Position statement on nurses and cosmetic medical procedures

It is great to have some explicit guidance for this area of practice and we are proud to say that we have been complying with all relevant requirements already. 

The NMBA has recently updated this position statement which includes the following that we have taken directly from their website:

1. NMBA general statements on all nurses working in the area of cosmetic medical procedures, the role of nurses working in this area and important connections to the NMBA’s and other relevant guidance documents
2. Cosmetic injections – detailed expectations of prescribers and the role of the registered nurse (RN).
3. Cosmetic medical procedures:
   1. RNs and cosmetic medical procedures
   2. Enrolled nurses (ENs) and cosmetic medical procedures
      1. ENs currently working in the area of cosmetic medical procedures
      2. ENs planning to work in the area of cosmetic medical procedures in the future 
      3. Supervision requirements of ENs 
   3. Nurse practitioners (NPs) and cosmetic medical procedures
4. RNs with a sole qualification in mental health nursing, paediatric nursing or disability nursing - seeking to practise in the area of cosmetic medical procedures

1. Nurses working in the area of cosmetic medical procedures

The NMBA recognises that nurses obtain and develop qualifications and expertise through the course of their careers. It is an expectation that nurses are educated and competent in their specific area of practice and hold the requisite skills required to meet the needs of their client group. 

Nurses (ENs, RNs and NPs) are responsible for making professional judgements about when an activity is within their scope of practice and, when it is not, for initiating consultation and collaboration with, or referral to, other members of the healthcare team.

The NMBA’s standards, codes and guidelines set the regulatory requirements within which nurses working in the area of cosmetic medical procedures must comply, to ensure ongoing competence and safe practice. This includes but is not limited to:

• The relevant standards for practice 
  • Enrolled nurse standards for practice
  • Registered nurse standards for practice, and
  • Nurse practitioner standards for practice 
• Registration standard: Professional indemnity arrangements
• Code of conduct for nurses
• Decision-making framework for nursing and midwifery
• Safety and quality guidelines for nurse practitioners
• Guidelines for advertising regulated health services
• Advertising compliance and enforcement strategy for the National Scheme, and
• Telehealth guidance for practitioners

Nurses working in the area of cosmetic medical procedures must know and comply with organisational requirements and relevant state, territory and Commonwealth requirements as jurisdictional differences are common. This includes:

• drugs and poisons legislation (however titled) regarding possessing, using, obtaining, selling, storing, prescribing, administering and supplying scheduled medicines. This includes Botulinum toxin type A (commonly called Botox) and dermal fillers. 
• the preparation and administration of platelet enriched plasma and other blood products
• infection prevention and control, and
• organisational policies, protocols and guidelines.

Nurses working in the area of cosmetic medical procedures should be aware of the Medical Board of Australia’s (MBA) Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures (MBA guidelines) in effect from 1 October 2016. These guidelines establish the MBAs expectations of medical practitioners who perform cosmetic medical and surgical procedures. The guidelines serve as an evidence-based framework for nurses, outlining the conduct and practice expectations required of medical practitioners providing cosmetic procedures, and the impact this may have on nurses' practice.

Ahpra and National Boards have published a fact sheet Supporting a safe choice about cosmetic injectables. The fact sheet provides information aimed at consumers on what they need to think about before deciding on a cosmetic procedure. The fact sheet identifies what ‘good practice’ looks like in the practice area of cosmetic medical procedures.

Employers must be aware of the scope of practice of all nurses they employ and must ensure there are sufficient resources to enable safe and competent care for the people for whom healthcare services are provided. This includes policies and practices that support the development of nursing practice within a risk management framework and that all policies and practices must be compliant with regulatory and legislative requirements. The National safety and quality primary and community healthcare standards outline the expectations for clinical governance, partnering with consumers and clinical safety for primary and community healthcare settings.  

2. Cosmetic injections 

Prescribing cosmetic injections

NPs are authorised to prescribe medicines in accordance with state and territory legislation and their context of practice. At all times, the prescribing practice of NPs must be supported by their education, skills and knowledge. This underpins the assessment of, or consultation with, the person receiving cosmetic injections. NPs must not prescribe Schedule 4 cosmetic injections unless they have a consultation with the person receiving the cosmetic injection either in person or via video conferencing. Remote prescribing of cosmetic injections by phone or email (or equivalent) is not acceptable. 

