Although aesthetic medicine is perceived to be a taboo discipline, nurses specialising in this area are still bound by the Nursing and Midwifery Council’s Code and professional guidance. Aesthetic nurses must therefore comply with the recently published guidelines on the duty of candour and continue to be open and honest with their patients. Julie Brackenbury explains how the guidance applies to independent practitioners.
In the first guidance of its kind, nurses have been told to be honest with patients and apologise when mistakes are made. Both the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) (2015) have come together to publish guidelines on the professional duty of candour, in an attempt to change the culture of the NHS following the Mid Staffordshire NHS Foundation Trust scandal (Francis, 2013). The guidelines also follow the publication of Sir Robert Francis’ (2015)Freedom to Speak Up review, which called for more openness and transparency. They focus not only on the duty to be open and honest with patients, but also on the need to be open and honest within organisations when reporting adverse incidents or ‘near misses’ that may have led to harm.
|Candour and aesthetics|
Some would argue that aesthetic medicine is not as widely accepted by other health professionals and that it is still considered a taboo discipline. However, the irony is that non-surgical treatments are in such demand from the public that some aesthetic practitioners simply cannot keep up.
The aesthetic industry workforce administering non-surgical treatments are and should only be GMC, NMC and General Dental Council registrants. Like all nurses, aesthetic ones have a duty to adhere to theNMC (2015) Code and any new guidance that is introduced, regardless of whether or not they seem to be working in somewhat of a ‘silent’ discipline. Revalidation is a positive move in which aesthetic nurses can collaborate with the NMC and ensure that aesthetic medicine is a recognised health-care discipline.
According to the NMC and GMC (2015), the professional duty of candour guidance should send out a clear message to registrants about their responsibility to support transparency. More specifically, the joint guidance requires registrants to explain what has happened to patients and apologise when a patient has suffered, or may suffer in the future, due to a mistake that has been made (Merrifield, 2015). The joint proposals also place a duty on doctors and nurses to provide ‘a clear and honest explanation’ if something goes wrong, as the patient has the right to receive an apology from the most appropriate team member, regardless of who or what may be responsible for an error in their care.
An apology is a statement given by one individual who has injured another. It includes recognition of the error that has occurred, admits fault, and communicates a sincere sense of remorse for having caused harm (Tavuchis, 1991). The messages contained in an apology can have a powerful effect on both the person offering it and its recipient. Apologies influence the ways in which people make judgements of responsibility, decreasing the blame that is attributed to another and reducing the likelihood that the cause of the injury is viewed as something that is internal to and controllable by the other person (Takaku, 2001).Commenting on the concept of apologising to patients, GMC Chairman Terence Stephenson stated that saying ‘I am sorry’ is intuitive and advised health professionals to avoid phrases like ‘the organisation that I work for regrets’, as these words could be perceived as being disingenuine (Campbell, 2015). Stephenson also stated that, in general, patients want a personal apology if something has gone wrong and would like the practitioner/team to show genuine contrition (Campbell, 2015). Crucially, the NHS Litigation Authority (NHSLA) (2014) reported that verbal apologies are essential because they allow face-to-face contact between the patient and practitioner.
|Fitness to practise|
Reflecting on the guidance, Merrifield (2015) noted that a fitness-to-practise panel may view an apology as evidence of insight. The GMC (2014) also stated that the failure to apologise may be considered evidence in a fitness-to-practise review.Interestingly, the Royal College of Psychiatrists (2014) maintained that a forced apology is no apology at all and adds insult to injury for the patient. The British Medical Association has also suggested that staff must not be forced to apologise and take the blame for any failings in care before it is established where the fault lies (GMC, 2014).
|Degrees of harm|
The NMC has produced a series of case studies to help nurses and midwives understand the professional duty of candour, what it means for their practice and how to meet it in a range of scenarios. The case studies have been produced in partnership with practising nurses and midwives to reflect situations that they may face. However, a scenario relating to aesthetic practice is not included and warrants being presented.The scenarios presented by the NMC have been classified as: moderate harm, severe harm, near miss, prolonged psychological harm, misdiagnosis and severe harm leading to death. Nurses’ professional judgement must be used to decide whether to inform patients of a near miss—an adverse incident that had the potential to result in harm but did not. With the above degrees of harm in mind, there are several key questions for aesthetic nurses: What constitutes a near miss in aesthetic medicine? How can aesthetic nurses audit a near miss? Who would the near miss be reported to? Although these questions are unanswerable at present, they are essential to consider to improve practice and protect the public. Overall, the cited degrees of harm are all applicable to aesthetic medicine—it is just a case of deciding which capacity they should be used in, and which clinical scenarios they should be applied to.
