Mistakes and Reputational Damage within the Veterinary Profession
Catherine Oxtoby, Head of Underwriting and Pricing at the Veterinary Defence Society (VDS), talks to fellow vet, and PhD Researcher at the University of Nottingham, Julie Gibson about mistakes in veterinary practice; how to learn from them, prevent them from happening again, and the emotional and reputational repercussions that surround them.
“We know it's uncomfortable, it's a real thing and it's a real problem for people. We know it really upsets clinicians and that it can have an impact on the care that we deliver. It can also have an impact on our joy in work, on our experience of work and whether we want to go back to it and what level we do it when we do go back.” Julie
There are many different factors at play when it comes to the negativity that surrounds making mistakes and discussing them, and whilst four broad themes emerged from Catherine and Julie’s discussion, Julie remarks that “fear of the reputational damage is the big thing.” Speaking of these, Catherine observes that “It's a lovely thing in some ways because I think it just demonstrates actually how much we care about our patients, our clients, our standard of work, our performance. We really passionately care about those things and that's fantastic. But when you invert that, when things go wrong, it can be a really uncomfortable, painful place to be.”
To watch the full recording, go to thevds.info/reputation
Process, Procedure and Time
It would be nice to hand-hold all the time with every single case that we ever had a query about, so that in the event that something went wrong, we could all say, ‘Oh, we were all there, so we can vouch for each other.’ But that's just not how it works, is it?” Julie
Having an internal process that allows for mistakes to be reported and discussed within the practice team is a great way for practitioners to learn, develop and improve, and consequently avoid similar mistakes being made in the future. But the way in which that process is put in place and enacted is just as important. As human beings, and as veterinary professionals, we like to know what we’re doing and where we’re at with things. The control or rather lack of control associated with such a process can, as Catherine explains, “feel very much like something that is being done to you.” Taking the time to explain the process to the individuals involved is a way to break down some of the anxiety around this. Those charged with leading those processes are unenviably faced with the dual role of supporting those involved and unpicking what happened in a non-threatening and positive way. Putting a structure around those conversations with a simple checklist or framework can be really helpful. There is a wealth of resources available to VDS members as part of the VetSafe system that can assist here. Understandably, given the challenges around time and the movement away from smaller practice teams, it can be tempting to reserve any kind of process for the times when things really go wrong. However, this can mean that things can be swept under the carpet and forgotten about, and important learnings may be missed. As Catherine explains, “It doesn't have to be the disaster case that you can actually get the . . . richest conversation out of and the most learning from.” Similarly, in cases where the outcome may not have been so bad, assumptions shouldn’t be made that those involved don’t need there to be something in place, whether that be a more formal process or just allowing a safe space to be able to discuss things with an empathetic colleague. Simply asking ‘do you need something to happen off the back of this?’ can avoid individuals being left “sort of hanging”, as Julie describes it, and opens the door for those conversations. In addition to the more reactive processes, practices may want to consider the benefits of more proactive approaches too. As Julie observes, “It should be that we're discussing more things . . . to kind of prevent those feelings afterwards so that, in the event that something does go wrong, we're used to talking about this stuff.” One way to do this is by using vignettes such as the cautionary tales in the VDS member newsletter. Because these scenarios don’t involve those sitting around the table, participants are able to disassociate themselves with the situation so that conversations can happen in a non-threatening way. Although the scenario isn’t real, the emotions and responses that are put on the table and discussed are, and this can really help to build the safe space that will be essential when it comes to talking about real life mistakes in your practice. From there, you might have people who are more comfortable sharing their experiences and mistakes, even if historical, which sparks a wider conversation, again all working towards breaking down barriers and building trust and psychological safety in the workplace.
Clients
“It has real implications for, again, how we deliver care and how we act with clients because we're so scared. So, we withdraw from those relationships and then that's a vicious cycle. Because you know if the client's got more frustration, they're probably more likely to complain about you. And they don't have that relationship with you.” Julie
Fear of the actions a client may take after a mistake has been made naturally impacts the likelihood of the practitioner disclosing the mistake to the client in the first place. Again, as Catherine explains, that comes down to trust and the assumed trust within the veterinary-client relationship, however it can be a case of ‘once bitten, twice shy’. When a practitioner has been judged wanting by one client, for whatever reason and whether that is justified or not, it is understandable that this can lead to a more careful approach in the future, a withdrawal from client interaction and the practice of more defensive tactics, which is damaging for both the practitioner and practice.
Trial by Social Media
“The frustration that a client can go on and say basically whatever they want without really the vet being able to action anything at all.” Julie
We all know the power of social media, with many of us using it daily as part of our personal and professional lives. But that power can be a real concern due to the speed with which things can happen and the way in which people can be influenced by what they read on social media. Online client complaints are a worry for veterinary professionals who fear their ability to damage professional reputation very quickly, and justifiably feel frustrated and powerless in terms of if and how they should respond. Despite any urge to retaliate, veterinary professionals need to always remain professional and conscious of potential legal ramifications of engaging in online interactions. Reassuringly, there are processes, procedures and frameworks that can be put in place for when things go wrong for both a practice and an individual that can eliminate some of the stress. VDS members can find further advice on this here.