The requirements for medical practitioners are set out in the MBA guidelines and mirror the above.

RNs and ENs cannot prescribe Schedule 4 cosmetic injections.

Administering cosmetic injections

The NMBA considers that the administration of cosmetic injections is within the scope of appropriately educated RNs. It requires a detailed assessment and planning of care, complex anatomical and physiology knowledge as well as decision-making relating to pharmacodynamics and pharmacokinetics.

RNs performing cosmetic injections must ensure safe and appropriate administration in accordance with best practice and clinical governance frameworks.

All nurses must ensure that their practice complies with state and territory legislation related to supply and possession of medicines. There must be an individual medication order for each person receiving cosmetic injections. The person receiving the cosmetic injections: 

• must have a consultation and assessment with a medical practitioner or NP, who is located in Australia, in line with the above
• is only treated by nurses with the appropriate education, skills and knowledge, utilising up-to-date knowledge of regional anatomy and safest practice, and
• is in a clinical setting that meets acceptable healthcare quality and safety standards.

3. Cosmetic medical procedures 

a. Registered nurses (RNs) and cosmetic medical procedures

RNs determine, coordinate and provide safe, quality nursing care. RN practice requires critical continuous thinking and analysis and the need to continue to develop professionally. RNs are responsible and accountable for the supervision and delegation of nursing activities to ENs and other healthcare workers. 

RNs working in or planning to work in the area of cosmetic medical procedures must ensure that they have the required education, skills and experience to practise safely. RNs that are intending to progress towards endorsement as a NP working solely in the area of cosmetic medical procedures are unlikely to meet the requirements for endorsement as an NP, as the NMBA considers that practising in the area of cosmetic medical procedures, such as cosmetic injecting, is not working at the advanced practice level (in line with the definition provided).

Advanced practice in nursing is demonstrated by a level of practice and is not by a job title or level of remuneration, or a set of procedural skills. Owning and running a health and/or nursing related business for example is not by itself an indication of advanced practice. 

b. Enrolled nurses (ENs) and cosmetic medical procedures

The foundational education entry requirement for ENs is not at a level that adequately prepares an EN for the risk and complexities associated with cosmetic medical procedures including the administration of cosmetic injections. 

i. ENs currently working in the area of cosmetic medical procedures

The NMBA expects that an EN currently working in this context of practice:

• is directly supervised by an RN for a minimum period of 75 hours for cosmetic injections, until competence is demonstrated and documented following an assessment by an RN
• does not undertake the administration of high-risk dermal filler injectables
• does not perform the administration of botulinum toxin off the face
• does not perform laser skin resurfacing
• engages in continuing professional and skills development relevant to this context of practice. 

If the RN is at a different location within the organisation, (providing indirect supervision), there must be a medical practitioner or nurse practitioner working in the same facility (on-site) as the EN, in order to respond and provide direction during a medical emergency.

If an EN ceases employment in the area of cosmetic medical procedures and later seeks to return to the area of cosmetic medical procedures, the EN must then meet the entry requirements outlined below. 

ii. ENs planning to practise in area of cosmetic medical procedures in the future

ENs intending to practise in the area of cosmetic medical procedures in the future, in addition to the expectations above, are required to demonstrate the following experience and education requirements:

• practise for a minimum of one-year full-time equivalent post initial registration to consolidate the foundational skills and knowledge of an EN, plus
• two years’ full-time equivalent experience in a related area of practice (for example dermatology, general surgery) prior to practising in the area of cosmetic medical procedures, and 
• completed formal education that is relevant to the practice in the area of cosmetic medical procedures practice.

Should a notification be lodged relating to a nurse’s practise in the area of cosmetic medical procedures, the nurse will be asked to demonstrate how they meet the NMBA requirements outlined in this position statement. 

iii. EN supervision requirements 

ENs must work under the direct or indirect supervision of an RN, as required in the NMBA Enrolled nurse standards for practice. Supervision by a health practitioner other than an RN − a GP or another medical practitioner for example − does not meet the NMBA’s supervisory requirement.

