Part 1 of this article was concerned with reflecting on communication in clinical practice, particularly with regard to breaking bad news in an oncology setting (Anderson, 2019). The initial inspiration for Part 2 was the receipt of a formal complaint by the author, a uro-oncology clinical nurse specialist (UCNS). This raised some pertinent questions about the communication process in the author's organisation. These included the management of the complaint, the issue of poor communication and its ensuing impact on the UCNS's feelings—chiefly the impact on her sense of professionalism, morale, self-esteem and overall confidence. The receipt of this complaint has also prompted reflection on the impact of the complaint and its handling on the UCNS's colleagues, and the organisation's management of the complaints process.
As stated by Gage (2016), complaints and their management are an important indicator of the quality of care. Therefore, effective management of complaints is central to improving services and achieving an open, honest and transparent health service. Emphasis is placed on the communication process. It is important to acknowledge the challenges involved in handling complaints and propose ways in which the complaints procedure could be reconfigured to ensure positive outcomes for all those concerned. The topics for discussion include: the emotional impact of receiving a complaint, the difficulties surrounding statement requests, poor communication, respect and feedback, and the health organisation's responsibility to the person making the complaint and to its staff.
In this article the specific nature of the complaint will not be discussed, only its management and the role of communication.
In Part 1, the importance of effective communication in health care was emphasised as being crucial to enabling healthcare organisations to deliver compassionate, high-quality nursing care to patients (Bramhall, 2014) and in facilitating effective interactions between the organisation and its employees (Barber, 2016; Ali, 2017). Likewise, poor communication can have a negative effect, in that it could result in patient dissatisfaction and ensuing complaints (Pincock, 2004; Evans, 2017). Complaints are inevitable occurrences in health care and effective management of these is crucial to ensuring positive outcomes for all stakeholders—patients, health professionals and the healthcare organisation (Barber, 2016; Gage, 2016; Ali, 2017; Evans, 2017; Doyle, 2019). However, based on the UCNS's personal experience, and on evidence in the literature, it could be argued that the management of complaints is not always effective and, as such, there is a need for some reconfiguration (Pierri, 2013; Gage, 2016; Evans, 2017; Doyle, 2019). The receipt of a complaint can be devastating and emotionally draining (Pierri, 2013), and effective communication is imperative to minimise the ensuing emotional impact on the individuals concerned (Ali, 2017; Evans, 2017; Doyle, 2019).
Challenges in managing complaints
The emotional impact of a complaint
A full understanding and appreciation of the impact of a complaint had not occurred to the UCNS until her department received one. The situation revealed a degree of complacency on the part of the organisation's management concerning the complaints procedure. At times certain doctor and nurse colleagues were surprisingly flippant about the complaint, making remarks such as ‘that's simply the way it is’, or ‘try not to take it personally’. Such a lack of empathy does come as a blow to someone who has been the recipient of a complaint for the first time, after more than 40 years of nursing experience.
It is evident that most nurses strive to deliver optimum care to their patients, and are thus mindful of upsetting them (Cancer Nursing Practice (CNP), 2017; Pierri, 2013). This is certainly true for the UCNS. Since most nurses will be more used to receiving chocolates, flowers or thank-you notes from patients, the receipt of a complaint is distressing. In considering her approach to this situation, the UCNS was undecided, until she read a comment piece in a nursing journal (CNP, 2017) that resonated with her feelings and highlighted salient issues concerning complaints.
Statement request
Receiving a complaint does not mean the person is guilty of poor conduct or an error (CNP, 2017). Nevertheless, how a complaint is managed may imply this. A request for a statement about the issue arrived via the UCNS's email, with no prior warning. This was the first indication that a complaint had been made. Not only was receiving it hugely upsetting, it also implied ignorance of the impact on the UCNS's feelings (Ali, 2017; Evans, 2017; Doyle, 2019). Writing such a statement is an arduous task, and one that requires the nurse to consciously examine the available evidence pertaining to the complaint and, in so doing, there are inevitably moments when the nurse reflects on whether they could have done more in a situation, and thus feelings of guilt may arise (CNP, 2017).
Stress levels are further compounded by the use of placatory and patronising terms in the management's email, such as: ‘This statement request is not about apportioning blame’, or, ‘You should not take this complaint personally’. These statements do nothing to stop the health professional experiencing feelings of being ‘guilty until proven innocent’. Based on the UCNS's and her colleagues' interpretation of their experience, receiving a complaint in such a way not only implicitly apportions blame, it is a personal slight on the individual's professionalism, and a significant knock to their confidence. Ensuing feelings of insecurity often result in the individual second-guessing their decisions or questioning their competency to do their job (Ali, 2017; CNP, 2017; Evans, 2017; Doyle, 2019).
