The impact of complaints on Clinical Psychologists Part 1: Evidence and insights
In this conversation Clinical Psychologist Professor Noelle Robertson discusses the profound impact of fitness to practice complaints on psychologists and other health professionals. She outlines the research in this field which highlights the emotional toll these complaints take, the inadequacies of support systems, and the long-lasting legacy they leave on practitioners. The discussion also touches on the increasing trend of complaints, the importance of preparing for potential complaints in clinical practice, and the need for open discussions within the profession to foster better support and understanding.
Noelle mentions the published paper: How do healthcare professionals experience being subject to complaint? A meta-synthesis of reported psychosocial impacts
About the speaker, Professor Noelle Robertson, Professor of Clinical Psychology at the University of Leicester: I am a chartered clinical and health psychologist who has worked in clinical training for over 20 years, having managed an NHS department of Medical Psychology before that. I have had a longstanding interest in working with, and conducting research on how we are affected by the work that we do. Having worked with HCPC as a professional registrant have become increasingly aware of the impact of complaints on health professionals, and have sought to explore this within my own profession.
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Transcript
Hi, I'm Dr. Paula Redmond and you're listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I'll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I'll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.
I wanted to start this series by looking at the research evidence and we'll be doing that over two episodes. In this first part, I spoke with Professor Noelle Robertson to explore what the literature can tell us about the impact of complaints on clinical psychologists and other health professionals, as well as her own personal and professional insights. Noelle also mentions the work of Dr Naomi Hogben, who I spoke with for part two, which focuses on research into the experiences of early career clinical psychologists who have received complaints. So make sure you tune into that episode too. I began by asking Noel to introduce herself.
Noelle Robertson (:I am a clinical and a health psychologist. I'm currently a professor of clinical psychology at the University of Leicester and I've had a long-standing interest in issues to do with governance generally from very early in my career, and more recently have acted as a professional registrant for HCPC in examining fitness to practice for clinical psychologists, and also have undertaken fitness to practice work within our medical school at the University of Leicester. So I've had a fairly long standing interest in this. And I think I, in an effort to be entirely candid, I experienced a complaint, which was a vexatious complaint, nevertheless, early in my career. And I suppose I've had a long standing interest in the impact that that had on me. And then obviously having been participant in fitness to practice processes and being involved in clinical training for a very long time, I've become aware of the impact of complaints that those in receipt of them can be very blindsided by the experience. And I suppose I became more determined to understand that better and think about ways by which we support practitioners to sustain themselves during complaints processes.
Paula Redmond (:So it’s really interesting to have that perspective, you know, personally, and then kind of supporting other colleagues, trainees, and also having an insight into how that HCPC process works. So I wonder if we could just jump into the sort of key question about what your observations are through this experience of the impact of fitness practice complaints on psychologists specifically.
Noelle Robertson (:Yes, well, the evidence for psychologists specifically is relatively circumscribed. Myself and my colleague, Naomi Hogben, published a paper last year where we reviewed the experiences of health professionals who had been subject to complaints. And perhaps unsurprisingly, the bulk of the papers that explore this focus on medical and nursing professionals, so that the evidence base around psychology comes from one substantive study that was conducted in South Africa where healthcare systems are rather different. So prompted by that thinness, we decided to have a look at what was out there in terms of health professionals. And I think what's interesting is that the impact of complaint irrespective of the country, the profession, the responsiveness of the fitness to practice processes in that jurisdiction are remarkably similar, so that complaints are experienced as highly aversive emotionally, that when practitioners are asked in detail about how well supported they feel they have been during the process, there's very little evidence of support that's felt to be meaningful and helpful. And I think the thing that I would also emphasise is that a complaint, and I can talk to personal experience about this, has a lengthy legacy for people. That it's not something that is easily dealt with over a short period of time, that it tends to influence practitioners for a long period of time. So I think overall, those three themes about intense and aversive experiences, a perceived inadequacy of support whilst going through a complaints process, and that having enduring consequences are the key messages I think I'd want to share.
Paula Redmond (:And that's interesting that that contrast or, you know, the very aversive experience of having a complaint, the high levels of distress, are set alongside a lack of support, that there's a real lack of, you know, I guess that being matched up that the emotional impact, the toll it takes on people. Do you think that, do you think part of why it's so difficult is because the support is so bad? Or do you think there's something about it not being recognised or talked about or acknowledged enough?
