail” is an important principle here. The content and method of apologising will depend on the circumstances and what you hope to achieve; however, there are some good generic principles.
Giving a meaningful apology is part of good interpersonal and communication skills and I believe it can be taught and rehearsed as part of the pre-registration curriculum and in continuing professional development. Role play, observation, simulation and media such as film and drama can be used to encourage nurses to practise their skills. Also, using tools such as the 3Rs, nurses can practise techniques at home and at work. How many times have you witnessed a good or bad apology in the service industries such as in shops or restaurants?
For a verbal apology, timing, tone of voice, content and body language are important. Ensuring that both nurse and complainant are as calm as possible is important to ensure the situation does not escalate. However, the very act of saying “I’m sorry” is often enough to calm everyone down and move on towards reaching a solution to the problem identified.
The apology should be natural and sincere and not defensive. Communicating shame, guilt, pain and humiliation in writing or verbally adds sincerity, as does showing empathy, by expressing regret, sadness, sorrow or sympathy for the harm experienced (New South Wales Ombudsman, 2009).
Is it ever too late to apologise?
Apologies are best given at the earliest opportunity, as soon as a wrongdoing is identified. However, sometimes this is not possible as an enquiry or investigation may be required.
Because complaints must go through the local complaints process before coming to the ombudsman, considerable time may have passed before their complaint has been fully addressed. The ombudsman’s role is to decide whether a complaint is upheld and to make recommendations for the future. Very often, one of our recommendations may include asking the organisation to provide a meaningful apology and we provide guidance (Scottish Public Services Ombudsman, 2006). But is this too late to apologise?
It is never too late to apologise. Lazare (2004) provided a historical example of apology: in American history, from 1932-1972, the US public health service studied the effects of syphilis on 399 African American men. The men were recruited with the promise of free medical care and were never told they had syphilis and received no treatment if they had the disease. Some 128 men died of syphilis or related disease and the condition was passed on to their families. In 1996, 25 years after the study was completed, and following media attention and lobbying from various groups, President Bill Clinton delivered an apology to the victims, on behalf of the US:
“No power on earth can give you back lives lost, the pain suffered, the years of internal torment and anguish. What was done cannot be undone. But we end the silence. We can stop turning our heads away. We can look you in the eye and finally say on behalf of the American people, what the US government did was shameful and I am sorry. To our African American citizens, I am sorry that your federal government orchestrated a study so clearly racist. This can never be allowed to happen again” (The White House, 1997).
Who should give the apology?
Apologies should be given by the right person. That is either the person who is responsible for the mistake, or someone who is seen as speaking on behalf of the organisation.
The method of delivering is important too: a written apology underlines the seriousness of the matter and the time and effort in the writing of the letter recognises this. Saying sorry verbally is often the right approach if a person wants to express their hurt or humiliation (which is more difficult to communicate in writing).
The most effective approach is to provide a verbal apology, followed up by a written, detailed letter.
The three Rs – a tool for nurses
This tool can be used in everyday practice, and has the power to de-escalate anger and aggression and defuse emotion. It can enable and empower nurses to manage conflict and resolve tension (Box 2).
Regret:it is important to recognise that something has gone wrong by acknowledging it, even if you are not at fault. Saying sorry, in a meaningful and sincere manner, is crucial. Often this first step is enough to de-escalate the situation.
Reason:even if you feel criticised and hurt, it is extremely important to provide a reason (if there is one) for the mistake, but to avoid being defensive. Make sure you are clear that the wrongdoing was not intentional or personal, so keep to the facts. Try to put yourself in the complainant’s shoes and step back from the situation. Stay objective.
Remedy:try to resolve the mistake there and then, if you can. Ask the complainant what they would like to happen and take responsibility to investigate, if necessary, and provide feedback to them as soon as is practicable. Encourage colleagues to be proactive too.
Nurses should use this tool at work and try it out at home and with their friends. I have found it particularly effective with my teenage children.
Box 2. Three Rs: regret, reason, remedy
- Meaningful, real, acknowledge wrongdoing
- Just say sorry
- Accept responsibility
- Be honest – this does not mean you will be sued
- The wrongdoing was unintentional and not personal
- Trying hard to do the right thing
- Next steps – who will do what
- Investigate to find out why
- Provide feedback
In my work as the ombudsman, I often hear people say they have not been listened to and they feel humiliated and powerless: that if only staff involved in a mistake or wrongdoing had been honest and open and provided an apology, they would not have pursued their complaint.
A meaningful apology is a powerful tool that we can all use to enhance our practice. Part of my work involves looking at the kind of apologies staff give to patients and their relatives. Unfortunately, we have collected some poor examples such as: “I’m forced to apologise, so I will.”
However, we have also seen exemplar statements such as: “Your complaint has made me reflect on what I did and here is what I have learnt from it. Here is what I’m going to do and I apologise unreservedly.”
Apologies are both simple and complex and each apology is unique. Many factors must be considered such as the nature of the mistake, ranging from minor offences such as delays in being seen and unappetising food, to more serious unprofessional behaviour or drug error. Mistakes can be made by one member of staff, the team or there may be systemic failure within an organisation. However, a successful apology can be a positive experience for all parties.
General Medical Council (2006) Good Medical Practice 2006. London: GMC.
Holden J (2009) Saying sorry is not the same as admitting legal liability. BMJ (letters); 338; 370.
Lazare A (2004) On Apology. New York: Oxford University Press.
Leape L (2005) Understanding the power of apology: how saying ‘I’m sorry’ helps heal patients and caregivers. Focus on Patient Safety; 8: 4, 1-3.
National Patient Safety Agency (2005) Being Open Policy. Being Open: Communicating Patient Safety Incidents With Patients and Their Carers. London: NPSA.
New South Wales Ombudsman (2009) Apologies – A Practical Guide. Sydney: New South Wales.
Scottish Public Services Ombudsman (2006) Guidance on Apology. Edinburgh: Scottish Public Services Ombudsman.
Sellar W (2007) When sorry seems to be the hardest word. BMJ, 15 September 2007.
The White House (1997) Remarks by the President in Apology for Study Done in Tuskegee. Washington, DC: The White House.
Woods MS (2005) What if we just said ‘I’m sorry’?Patient Safety and Quality Healthcare. November/December, 2005.