The supervision of ENs may be direct or indirect supervision. Direct supervision is where the RN is physically present and personally observes, works with and directs the EN. This may be necessary for example, to determine an EN’s competence against the standards for practice. Indirect supervision is where the RN works in the same state or territory-based organisation, is readily available but does not constantly observe the ENs activities. 

The NMBA’s Decision-making framework for nursing and midwifery provides direction on decision-making relating to scope of practice and delegation. 

Employers are accountable for ensuring the appropriate supervision of ENs. The need for an EN to have supervision arrangements in place with a named and accessible RN at all times and in all contexts of care for support and guidance is critical to patient safety. 

At all times, the EN retains responsibility for their actions and remains accountable in providing delegated nursing care. Where competence has not been demonstrated and appropriate education, training and experience has not been undertaken, the EN refrains from undertaking related activities.

c. NPs and cosmetic medical procedures

NPs practise in a generalist or specialist advanced practice level that incorporates professional leadership, education, research and support of systems into their nursing practice. Their practice includes relevant expertise, critical thinking, complex decision-making, autonomous practice and is effective and safe. It reflects the practice of nurses who are responsible and accountable in managing people who have complex healthcare requirements. 

NPs are educated and authorised to prescribe and administer scheduled medicines and order diagnostic investigations. NPs must work in accordance with the relevant state, territory and Commonwealth drugs and poisons legislation, organisational policy as well as Commonwealth legislation regulating blood products and medical devices.

At annual registration renewal, NPs are required to declare that they have met the minimum practice requirements of the Registration standard: Recency of practice, at an advanced level, have met and comply with the NMBA Nurse practitioner standards for practice and have direct clinical contact relevant to their endorsement.

4. Registered nurses with a sole qualification in mental health nursing, paediatric nursing or disability nursing – seeking to practise in the area of cosmetic medical procedures

RNs with a notation that states ‘solely qualified in the area of mental health, paediatric or disability nursing’ are unable to practice in the area of cosmetic medical procedures. If RNs with this notation want to change their context of practice to work in the area of cosmetic medical procedures, they must complete an NMBA-approved entry to practice program of study leading to general registration in order to have the notation removed. They also need to ensure that they have the appropriate education and experience to work in a different context of practice. Additional information can be found in the Fact sheet: Nurses with a sole qualification. 

Definitions

Advanced practice is where nurses incorporate professional leadership, education, research and support of systems into their practice. Their practice includes relevant expertise, critical thinking, complex decision-making, autonomous practice and is effective and safe. They work within a generalist or specialist context and they are responsible and accountable in managing people who have complex healthcare requirements. 

Advanced practice in nursing is demonstrated by a level of practice and not by a job title or level of remuneration.

Advanced practice for the purpose of the nurse practitioner endorsement requires 5,000 hours clinically based advanced practice in the past six years.

Cosmetic injections are serious medical procedures that involve injecting a substance under the skin to change an aspect of appearance. For example, reducing the appearance of wrinkles or lines on the face, or putting filler into the lips to make them fuller. If used incorrectly, the substances in these injections could cause skin damage, blindness or even death (Therapeutic Goods Administration)¹.

Cosmetic medical and surgical procedures are operations and other procedures that revise or change the appearance, colour, texture, structure or position of normal bodily features with the dominant purpose of achieving what the person perceives to be a more desirable appearance or boosting the persons self-esteem. 

Major cosmetic medical and surgical procedures (‘cosmetic surgery’) involve cutting beneath the skin. Examples include breast augmentation, breast reduction, rhinoplasty, surgical face-lifts and liposuction.

Minor (non-surgical) cosmetic medical procedures (‘cosmetic medical procedures’) do not involve cutting beneath the skin but may involve piercing the skin. Examples include non-surgical cosmetic varicose vein treatment, laser skin treatments, use of CO2 lasers to cut the skin, mole removal for purposes of appearance, laser hair removal, dermabrasion, chemical peels, injections, micro-sclerotherapy and hair replacement therapy.

Nurse practitioner (NP) is a registered nurse endorsed as an NP by the NMBA. The NP practises at a clinical advanced level, meets and complies with the Nurse practitioner standards for practice, is able to practice independently and has direct clinical contact. 

NPs practice collaboratively in multi-professional environments. 

The NP practises within their scope under the legislatively protected title ‘nurse practitioner’ under the National Law.