The impact of complaints on Clinical Psychologists Part 2: Early career experiences

Paula Redmond (: 00:04

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.

We return this week for the second part of our exploration into the evidence base around the impact of formal complaints on clinical psychologists. For this week's episode, I was joined by Dr Naomi Hogben, clinical psychologist, who has conducted one of the few research studies looking directly at the experiences of clinicians who receive complaints. Her study focused on early career clinical psychologists in the NHS. And we started off by discussing what drew her to this research topic.

Naomi Hogben (: 01:12

I think it's really interesting. It wasn't something that I had considered before I think. Prior to training, I had worked in, kind of outside the NHS in a private inpatient facility where there were lots of complaints made by kind of young people, staff, their family, the young people's families, as well as kind of through the CQC, and I think it was something that was around a lot of the time and kind of witnessed a lot of staff, having a lot of anxiety about their complaints, a lot of kind of media backlash around some complaints and things and also a lot of the young people felt really strongly about some of the things that were being said in the media or some of the complaints were being made that didn't quite align with their experiences of the care that they'd received. So was, yeah, I guess it's quite an unusual place where I'd witnessed them from lots of different positions. And then my research supervisor, Noelle Robertson, had kind of a background doing some work with the HCPC and exploring complaints. And it was something we got talking about, and once we started looking into it, realised that there really isn't very much research at all, and about the experience of kind of a clinician receiving a complaint, there's quite a lot about patients who make complaints, but not what it's like for the clinician to receive the complaint. And that's kind of across healthcare professions. But there is one study that I'm aware of that's explicitly looked at it from a psychologist's perspective. So it was kind of a real big gap that we wanted to explore a lot more because we knew and had kind of seen around us the kind of really big impact that it does have, but was just a really interesting gap that nobody seemed to have explored very much in the past.

Paula Redmond (: 03:11

Yeah, that's quite shocking that there's so little research. So could you give us an outline of your study? Tell us about some of the background details and how you went about it.

Naomi Hogben (: 03:27

Yeah, of course. So my literature review as part of my thesis was on kind of broader healthcare professionals' experience of complaint and that really highlighted the emotional difficulties, their experience following a complaint being made against somebody, as well as raising kind of lots of questions about the, like when complaints are made in a person's career. So some research has highlighted that newly qualified staff are more susceptible to a complaint being made against them as well as kind of end of career staff, so the real tail ends of a person's career and the research has kind of highlighted that early in a career people are trying to progress quite quickly, people are often feeling like they're at their depth, kind of maybe putting themselves in situations that they're not fully competent in or equally might be just trying kind of a lot harder and maybe not as aware of some of the processes, as some of the reasons for complaints. However, lots of the complaints documented seem to be more around kind of communication difficulties, interpersonal difficulties, and I guess differences in opinion around kind of where a person's care should sit or how that should happen. And then I guess when we looked a little more specifically at psychologists in the UK, we're regulated by the HCPC, also a pretty unique position in that we sit within the NHS, a publicly funded service which doesn't translate or copy across to other countries where research has been explored in the past. So we were really interested in kind of thinking a little bit around that setting of the NHS and whether the fact that your training is funded by the NHS and whether that also would, I guess would potentially be different if you were working outside the NHS and there's different systems for that. So we decided to sit quite firmly within looking at clinicians that work within the NHS. However, the HCPC data doesn't differentiate whether a person is kind of practicing privately or within the NHS. However, we were really interested to see how many complaints had been made. We were quite shocked, I think, when you look at the data. I mean, maybe I was just really naive to it, but I hadn't realized how many complaints are made each year to the HCPC. And then I guess it kind of led me down a bit of a spiral of thinking if that's how many are made to the HCPC, how many are made at a trust level, or how many are made at kind of a service level, or how many are made that don't get to a kind of a formal level, which I don't think I'd quite appreciated beforehand how frequently they are made. And another part that really interested me is where the complaints came from. I think I had this idea that they would come quite heavily from patients complaining about wait lists or kind of the type of therapy that was offered to them or the type of care that was offered to them. But actually the HCPC used to break down why those complaints had been made and lots of them came from places I was quite surprised from, so from other professionals, from trusts and didn't, yeah, I guess it was just quite shocking to me that a lot of it wasn't from patients and that's a bit of a difference for me. I think from the start, they led me thinking that actually there's a lot of this that isn't quite explored and isn't as known about as maybe it should be or isn't spoken about as much as it should be.