Noelle Robertson (:Well, I think it's interesting that there is remarkably little evidence that the impact of complaints on practitioners is relatively under-researched. So that may reflect a number of things. I think there's an interesting disjunction in modern healthcare systems where we do have clinical systems that seem to be, you know, in many respects, rightly, so intolerant of error. And yet there is an understanding of clinician fallibility. And I think that's probably worthy of a bit more exploration. But I wouldn't like to ascribe the impact solely to a lack of support. I think we can return to that. I think particularly for people who deem themselves to be caring professionals, it's quite an assault to the self to feel that you might have done harm. So I think self-identity is challenged, professional identity is challenged. And I think the spectre of being stigmatised or shamed within your profession as being inadequate is powerful, as is, to be frank, and the research in non-NHS settings is interesting, and this is a curtailment of livelihood. So people are obviously fearful that their career is going to be curtailed or ended and that they are going to be somewhat vulnerable professionally and financially.
Paula Redmond (:Yes, it's quite potentially quite a sort of existential crisis.
Noelle Robertson (:It is, it is potentially. And I think the, you know, there's no particular blame ascribed to this, but the systems that then people enter may be quite unfamiliar to them. They're not much talked about in training. Certainly as a trainer in clinical psychology, whilst we do some teaching on this, I'm not sure how widespread that is. So that the preparedness for difficult therapeutic engagement and difficult therapeutic conversations, I think is an implicit part of training. But I think that preparation for the potential for complaint is perhaps less developed. So, you know, we may have scope as a profession to think about better preparation and expectation management.
Paula Redmond (:Because I guess that shock is a big part of what people might feel.
Noelle Robertson (:Yes, shock, fear. I think the evidence would tell us that there's quite a lot of ruminative anxiety, particularly if you're being held in limbo during an investigatory process. Within the literature, you hear, you know, you see narratives of people describing the experience as worse than the death of a close family member that people do describe being quite traumatised from the experience. And certainly consequences, which I think is, the consequences of complex are perhaps better described, are to do with avoidance and defensive practice, which are understandable, but it may well be that actually we are losing good clinical skills because of the intensity of the experience.
Paula Redmond (:And I know that the research basis you've described is limited, but does that fit with your experience of people that you've kind of come across in your career who've gone through the complaints process?
Noelle Robertson (:I think seldom have I heard people talk positively about the experience. I think some of us see these processes as learning experiences. And the other thing I think I should emphasise, of course, much of the angst is carried by an individual where there may be wider organisational and systemic feelings that are less attended to. So I think, whilst I think, as is often the case, the individual holds this sense of responsibility, I should also say that complaint processes are often levelled at wider issues within health services. I think, forgive me, I think the data at the moment suggests that over 40 % of complaints are targeted more generically at the delivery of health care than they are the specific practitioners within it.
Paula Redmond (:And am I right, I think that there's something you mentioned in your paper that there's been an increase in complaints in recent years?
Noelle Robertson (:Yes, it's a modest but growing pattern.
Paula Redmond (:And how do you understand that?
Noelle Robertson (:I think there are probably a variety of factors going on. I think if we think about why complaints arise, it's often because expectations aren't met. I mean clearly there can be deeply suboptimal care, but many complaints can arise through communication issues, expectations not being met and that can be within systems, colleagues, managers, as much as it can be clients who express dissatisfaction. I think it would be no surprise to say that the health service has been struggling for a number of years in the global north as the challenges of aging populations, cost containment, staff distress and burnout, you know, there is wider opportunity, I think, for distress to be expressed and complaints are part of that I suspect.
Paula Redmond (:So you've outlined there some of these, the individual, the sort of aversive experience of having a complaint and some of that really difficult and distressing impact on the individual. The other part that you mentioned was about the support structures in place and what people have reported that that has, I suppose, not been so helpful.
