Understanding the Second Victim in Complications

By Linda Mather / 17 Jun 2020

Aesthetic nurse prescriber Linda Mather explores the psychological concerns practitioners may face after causing an aesthetic complication and provides recommendations for overcoming them

Adverse events (AE) occur within all healthcare settings. When an AE occurs, it can have a negative impact on the physical, psychological and the social wellbeing of the practitioner responsible, resulting in the healthcare practitioner (HCP) becoming the second victim (SV); the affected patient being the first victim. 

The term second victim was first established in a paper by Wu in 2000,1 but it was in subsequent work by Wu and other authors where detailed definitions of this phenomena began to appear.2-5 Scott (2009) described SVs as ‘healthcare providers who are involved in unanticipated adverse patient events such as medical error and/or patient-related injury where the provider of care becomes traumatised by the event’.5

It is common knowledge that there is a rise in patients requesting and receiving non-surgical cosmetic interventions and, subsequently, a rise in the number of adverse events. Despite this rise there remains a paucity of published work that considers Second Victim Phenomenology (SVP). This I did not find surprising as there is little done to support SVs in other healthcare settings, despite the healthcare setting becoming the third victim when an AE occurs.6

Aesthetic procedures such as dermal fillers carry risks to patients. Although most practitioners may be extremely skilled and appropriately trained, they may still experience adverse events that can occur during or following a treatment episode.

This article aims to provide reference to the current literature, as well as to consider a small study undertaken for dissertation work in an attempt to better understand ‘second victimhood’ (SVH) and determine whether it exists within aesthetic practice. This may serve to forewarn and forearm future practitioners should they be faced with adversity in the form of a dermal filler related AE.

Adverse events and second victim in healthcare

A review of the literature demonstrated the existence of SVH within healthcare settings, but no published material pertaining specifically to SVH within the context of aesthetics.

According to one paper by Conway et al. AEs occur daily within healthcare.7 Daniels and McCorkle discuss that despite the complexity of SVH, little is done to prepare HCPs on how to deal with it.6 Other safety critical disciplines such as pilots, fire fighters and the police however, receive education pertaining to the expected stressors of SVH. The complex feelings associated with SVH can cause the second victim to survive, thrive or drop out.2

Most of the literature that discusses AEs and SVH does not include direct quotes from participants, but rather, such as one study by Seyes et al., includes tabled results, demonstrating that feelings of guilt, psychological distress, fear and irritation scored highly in the aftermath of an AE.8

My interest in SVH evolved when I began supporting practitioners whom had experienced AEs. I noticed similarities in their emotional responses and felt that these responses required further investigation. Therefore, I conducted a qualitative phenomenological study with ethics approval that aimed to answer the question, ‘What is the lived experience of an aesthetic practitioner following a dermal filler adverse event?’ A convenience sample was selected of eight experienced aesthetic practitioners, all of whom were female nurses, with the age range of late 20s to 60s. They had all experienced a significant AE whilst treating a patient, for example vascular occlusion (VO).

Scott et al. discussed that every SV has their own way of coping, but described a general six-stage recovery trajectory for SVs.5 These were used as parallels to my own findings from the eight aesthetic practitioners and are as follows:

  1. Chaos and accident response. Here the participants within my study panicked and almost lost the ability to respond to the incident, before rallying themselves to deal with the incident in an appropriate manor.
  2. Intrusive reflection characterised by ‘what if’ questions. Participants without exception questioned themselves as nurses and in fact as people.
  3. Restoring personal integrity by looking for support to tell their experience or understand the impact on them personally and professionally. Participants began to make sense of what had happened and the associated feelings that they were dealing with, and therefore sought out support and the means to reflect.
  4. Enduring the inquisition from others and wondering about the impact of their mistake. There were heart-breaking comments from the participants within this study who felt that they had lost credibility not only in the eyes of other practitioners but also from their families.
  5. Obtaining emotional ‘first aid’. Unanimously the participants looked for someone who understood what they were experiencing and could guide them forward.
  6. Moving on or dropping out, surviving or thriving. All the participants, despite strongly wanting to drop out, managed to find a way through their trauma and not only survive, but they thrived and developed better practice because of it.