Paula Redmond (: 07:13

So, tell us about your methodology. How did you go about setting up the study?

Naomi Hogben (: 07:19

So we were looking at using semi-structured interviews. So we developed our interview schedule based off of primarily the research around doctors, but also Kirkcaldy's study on psychologists in South Africa. And I guess we wanted to give a space where people could really share their experience kind of in as much detail as they wanted to or were able to, to really understand what it was like for them and give them a chance to talk about it. I think that was something that was really important, particularly considering how many complaints are made, but how much research is out there. It doesn't seem like clinicians who have experienced a complaint have had much of a voice about their experience of that. And it was really hard to recruit participants. It was one of the things that we had expected considering that it's not really talked about and considering the lack of research already out there. We didn't know whether that was one of the barriers that stopped people looking into it more or whether it just was something that hadn't been thought about to be explored in the past. We went through the route of advertising through social media and giving people the option to kind of agree to the research in any way that they felt they wanted to, so didn't want to be really specific about. I guess we'd considered recruiting through trust, but didn't want people to be concerned that it would get back to their trust. So we wanted to do it in a way that people felt comfortable in sharing their experience in an anonymous way. We had explored kind of going through unions and different bodies to support that, however, came up with a lot of barriers there as well, which we thought was really interesting just for thinking about some of that difficulty around talking about complaints and supporting people through complaints, but we were able to get 10 participants who very kindly gave up their time to talk to me about their experiences and shared a lot of really kind of personal information and a lot of their personal experience that was really helpful for the research.

Paula Redmond (: 09:31

What were your inclusion criteria?

Naomi Hogben (: 09:34

So we were looking specifically at clinical psychologists who had experienced a complaint within their first five years post qualification.

Paula Redmond (: 09:45

And so that could have been a complaint at trust level or HCPC, including both.

Naomi Hogben (: 09:52

Yes, so we didn't differentiate kind of where it had to be made, but it did have to have been a formal complaint. So not something that was just informally managed to kind of by their manager, but something that had been kind of made formally.

Paula Redmond (: 10:04

So what did you find? What were your findings?

Naomi Hogben (: 10:08

So we had two overarching themes. One that was system indifference, really looking at the, I guess, participants' experience of having a real lack of support during the complaints process and really feeling unprepared for that. A lot of the participants spoke about how they hadn't realised that there was, I guess the possibility of experiencing a complaint so early in their career or hadn't thought about the possibility of experiencing the complaint early in their career. And then when it happened, not always receiving the support that they had hoped they would or thought that they would through the process. So one participant spoke about having a supportive supervisor and how that really made a difference for them. But I think the key take home was around how the complaint was managed really matter to the participants' experience. We had participants who had to go through the process again because it was so poorly managed the first time. We had participants who, so one participant had a really positive experience where they felt like they were really listened to and their information they felt was collected in a way that felt really kind of unbiased and really supportive of their position. However, the majority of participants spoke about a real lack of communication throughout the process. So always feeling like they were in a bit of a limbo where they didn't know what was happening with the complaint, which then kind of led to worries about what would happen kind of coming up. But also I think, which I found quite kind of shocking was that they didn't know or wasn't aware a lot of the time of when the complaint had even ended or concluded. So they were left in this limbo for maybe potentially longer than they needed to be or just weren't aware of what the process was or how long it would take to happen or what would be shared when it was happened. So they never really knew where they stood within that and that yeah, I guess really intensified their experience and how they felt at the time.