Noelle Robertson (:I think the evidence would just suggest that there is an absence of support, that there's a lack of clarity about the processes that people become involved in. That sometimes, of course, if there's a very serious complaint, then professionals will be restricted in terms of the professional activity that they can undertake. So there's time to kind of be held in this limbo, which can be difficult. And I think because we don't discuss likelihood of complaints and norming that as a possibility, then people may feel reluctant to expose the difficulties that they're experiencing. I think Naomi's work, looking at early career psychologists particularly, is instructive because as people are transitioning into the early stages of their career, they're obviously concerned about how they might be viewed by others because people don't know them well, they haven't yet established themselves. So I think that that point, the points of transition can be particularly difficult for people, but the research base across professions, which would include psychology, is that in the event of a complaint, there are not really many things in the way of providing structured professional support. So anecdotally, what people talk to is talking within their families, which of course may put pressure on those systems and there may not always be sufficient understanding of the pressures on the clinician. And I think that often those who are in the process of being complained about will seek out peers who they know have also experienced something similar. So I think the scope for looking at peer support, but again, if we don't talk about these things, then that might be covert. So I suppose we have to have a discussion as a profession about how open our engagement is and what reflective processes we encourage about this really from training onwards.
Paula Redmond (:Yes, I feel for me, I've been qualified over 15 years and these are the first discussions that I've had about, you know, about complaints. It's really interesting, that.
Noelle Robertson (:I think there are opportunities. It's very difficult. I mean, you know, as a trainer, being a clinical psychology trainer for a long time, finding sufficient psychologically safe spaces to discuss this sort of stuff when you're under constant scrutiny and evaluation is an interesting paradox that you have to work with. But I'm a great believer that I think within the sorts of reflective processes we are good at, then I think we can talk about our fallibility and we can talk about what happens in the event of, and we can perhaps learn better to understand how and why complaints can arise and our role within the structures within which we work in terms of governance. And I think, you know, foster something that acknowledges the rigour that is expected of us absolutely as practitioners, you know, to be fit to practice means that we provide excellent service to our clients and that we maintain confidence in the profession. But we need to think about how we support people compassionately as they go through investigatory processes. I'm very struck that I've done work with jurors in the court system and the idea of acknowledging that through adversarial systems we provide trauma-informed support, I think, you know, thoughtfully be applied to these sort of contexts as well.
Paula Redmond (:The third thing that you mentioned that's come up in the research is around the legacy of complaints. Can you say a bit more about that?
Noelle Robertson (:The legacy, what the evidence tells us. Well, it tells us, as I say, that the impact on self and professional identity lasts for a considerable period of time. When we looked at the research evidence in extremis, in terms of legacy, some practitioners described themselves as moving from a competent professional to becoming a pariah. And I think it's most obviously demonstrated in, and again, the literature is mainly medical in defensive practice, what would be termed defensive practice, but within our own domain, I think you could see people avoiding particular contexts within the workplace, particular client groups seeking out additional support to maintain themselves in areas in which they wish to continue to work. But in extremis, people will leave the profession. There's plenty of evidence that people will walk away. It has been that destructive. And that's a great shame. But I do want to put in a caveat because I think it would be very easy when we'd consider the impact of complaints on us as practitioners to fail to consider the legitimacy of those complaints. So, it may mean many of these complaints may be entirely legitimate. The difficulty at the moment in understanding clinicians responses to complaints is we don't have contextual data. The paper that we published did not provide us with contextual data on the nature and legitimacy of a complaint, but you could well imagine that the severity of a complaint or some very adverse outcomes might well have more damaging consequences for the practitioner. But we don't really, from the qualitative narratives we have from healthcare practitioners, we don't have that data. But in the instance, for example, if a complaint does not proceed or is found to be unsubstantiated, in terms of legacy issues and individuals holding that, then I suppose there is a concern that if you are expending a lot of energy managing your own distress, then of course you render yourself potentially more vulnerable to less optimal care if you're not attending, or if you need to take time away then that's a huge loss in resource to the health service if distress means that you take time away.
Paula Redmond (:And I suppose, I think that's such an interesting point about the legitimacy of the complaint. And I guess that could be quite a subjective process as well in terms of how the person who's been receiving the complaint relates to it, whether or not it's found to be, whether there's consequences or, you know, whether there's a sort of case to answer or not, people, you know, whether they relate to it in a way that, where they hold some responsibility for what happened or not, I imagine would really impact, yeah.