Second victim in aesthetics

After collating the data from my eight participants, themes were drawn from the transcribed interviews. A very brief synopsis of the themes are outlined below.

1. Physical symptoms of the patient

Physical symptoms of the patient became one of the first themes to emerge due to its importance to the participants. All participants discussed the presenting factors of the VO that they and their patient had experienced.

Participants described the visual signs of VO. One participant said, “It was going blacker before my eyes”, another described it as, “Oh my goodness, her lip is blue”, and a third said, “Her lip; it turned white”. Although I had not anticipated this theme, I believe it’s important to recognise it because although these three complications were VOs, they all described different presenting factors which may be confusing to new or inexperienced practitioners as they may not understand that the symptoms of a VO can present very differently. This in turn could result in to misdiagnosis, leading to inappropriate treatments and less than satisfactory patient outcomes.

2. Visceral feelings

The participants were graphic in describing and recalling their initial feelings when they experienced a serious AE; these feelings had also ranked as high importance within the literature. 

One participant described it as, “One of the worst feelings of my entire life; I wanted to be sick”, while another said, “I actually felt like I had run somebody over. That’s how bad I felt”, and another stated feeling, “Absolutely terrified – I was in a blind panic”. One participant went as far as describing feeling so panicked they felt as though they wanted to, “Throw themselves off a bridge”.

All the initial reactions described by the participants to a serious AE were strong visceral reactions. In highlighting this it may help to prepare practitioners for these negative and unsettling emotions that are experienced in the initial stages of experiencing an AE.

Without exception, the participants all described a feeling of denial and this was documented as a sub theme, as was justification. Within this sub theme, many of participants attempted to justify what had happened by using words such as, “I was so busy, I was running from room to room,” or “I had used that product before and it had always been fine”.

3. Longer-term feelings

Despite the participants experiencing negative emotions, going into denial and attempting to justify their actions, they each managed to take control of the situation and ensured that the patients made a full recovery. However, despite this, the participants described a subsequent wave of emotions that affected them in the longer term. They began to experience feelings of fear, blame, shame and guilt and these were unanimous within the study. These feelings sat alongside empathy for the patient that had suffered the AE. Each participant discussed negative feelings relating to delivering a treatment that should have enhanced the patient’s life in some way, but had ultimately led to harm.

4. Intellectualising

The participants demonstrated resilience and emotional recovery unanimously. Recovery occurred when they were allowed time to reflect. It was not addressed how much time was needed for this recovery. A paper by Chan et al. discussed two major coping strategies that could be employed in the aftermath of an AE. 

The first was problem-focused strategy, which involved developing constructive attitudes and behavioural changes, while the second was emotion-focused strategy.9 Emotion-focused strategy was employed by the participants wherein they managed their personal distress by accepting responsibility and implementing positive changes to their practice to reduce future error. They used problem-focused strategy wherein they constructed new ideas about their practice and adopted behavioural changes.

5. Lessons learnt

Each participant had a plan of varying degree as to what they would do in the event of a significant AE. These plans ranged from ‘phone a friend’ to being fully rehearsed and ready; most of them having the Aesthetic Complications Expert (ACE) Group guidelines to hand and having read through these guidelines.11

Wu and Steckleberg discussed that the disclosure of adverse events is necessary if practitioners are to learn from mistakes and improve patient safety.4 Participants described not only feeling better after disclosure but also discussed changes they made to their practice following their experience. 

Without exception, the participants changed their consultation process. They also described tightening up on their documentation and ensuring full disclosure of potential risks and side effects to the patients. However, no matter how prepared they were, none of them felt prepared for the shock of feelings that they experienced.