Paula Redmond (: 12:29

Can I just jump in there? Because I guess, yeah, it sort of just made me think about the conversations I've been having around this podcast, and that theme has been really, you know, prevalent about people's experience of the process being really traumatic, actually. And that thing of the lack of communication, the sort of lack of transparency just so much unknown about timelines, about processes, about where to get support, making a very difficult situation a million times harder to deal with.

Naomi Hogben (: 13:12

Absolutely and a lot of participants also shared their experience of feeling quite blamed throughout that process because of how it was managed as well, and feeling like the person who was managing the complaint wasn't always potentially the most suitable person, who didn't really understand the clinical decisions or the rationale of why they had done certain things or understood the nuances of where they worked or the complaint as a whole, which then made that process more difficult because they were trying to explain themselves, it felt like the person maybe didn't have all the knowledge they needed to be able to understand that and then didn't know what happened after that or where it went, which was really difficult.

Paula Redmond (: 13:52

Yeah, yeah. And that feels really important because I guess there's something about complaints being an important part of our healthcare system. You know, we want to have processes in place for people to make sure they're getting the right kind of care and that professional standards are maintained and all of that. But I guess, and so having the risk of having a complaint is going to be there and not avoidable, preventable entirely. But I guess some of these bits are avoidable, preventable, and not necessarily rocket science to be able to do something about transparent communication and decent timelines and all of those procedural bits.

Naomi Hogben (: 14:40

Yeah, absolutely. And I think that's where a lot of people felt a lot of frustration with how it was managed. And it's, I guess, as an outsider, sometimes it seems like there are these key things that people could do differently or trusts could do differently and services could do differently. But nobody's ever quite sure why they aren't. Potentially it's not being raised why they aren't.

Paula Redmond (: 15:05

Yeah and sorry, I interrupted you there you were just about to go on to talk about your second theme.

Naomi Hogben (: 15:12

Yeah, so the second theme that we found was the question of, I am a good clinician. And this theme really explored the participant's emotional experience of the complaint. There were lots of very strong emotions felt throughout the experience, both kind of initially once receiving the complaint, kind of this idea of being in disbelief, a lot of stress going into that fight or flight response, that almost panic, but then also throughout the experience of the whole complaints process, lots of participants reported feelings of shame and lots of people spoke about that kind of real difficulty of viewing yourself in that way of shame or naming yourself as… so one participant, the quote that we picked out that we thought was really strong was, they felt really disempowered and like a victim, but that is a disgusting attitude to have because they felt like they couldn't be seen as a victim or feel themselves as a victim when they're the one that's had the complaint made against them. But the way that the process was managed and set up was making them feel like a victim at the same time. And there was this real struggle kind of internally about whether their emotional response was, I guess, acceptable, if they were the one that was having a complaint made against them. And we also found that the emotional experience went far beyond just the complaints process. When talking about their experience with me, for a lot of them, it was a number of years after their experience. However, a few still became emotional during their experience of sharing what it was like for them to receive a complaint or felt a few participants noted that they felt anxious before coming on when they were kind of going back over some of the information they had or documents they had of the time of when they had a complaint or yeah, just that kind of frustration re-bubbling when thinking about their experience and what they went through and how that experience had still sat with them now many years after it happened and it had been finished. And the other kind of really big part of that theme was this kind of worry and fear around their reputational damage. A lot of participants spoke about the impact of having received a complaint so early in their career and thinking about what that meant for them both at the time but also their future. One participant spoke about feeling like people were judging them based on not being experienced enough to have had a particular client in the first place, or participants spoke about being part of a team that didn't really know you very well and how it potentially may have been different if you were already embedded in a team or in a service and a trust that knew you and knew how you practiced, where you're trying to advocate for yourself in the complaints process but also trying to advocate for yourself in the service that you're now working in, and trying to prove that you're not the thing that this complaint is saying you are on top of the pressure that we all feel as newly qualified psychologists being thrown out into the world of psychology and feeling like we're never quite good enough or we're not experienced enough, then having a complaint almost reinforcing that belief and strengthening this idea that maybe they weren't good enough or maybe they hadn't been the right person for a particular piece of work, and that really intensifying that emotional experience that they did have. And a couple of participants also spoke about how they still don't know whether there has been a consequence of having that complaint or whether there'll be a repercussion in the future. One person stopped practicing as a clinical psychologist and another moved area entirely. And there was that kind of fear of what if they come across somebody from their previous job, or what happens when you change job? Do you have to disclose it? And lots of worries around kind of future impact of their career or if they see somebody from that time.