Noelle Robertson (:Yes, I think that's true. The difficulty and the hesitancy I've got at the moment is actually we just don't know that much about psychologists. Much of the evidence that I'm drawing on is predominantly from medical and nursing contexts and often those which are high risk. So, for example, obstetrics and midwifery, staff with those contexts are prominent within impacts and of course you can imagine if there have been terrible things happened in terms of outcomes then the impacts are profound for clients, patients and the clinicians. But we just don't know enough about psychologists.
Paula Redmond (:And why do you think that is? Why do you think there is such a limited research?
Noelle Robertson (:I genuinely don't know. I think I would be speculating. As I said earlier, I think there's this interesting disjunction between clinical systems who are rightly focused on the highest quality care that can be delivered for all of us as patients, and therefore wishing to ensure that human error or dysfunctional systems are mitigated. And yet there is an acknowledgement of clinician fallibility. And I don't know at the moment, it may well be we're very focused on the pressures of getting it right without considering that we need to balance that with all of our human frailty doing the best jobs that we can in systems that are challenging. But don't know, sometimes I do wonder why areas aren't examined. And I don't think I have any easy answers. I'd be delighted if people would like to step up to the plate and start doing some research with us, you know, to explore this further.
Paula Redmond (:In wonder, again, in terms of the legacy of these experiences, what your thoughts are on how that may impact people's relationship to the NHS as a system.
Noelle Robertson (:Oh that's interesting. I don't know because I suspect this is evolving. You know, I'm someone who's been, you know, I'm a product of the late 80s and early 90s in training, so I've been qualified a long time. And, you know, because of my own background as a Scot, as a child of the 70s, I guess, then, of course, I view the NHS, if not quite like the national religion, then I'm deeply, deeply committed to its role in improving all our lives. And, you know, remember conversations with my father about what things were like in rural Scotland before the advent of the NHS. But of course, that's my cohort and my parents' cohort. How people view the NHS now, I'm not quite sure. I do think there is an expectation though that as your employer, you know, that your strengths and vulnerabilities are supported to be the best clinician you can be, and if you find yourself experiencing a complaint, then you would hope that your employer would provide support. I'm not sure that from our own experience of Naomi's work on early career NHS psychologists that that's what they felt. And I think that, you know, benignly there is huge variability in the quality of support available through what is a very large organisation. So there's likely to be huge local variability. But, you know, it does often feel that in striving to deliver the best quality care, there can be a fear that's engendered rather than an understanding. And I do understand that this difficult drive to ensure that, you know, when you receive NHS care it’s the best that it can possibly be and therefore where it falls short. But equally, you know, I hope what I haven't suggested today that this should rest on the shoulders of us as individual practitioners, you know, there are clearly systemic and organisational features that are occurring within what has been an under resourced organisation, series of organisations for a long time that are particularly challenging.
Paula Redmond (:And what about your experience as a professional registrant within the HCPC? What kind of lens has that brought for you in thinking about this?
Noelle Robertson (:That's an interesting question. I think it has offered me insight into some of the significant organisational and systemic issues in which psychologists are endeavouring to deliver best care. I think it has shown me the best and worst of practitioner behaviour. It has shown me the sensitivity and rigour with which the investigation process is undertaken and the very excellent legal advice that we have as panel members. And in recent years, it has revealed, as with many of our systems, a lengthy waiting time before people are necessarily seen. So there are parallels with our legal system at the moment in terms of a backlog of casework and staff within the tribunal service who are having a lot to do to juggle and do that. But I think it's felt very worthwhile to do that. I would suggest to colleagues though to consider it as something that they could both bring their skills to but also learn from. I want to encourage people to consider actually becoming a registrant panel member because they can bring their formulation skills and learn and then be able to disseminate to others how these processes happen.
Paula Redmond (:Great, yeah. So what do you think is important for psychologists to know in terms of, you know, what you mentioned, preparing ourselves for the possibility that we might face something like this in our careers?