6. Help and support

Harrison et al. suggests that supporting clinicians in the aftermath of an AE may prevent future errors and SV burnout.10 In a web-based survey of 5,300 faculty members (898 surveys completed and returned) by Scott et al., it was found that organisational respite was the most frequent type of support desired by their participants.

They needed ‘time away’ to compose themselves and make sense of what had happened. However, participants within my study were unable to have any time out as they were lone workers with the pressure of appointments and had all of the financial issues associated with running a business. This was considered an extra pressure by some of the participants.

It is unlikely that organisational respite within aesthetics would be possible as the majority of practitioners are dependent upon their earnings to support their lifestyle. Participants discussed family and friends as being important for help and support, but conversely the participants were confounded by embarrassment at having to admit that they had ‘done something wrong’.

All but one of the participants discussed the ACE Group guidelines as a source of invaluable support,11 alongside having a knowledgeable and experienced colleague that they could access for counselling and help. I found it surprising that despite the current culture for practitioners to access support by social media, only one of the participants mentioned this, which demonstrated that the participants had access to direct support.

6. Going back to practice

All of the participants discussed the impact of events as so overwhelming that they wanted to give up their aesthetic careers. Scott et al. demonstrated that 30% of their participants suffered anxiety and depression, questioned their own skills and wished to leave medicine.2 It was generally support from others that helped them through this stage of their experiences. Wu and Steckelberg discussed that interactions with other medical colleagues can be critical to the coping process and without this the practitioner may feel isolated.4

Participants in my study said that they had given prior consideration to what they would do in the event of a VO occurring and had rehearsed this circumstance. However, they went on to state that this did not prepare them for the shock that they experienced. They agreed it would have been far worse without this preparation and felt that it was the support of others that enabled them to return to their practice and carry on.

Discussion and recommendations

This small study suggests that SVH does exist within aesthetics and may be very similar to SVH within other healthcare disciplines, causing individuals to feel initial numbness, detachment, depersonalisation, confusion, grief anxiety and depression.4

Aesthetic practitioners should always consider every aspect of the patient journey in an attempt to avoid an AE. The patient should be fully consented in line with governing body principles and practitioners should only carry out procedures that are within their sphere of competence using products that have excellent safety profiles based on clinical studies. Despite this though, AEs can still happen.

By accepting that things can and do go wrong, practitioners may be better prepared physically and mentally should an AE occur. Having a watertight plan of what to do and rehearsing can also go a long way to helping practitioners to look after their patient in this scenario.

It can help to recognise that in the event of an AE you may feel shocked, upset and likely have a visceral reaction such as shaking and feeling faint. Accept that this is normal; forewarned is forearmed. Some of the participants discussed having trained colleagues, whom they worked with, who could help in the case of an emergency. However, most practitioners work in isolation; if this is the case then make sure you have a colleague you can call, and have a backup number. Ensure your phone is to hand and always fully charged.

Building relationships and accessing support was seen as paramount within this study. It helped the participants, in their time as SVs, to survive and thrive as opposed to dropping out.

Develop a plan of care for YOU. We often fail to look after each other and ourselves, especially in the aftermath of an AE where we are likely to be crushed with blame, shame, guilt and self-doubt. Access clinical supervision whether you have suffered an AE or not. We have an obligation morally and professionally to ensure that we are mentally and physically fit for practice. Although there is a paucity of published work considering clinical supervision within the specialism of aesthetic practice, we must remain aware of the importance of clinical supervision as aesthetic practitioners usually work in isolation.12

Summary

There is very little data to demonstrate the number of AEs within aesthetics and certainly further data collection is required, as is further investigation into second victimhood within aesthetics. This study highlights that the physical presenting symptoms in the case of a VO are often different, and may occur in other types of AEs. It may also help to prepare practitioners for the very strong, very negative emotions that are experienced in the initial stages of an adverse event and how they can develop resilience. 

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