Loss of Clinical Confidence and Defensive Medicine
“This moral load that we carry really affects how we emotionally respond and how we feel when the outcome isn't good.” Julie
A common response in the aftermath of a mistake is for the individual involved to lose clinical confidence; potentially practicing more defensive medicine or stepping away from certain disciplines, procedures, or clients entirely, because they don't want to put themselves back in that situation. Though that fear and eagerness to protect oneself is entirely understandable, it can be professionally very stifling, which is not only harmful to the individual but, as Julie says, has wider implications for the practice with certain team members reluctant to do certain things.
Reputational Damage Amongst Peers
“We're all kind of sitting in these individual bubbles of our own, in these individual worlds that we have, thinking that everyone's going to be judging us and, actually, that cannot be the case.” Julie
Reflecting on the findings of her own research, Catherine explains that professionals had a multitude of concerns when it came to reporting and discussing mistakes ranging from the patient to their boss, and the client to the College, but that there was a real strength of feeling around the topic of reputation damage amongst peers with people saying, “I'm really worried about what my mates think about me, what my peers think about me.” Catherine reflects, “It was that sort of cultural… insidious unsaid feeling that they didn't feel like a trusted member of the team anymore. And that really upset people.” This has also shone through in the research of PhD student, Julie, who goes on to explain that professionals’ fear of reputational damage is often in stark contrast to the actual reputational damage that may be caused and that, instead, this is something of our own making linked to concepts around professional identity, blame, humiliation, imposter syndrome and the sense of perfectionism. Culture and trust both have a significant role to play here too. Julie explains that we tend to turn to our very close colleagues for that initial emotional support, but that this, if perpetuated or in isolation, can lead to silos of people within an organisation and pockets of trust. Interestingly, Julie says, people are less concerned about things that may be considered a ‘genuine slip’, and moreover it’s actually in ‘grey area cases’ where people are most worried reputationally. Julie explains that this tends to be a decision or decisions that have led to something not being optimal, or perhaps where something was outside of their comfort zone, or perhaps could have been referred. The reason for this is that people feel that they will be judged on their knowledge or, in this case, lack of knowledge.
“They're still the ones that I really regret that I feel like I didn't do a very good job on that. And I feel like when my colleagues understood what I'd done, they weren't particularly impressed with what I'd done either because I could have done better. But at every point when I was treating that animal, I was trying, obviously, to do my best for that animal. But the outcome wasn't great. And like you say, you know, that lens of hindsight is pretty uncomfortable sometimes, isn't it?” Catherine
So, what can we do?
Firstly, it’s important to acknowledge that there isn’t a one size fits all and there will be different things that will work for different individuals, practices and cultures within those practices. Broadly speaking, Catherine summarises that, in an ideal world, there are two things that would represent a good outcome. The first is providing emotional support and an arm around the shoulder for those involved, and the second is the broader reflective process and learning that aims to prevent or reduce the risk of the same thing happening again. Standing up in front of your peers and saying ‘I got this wrong’ can be an incredibly daunting and intimidating place to be so allow the individual or individuals involved a bit of time and space, and perhaps the opportunity to unpick things on a one-on-one basis before being thrown into that group environment. But even then, Julie encourages practices to ensure they have created the right atmosphere for these types of conversations and to apply an element of ‘softness’ to the reflective process recognising that people may still find this difficult. Some of the proactive measures are helpful too, such as working through theoretical scenarios, vignettes, VDS cautionary tales or historical examples that can help to create the right culture for those conversations by building trust, breaking down barriers and getting comfortable with the process and types of conversations required. VDS members can find support in many ways from the VDS on the themes raised in this discussion and article. Developed by the VDS in response to Catherine’s research around mistakes and after identifying a gap for veterinary professionals to record their mistakes so that these conversations could happen, VetSafe is the Society’s confidential adverse event reporting tool. It's online and available as an app too. Along with the VetSafe tool itself, you’ll find some of the resources, processes and frameworks that Catherine and Julie spoke about that will support those conversations. In addition, VDS Training provides a range of non-clinical training for which VDS members receive an exclusive discount. Some of the training provided covers themes raised in this discussion around imposter syndrome, confidence, communications and online complaints handling. For more information go to www.vds-training.co.uk.
Notes Julie Gibson is currently studying for her PhD on how the profession can reassure and support practitioners in relation to clinical decision making, whilst ensuring standards of care through appropriate learning and accountability channels. Catherine Oxtoby is Head of Underwriting and Pricing at the VDS, and a vet whose previous research focused on mistakes made in veterinary practice. Any views expressed here are the views of the individuals speaking and do not necessarily represent the views of the VDS.