Noelle Robertson (:Well, I think, you know, we do a lot of work in preparing ourselves for challenging clinical environments and potentially difficult therapeutic engagements. So I do think as we learn, there ought to be an orientation starting in training to prepare and expect the likelihood of a potential dissatisfaction with something about what you do, that it might not ever reach the status of a formal complaint, but I it's wise for us to start at a very early stage to say this is the type of work we do, we’re in a regulated profession, people have recourse to express their dissatisfaction. And that's not an unusual part of being a regulated profession. I think that's norming it. I think it's important to understand, as I said earlier, the how's and why's of how complaints can arise, how dissatisfaction can arise and is expressed and encourage transparency really from the early stages about that. I think one of the key elements in training an early career is to understand how governance processes operate within your employing trust. And I think it is quite useful too, to have an understanding of if and when complaints arise or are formalised. mean, there are stages to this, obviously, then what processes do those encompass and what would a process entail if you were experiencing that? I think, you know, I could go on, I think, reflective space with mentorship, particularly early in career. And again, because you, I think, want to discourage the notion that this is necessarily an individually held locus or responsibility, actually, to discuss some of the challenges about working in difficult environments and what that might expose you to in terms of risk. Because I think one of the things I have seen through regulation work is people getting themselves into a pickle because they've actually been endeavouring to do their very best, but that might have meant, for example, that they've worked out with their competence or they have breached therapeutic boundaries or whatever. But you can almost see the system in which they're working as they try to negotiate some of the things they’re trying to do, I think, in order to be most helpful.
Paula Redmond (:And I'm curious about what advice you might give to anyone who might receive a complaint having been on both sides of that experience.
Noelle Robertson (:I, that's quite difficult at the moment. I think, I go back to in a sense to my previous point, I think you have to, perhaps better than I was, you know, five year qualified, be prepared for this as a possibility. I know that's the kind of preemptive element before it actually happens to you. I think, you know, from the earliest work I did before I was working clinically, I researched in audit and governance and was somewhat familiar with quality management approaches early in my career, and I think I always felt that candour, transparency, openness, seeking out support, understanding one's own fallibility was really important. I caveat that though, because I think, you know, for some people having talked over the years to people who have experienced complaints, it's where do you take that? So I think, you know, as a profession, we need further discussions about those spaces and those supports that can be made available. I mean, you know, we have obviously organisations like ACP, you know, but there's an issue about being able to discuss this at its earliest. And as I said earlier, there is suggestion from research evidence that utilisation of peers who have been through the process, so whether actually people identify themselves as mentors again pre-emptively might be a possibility. I think avoidance is not a strategy that's going to work.
Paula Redmond (:I guess there's something with all of this about just talking more about it. And as you said, you know, being able to have and create spaces where that feels safe to do so, I guess to, you know, just to hear, you know, those stories of peers who've been through it and survived and, you know, that kind of, I can imagine it must be a very isolating experience.
Noelle Robertson (:Yes, I think it can be. And I think we can do better as a profession. I mean, we are thoughtful, we are reflective, we are, I believe, you one of the most open of health professions in terms of our consideration of issues, and we are creative. And of course, we draw on best evidence. So I think, you know, with all those bits of scaffolding, I think we can do better.
Paula Redmond (:And just sort of along those same lines, whether there's anything in addition you would say about, you know, those supporting colleagues who might be going through something like this, whether that is a trainee or a supervisee or those working in staff support who might have a clinical relationship with another psychologist.
Noelle Robertson (:Yes, I think I would welcome further discussion actually with colleagues. I don't think I have, you know, specific answers myself. I think there are fora, there are fora where we could discuss the best way forward or create fora to discuss the best way forward, because clearly I realise, you know, I've been talking about a narrative that actually could be potentially fear inducing, you know, that the evidence is out there that being subject to complaint is not a pleasant process. And I think we can have discussions about how we can make it more endurable and actually that fosters learning and a capacity to thrive in an environment where that's a possibility. So yeah, I think I'm not a guru in these matters, I do think I would welcome conversations with colleagues about their views because again that's what psychology is good at, you know, coming together to formulate from numerous perspectives what could be better.
Paula Redmond (:Thank you for listening. If you've enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I'd love to connect with you, so do come find me on LinkedIn or at my website, and do check out ACP UK and everything it has to offer. All the links are in the show notes. Thanks again, and until next time, take good care.