Paula Redmond (: 19:45

So it still felt very live for the participants, even though it was something that happened some time ago. It feels like they were still, as you said, really still holding that and still really activating a threat system for them that’s hard even to talk about it with you. And it makes me just think about the… I suppose that I sort of work with a lot of psychologists, you know, even very, very experienced ones and that imposter syndrome is never far away even if you've been working for 30 years. But that early career time is such a vulnerable time for that developing your sense of self as a profession and you're often still needing to recover from the experience of training. Gosh, such a really vulnerable time for something like this to happen in terms of how it shapes how you feel about yourself as a professional, as a clinical psychologist. And yeah, that comes through.

Naomi Hogben (: 20:54

Yeah, and I think that combined with the lack of support that a lot of the participants felt. And I guess one of the things that Noelle and I reflected on from the findings was around, I guess, the difference from when you're quite heavily supported in training as a trainee on placement, you're fairly well protected, you've got a lot of support on placement, you've got support at the uni, you've got like a really close cohort and how then you're newly qualified and you don't see your cohort as much and suddenly you're not protected as much and there's lots of differences between kind of how much support is offered or how much supervision is offered, and I guess the impact of then receiving a complaint when you've already lost a massive support network that you had on training to them being newly qualified and then hit with a big complaint and feeling really unsupported through that, what that must be like at that point as well.

Paula Redmond (: 21:51

Especially, I guess for most people, kind of, reaching qualification, you know, has seemed like this holy grail, you know, that you work so hard to get there and it's, you know, going to be this amazing experience. You know, you've probably put 10 years plus into getting to that point, striving for that. And to have this experience at that stage must be pretty devastating. And there's these two parts, there's the trauma of receiving a complaint, and then just like with all traumas, how that's responded to by your context really matters in terms of how you can heal from that, how you can process, how you can think about it and the shadow that it casts for your future life. And I guess I'm just wondering, that relationship you have with the NHS, with this profession that you've worked so hard to become part of, and yeah, really sad to hear as you say that some people think that couldn't be, wasn't repairable, wasn't possible to continue.

Naomi Hogben (: 23:03

I think there was a big disillusionment of the NHS and what it meant to be working in the NHS or whether you would or wouldn't be supported through experiences such as kind of receiving a complaint that it sounds like happened really quickly for some of these participants who had experienced a complaint so early in their career that came, as you're saying, as quite a shock at that point and didn't quite meet the expectations of what they were expecting. And then having to find that support elsewhere.

Paula Redmond (: 23:38

And how did, what were your observations on how the participants conceptualised the complaint in terms of whether they were a, you know, whether there was a level of kind of accepting the grounds of the complaint or how they related to the complaint itself?

Naomi Hogben (: 23:59

I think it varied between the participants. I think some spoke about working in quite a specialist area where there was always this idea that people may potentially be unhappy with the outcome of their care they had received or an assessment that had been made. And there were other people who, I guess it almost felt like we're looking for a place to place the blame, and almost saying that they saw the signs really early on that this person may have potentially made a complaint or that type of presentation from them or their family may have made a complaint. And other people who were just really shocked by the experience and didn't quite know how to make sense of it and then would kind of slip into almost self-protective measures with their practice moving forward, and worrying about whether it would happen again because they'd almost been blindsided by it happening in the first place.