|Admitting legal liability|
Research shows that many patients only resort to legal action because they feel they have not been told the truth about a lapse in safety (Campbell, 2015). The guidance from the NMC and GMC (2015) seeks to reassure staff by emphasising that apologising ‘doesn’t mean that we expect you to take personal responsibility for system failures or other people’s mistakes’ (Campbell, 2015). However, it could be argued that this new guidance has been published to help prevent legal action. The move could ultimately reduce the rising tide of medical negligence against the NHS, which now costs it about £1.3 billion a year in damages and legal fees (Campbell, 2015).Ultimately, patients who are injured as a result of a medical error do not look kindly on the health professionals who are responsible for them. A substantial percentage of such patients believe malpractice litigation is warranted and that disciplinary action should be imposed on the errant practitioner (Berlin, 2006). The NHSLA (2014) reported that saying sorry when things go wrong is vital for the patient, as well as to support learning and improve safety. The report also stated that, of those who suffered harm as a result of their care, 50% wanted an apology and explanation.Following consultation of the draft guidance last year, an extra section has been included in the final version clarifying that saying sorry does also not mean the health professional is admitting legal liability for what has happened (Merrifield, 2015).
There is no doubt that the media has great influence and can change the dynamics of a society for the greater good, or some would argue, for the worse. National coverage of the duty of candour guidance will enable people to be well informed, making them feel more protected and letting them know where to go and how to act if they feel they have not been treated with the correct standard, as per the regulatory body standard. Patient education via the media is therefore key.
|The bigger picture|
As the number of aesthetic procedures increases due to the ever-rising demand from the public, more aesthetic procedures will be administered and there will be more opportunities for errors. A key question relating to the duty of candour in the field of aesthetic medicine is: should an apology come with a refund? This is a grey area that requires further discussion and analysis.
Overall, the key message is that aesthetic nurses are not different because they work outside of the NHS—aesthetic medicine just needs to be more recognised as a discipline that provides a need to the public. Nurses in all disciplines need to ensure they read the guidance on the duty of candour so they will be prepared if they receive a complaint, as disclosing such errors and other adverse events to patients is now a central part of patient care. This has relevance to patient safety and aesthetic medicine needs to be able to contribute to this reality.
- Berlin L (2006) Will saying “I’m sorry” prevent a malpractice lawsuit? AJR Am J Roentgenol 187(1): 10–5 [CrossRef]
- Campbell D (2015) NHS staff told to say ‘I am sorry’ to patients for medical blunders. http://tinyurl.com/qzez657 (Accessed 20 August 2015)
- Francis R (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/p2ebw82 (Accessed 20 August 2015)
- Francis R (2015) Freedom to Speak Up. An Independent Review into Creating an Open and Honest Reporting Culture in the NHS. http://tinyurl.com/oqysbj4 (Accessed 24 August 2015)
- General Medical Council (2014) Reviewing how we Deal with Concerns about Doctors. A Public Consultation on Changes to our Sanctions Guidance and on the Role of Apologies and Warnings. http://tinyurl.com/paryccq (Accessed 26 August 2015)
- NHS Litigation Authority (2014) Saying sorry. http://tinyurl.com/nml545y (Accessed 20 August 2015)
- Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.http://tinyurl.com/ozogs2u (Accessed 20 August 2015)
- Nursing and Midwifery Council, General Medical Council (2015) Openness and Honesty When Things Go Wrong: the Professional Duty of Candour. http://tinyurl.com/pc983k4(Accessed 20 August 2015)
- Merrifield N (2015) NMC issues guidance on duty to be ‘open’ about errors. http://tinyurl.com/q9g6l3x (Accessed 20 August 2015)
- Takaku S (2001) The effects of apology and perspective taking on interpersonal forgiveness: a dissonance-attribution model of interpersonal forgiveness. J Soc Psychol 141(4): 494–508 [CrossRef]
- Tavuchis N (1991) Mea Culpa: A Sociology of Apology and Reconciliation. Stanford University Press, Stanford: CA
- Royal College of Psychiatrists (2014) Response to: Reviewing how we deal with concerns about doctors—A public consultation on changes to our sanctions guidance and on the role of apologies and warnings. http://tinyurl.com/puxv4my(Accessed 20 August 2015)