Acknowledging the impact of a complaint on doctors
While this article considers the impact of complaints on nurses, it is important to acknowledge that complaints have an impact on other health professionals, such as doctors. In exploring the evidence, the UCNS has found that there is increased recognition of the impact of complaints on doctors' health and wellbeing (Haysom, 2016). The threat of a complaint or actual legal process can cause psychological, physical and behavioural changes (Haysom, 2016). Doctors facing complaints are more likely to have poorer health and wellbeing, and may suffer from insomnia or relationship problems; they may also perceive the receipt of a complaint as a challenge to their professional and personal identity and, accordingly, lead to a questioning of their professionalism (Nash et al, 2004).
A survey by the General Medical Council (Bourne et al, 2015) revealed that doctors who have been the subject of a formal complaint are at significant risk of moderate to severe depression, anxiety and suicidal thoughts, and practising defensively, including avoidance of procedures and high-risk patients. Nurses' experiences could well be similar (CNP, 2017).
Respect and feedback
Following the submission of her statement, the UCNS received no acknowledgement and no feedback. This was perplexing and, understandably, was interpreted by the UCNS as a lack of respect and a dismissal of her feelings and concerns. Doyle (2019) stated that managers' and supervisors' ability to give constructive feedback to their employees is an important communication skill that can greatly increase motivation. The UCNS considers that healthcare organisations should aim to provide feedback promptly. In this case, the complaint was received 2 years ago and, to date, the UCNS has not received any feedback from management regarding the outcome.
The healthcare organisation's responsibility
The UCNS strongly considers that patients have the right to make a complaint if they feel this is justified, with the added expectation of a speedy response. Likewise, in the event of a complaint being made against them, health professionals have the right to expect acknowledgement of their feelings, and to rely on the organisation's support. Taking into consideration the UCNS's personal experience, and that of her colleagues, and the, admittedly limited, evidence from the literature (Pierri, 2013; CNP, 2017), it is feasible to conclude that receiving a complaint is distressing and requires an effective response.
There seems to be scope for NHS organisations to improve their response to complaints (Gage, 2016). Based on her experience, the UCNS thinks that improvements are needed and emphasises the importance of effective communication. Effective communication in the workplace is deemed beneficial to improving employees' professional standing, self-esteem, morale and self-worth (Ali, 2017). Poor communication, on the other hand, is likely to result in hurt feelings and disappointment (Evans, 2017), which, as the UCNS personal observations have shown, can have a detrimental psychological effect on the individual. Admittedly, the organisation may not be aware of the emotional impact of a complaint on a health professional (Ali, 2017; CNP, 2017; Evans, 2017); increased insight and awareness of this fact could accordingly prove beneficial to lessening the impact of a complaint.
Reflecting on complaints
Receiving a complaint is a challenge and could be construed not as a negative, but as a positive, if it has prompted reflection on the issue of concern, and enabled the nurse to evaluate the experience (Royal College of Nursing (RCN), 2014). Effective communication in the healthcare organisation's management of complaints will help ensure positive outcomes for all parties (Barber, 2016; Ali, 2017; Evans, 2017; Doyle, 2019). However, in the UCNS's experience, management is often focused on appeasing the patient's concerns and minimising the organisation's culpability, and is less focused on the health professional's feelings. Health professionals need to feel supported by the organisation they work for. Therefore, in the eventuality of a formal complaint being made against them, their feelings and concerns must be acknowledged and respected (Ali, 2017; Doyle, 2019). In the UCNS's experience, employees who feel valued and respected not only take pride in their work, but the associated increase in self-esteem, morale, self-worth and job satisfaction is conducive to ensuring they become more proficient health professionals.
To reduce the impact of receiving a complaint on staff, healthcare organisations could:
Conclusion
The management of complaints is a key indicator of the quality of care provided by an organisation, and helps to ensure an open, honest and transparent health service. However, there is scope for improvement. In this instance, effective communication is key to securing successful outcomes for all concerned parties. Evidence from the literature has shown that, not only are complaints a regular occurrence, but that they are also a national problem, at the heart of which is poor communication.
Patients have the right to make a complaint, with the added expectation of a speedy response. Likewise, health professionals, in the event of a complaint being made against them, have the right to expect an acknowledgement of their feelings, and to the organisation's impartial support. It is evident that, for the health professional, having a formal complaint made against them is a harrowing experience. Poor communication in the subsequent management of the complaint can significantly impact the individual's feelings. It is also evident that, despite the emotional implications of having a complaint made against them, organisational support for the health professional is often lacking. For this reason, ongoing review and reconfiguration of the healthcare organisation's complaints procedure, incorporating a formal support network for health professionals, is indicated.
As highlighted in Part 1, learning how to communicate more effectively is beneficial in terms of improving the internal interactions with patients and colleagues and also with the world outside of the healthcare system. Poor communication can have serious consequences for the general public, patients and health professionals. In fact, based on personal experience, the author contends that poor communication causes actual emotional harm. Crucially, we should all look at the way we interact and communicate with each other and, accordingly, take the necessary steps to improve this basic, but extremely important, activity.