Paula Redmond (: 25:01

I think it's really complex, isn't it, that the sense of, again, how we view the role of complaints as being important and, you know, needing to accept that we can screw up and that we can make mistakes. But I suppose I'm thinking about that lack of support bit, that if you haven't got safe spaces to reflect on this process, you can't really think about it in that way. You're not going to be able to own what maybe is your part in that process will be too much maybe and it would be very natural to be locating that elsewhere whether that's the problem patient, the vexatious family, the system and all of that may be playing a role but hard to sit and think about your own part in this if you're not supported. Which is sort of ironic because the whole point of the process is that we learn, I guess, and that systems can learn doesn't feel like that's set up well for that, either for systems to learn or for clinicians to learn through this process.

Naomi Hogben (: 26:17

Yeah, I think it's really tricky. I think it, again, it varied quite a lot in terms of, as you were saying, the participant who felt quite supported and felt like they had a supervisor who did check in and ask things, the experience was very different from kind of participants who felt very isolated during the experience and kind of some people managed to find kind of colleagues they knew in other areas or other services that they could lean on, whereas other people said that they would just almost like ranting emotionally at family, but not really having space to actually explore what had happened or what was going on, further than just the emotions they felt in the moment, because that's what they could talk about with people who don't have an understanding of their job or career or kind of within the confines of confidentiality. But there doesn't seem to be, I guess, our participants were from kind of across the UK in very different services. And there doesn't seem to be like a universal process that is identified or followed to support people. So there are these really big differences in people's experiences because of that.

Paula Redmond (: 27:35

Yeah. And I'm curious for you what this process is like as someone who, when you were doing this, was still on the, you know, still on the path to qualifying, a trainee, stepping into this profession. What's it been like for you to do this work?

Naomi Hogben (: 27:55

I think it's really interesting. I think initially at the time I was like, wow, like this happens a lot. And then kind of almost parked it to the side, I think, in the realm of doing a thesis and managing placement and kind of doing the busy life of a trainee. And then it wasn't until kind of more like around, like preparing for my viva, that I sat and thought about it a bit more and was like, oh, actually, maybe I do need to think about this a bit more, like it does actually happen a lot and it has really impacted on the participants who are really kindly shared their experience for a long time after it's happened as well. I think it definitely made me join a union straight away and think about kind of, yeah, I guess it just made me a bit more aware of kind, of where I work and what support is in place. I think I was really aware when I was looking for my first qualified job, thinking about kind of who was going to supervise me and what level of support I was going to receive and I guess, yeah, thinking about the trust probably more than what I think I would have if I hadn't done this as my research and kind of explored into the depths a lot more, which I think is, yeah, it's really interesting when you sit and think about it now, particularly kind of when I was thinking of like kind of going back through my research before meeting with you, thinking actually like, I'm nearly two years post-qualifying, some of these people had already experienced a complaint by this point, and to me, that just feels kind of crazy. Like, obviously I know that it can happen, but I don't know, like, how I would manage that. Kind of being where I am now, like, I feel like you're still so new to the profession, whilst you've been doing it for a few years and you've been building up your skills and things, it still feels very new, I guess there’s still that imposter syndrome is still very much there, that I can understand why it has such a big impact when it happens at this point in a person's career.

Paula Redmond (: 30:01

And what do you think for people who might be listening to this, any kind of key messages you'd like to get across for, I guess, other psychologists, maybe even newly qualified psychologists, trainees, training courses, trusts, the HCPC itself, what would you like people to really hear?

Naomi Hogben (: 30:23

I guess just this idea of talking about it, I think the thing that seems to really make a difference is when you have that support network around it. One participant reflected really nicely on how it's now they're much further down their career and they're supervising other colleagues and professionals, how they're able to use their experience when it's happened to another person to share and be like, this has happened to me. Like, I know that it's really difficult and how much they feel like that's valued and really appreciated at the time. And I think it is still such a taboo subject and it comes with a lot of shame and a lot of feelings of kind of blame and hurt that people find really difficult to share. But if we're not sharing it, then we can't also have like, receive some of that support or be able to find some of that support, I think kind of as colleagues being able to talk to our colleagues, talk to supervisors, talk to any staff that we might be supervising around any experience of complaint, or just the idea that it can happen. And thinking about making sure people know what those processes are, that anybody in the service your working could have a complaint made against them. It's like being more transparent, what is the process around that? Where can people get support from, both within the service, through the wider trust, other services that can support them, such as unions and kind of wider psychology services that are out there. Thinking about that process and how if you're the person that's looking into a complaint, how you really clearly communicate what's happening currently, what the next steps are, when that outcome has been made, kind of what that means for the person that's involved, because that really does matter and it really does make a really big difference to the person's experience of having a complaint made against them. So I went to the University of Leicester and one of the things that Noelle and I have been doing is talking to third years and having a teaching session on complaints and just talking about this does happen. We're not trying to scare people, we're not trying to say that this is definitely going to happen to you, but trying to just raise that awareness that it does happen. So it's not so much of a shock if it were to happen. And thinking with them about looking at those types of things, like who are your support networks? Who can you go to for support? Making sure that you know who your supervisors are, who these people are that you can go and talk to when they're at that kind of point. So we try to do it kind of earlier in third year, before they start looking for jobs. So the kind of things that they're thinking about going forwards so that, yeah, it doesn't become this massive shock factor when it may happen at some point in their career. And then I guess it's the more the process side of things, just how do we become more transparent? How do we let people know what's happening, how do we support people through that? How do we make that more structured instead of putting everything on to the person who's already going through a really stressful time to have to seek out these things? How do we make sure that it's offered alongside the process of investigation that needs to happen? How do we then have a place for reflection afterwards so that people can do some of that thinking about what can be done differently and thinking about their emotional reaction of that and the impact that has on their work.

Paula Redmond (: 33:45

It just sounds like there's these two key parts around the pragmatic sort of stuff around the process itself and the communication and the transparency and, you know, having clear pathways to access support, but also the availability of emotional support and that those two things are really important. I think I really like how you phrased it earlier about sort of how it's managed really matters, that that really, really has an impact on the impact on how the experience lands and affects people and it seems like there's a lot we can do around that that would really help.

Naomi Hogben (: 34:30

And I guess just giving a voice to people to share what their experience was. Just because it may not be happening right now doesn't mean that it hasn't happened already. There may be psychologists out there who had a complaint early in their career, but that was many years ago. But I'm sure talking to people through this research has kind of helped me to see and understand that that's still having an impact now. So just because it's not something that's happened in the kind of near past doesn't mean that it's not still playing on somebody's mind and impacting on them as a clinician. So thinking about, I guess a little bit more long term around how that's kept on the radar and how people are still checking in around that.

Paula Redmond (: 35:12

And I guess if people are listening and realising that, you know, they've been through a complaint process and it is still something they're holding, that, you know, getting some support for that would be a good idea, maybe.

Naomi Hogben (: 35:26

Absolutely, and I think if we were more open about talking about when it did happen and there was less shame around, we'd probably realise that lots of people we both work with now and have worked with in the past have also had this experience, but everybody's almost suffering in silence, which is making that isolation, this feeling, much worse.

Paula Redmond (: 35:47

And I guess we don't hear or see those stories of people who've been through it and survived and it's been okay. It's kind of this terrible black hole that you might be fearful of or find yourself in the midst of and there's no, because it's not talked about, there's very little to hold on to to know that you can get through and it'll be okay. So yeah, I think talking about it.

Naomi Hogben (: 36:14

And it doesn't necessarily mean that it's going to happen again.

Paula Redmond (: 36:16

Yes, yeah. Well thank you so much Naomi. Is there anything that I haven't asked that you wanted to add?

Naomi Hogben (: 36:23

I don't think so. I think I'm just interested to hear the experiences of everybody else that's in your podcast series. I think it's such an important topic that we do start talking a bit more about. So thank you for the chance to come and share and talk about it. I guess I'm raising it as one of the things that we should be doing. So thank you for the opportunity to help me to do that.

Paula Redmond (: 36:47

Great, well, you're so welcome. Thank you for coming along.

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.