Administering Cosmetic Treatment and Cosmetic Procedures

Joint statement from the Australian College of Nursing and the Australasian College of Cosmetic Surgery, 15^th May 2018

There is increasing demand for a large variety of cosmetic services in Australia.(1) In this rapidly expanding sector, nurses must pursue and provide safe and legal practice in the delivery of all cosmetic procedures.

‘National Law’ – applies to ALL nurses working in the area of cosmetic procedures

This national regulatory framework applies to ALL enrolled nurses (ENs), registered nurses (RNs) and nurse practitioners (NPs) working in the area of cosmetic procedures at
 ALL times.

There are no circumstances or practice settings within which nurses are exempt from complying with the National Law and the professional standards set by the Nursing and Midwifery Board of Australia (NMBA).

Nurses working in the area of cosmetic procedures are obliged to have knowledge of and comply with:

• the NMBA’s registration standards, codes, guidelines and policies 

• relevant state and territory legislation and regulation and associated local policies, procedures and guidelines. These include (but are not limited to):
- licencing regulations 
- drugs and poisons legislation (however titled) in relation to obtaining, selling, storing, prescribing, administering and supplying scheduled medicines. (3)

• Infection Prevention and Control Standards as set out by the Australian guidelines for the prevention and control of infection in healthcare (2010) and where relevant the use of standard precautions for non-health care settings e.g. own home or personal care and body art industries as set out by the health guidelines for personal care and body art industries. 
Additionally, nurses working in the area of cosmetic procedures must be aware of the NMBA Position statement on nurses and cosmetic procedures and the Medical
 Board of Australia’s (MBA) Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures. 


Nurses: Know your responsibilities and service requirements

Cosmetic procedures can pose varying levels of risk 
to consumers. Any EN, RN or NP providing cosmetic procedures are reminded of their obligations to comply 
in full with the requirements and expectations of the profession REGARDLESS of their practice setting (Note: This includes running a registered business from your own home you must have a public health inspection) and/or service arrangements. This includes, but it is not limited to, working within scope of practice at all times. While nursing is nationally regulated, nursing scope of practice is governed by national as well as state and territory legislation and is heavily influenced by jurisdictional service arrangements and organisational context, policies and models of care.

Depending on jurisdictional requirements, examples of cosmetic procedures that nurses may deliver include, but are not limited to:

The provision of skin care advice and referral

• skin cancer checks

• management of common skin disorders
• wound care

• acne management

• scarring

• rosacea

• anti-ageing/skin fittness

• skin sensitivity

• sun damage

• pigmentation

• leg and facial capillaries

• removal of unwanted hair

• removal of benign skin lesions

• skin tightening

• referral to a specialist
• administration of:


Treatments

• intense pulsed light 

• laser (including but not limited to Thulium/Erbium, Nd:YAG, Ruby Alexandrite) 
• microdermabrasion 

• chemical peels (AHA, BHA, Jessner, TCA, Retinoid) 

• light emitting diode (LED) therapy 

• radiofrequency therapy 

• dermal rollering/needling 

• platelet rich plasma 

• photodynamic therapy 

• cosmetic tattooing 

• tattoo removal 

• sclerotherapy 

• fat reduction 

• prescribing medicines.4 


ENs, RNs and NPs delivering these and/or other cosmetic procedures are obliged to comply with relevant clinical policies, standards, and guidelines in their state or territory, included but not limited to: clinical governance, infection prevention and control, quality use of medicines and emergency procedures. 


Spotlight on Injecting 


When cosmetic procedures involve injecting, in addition to other key requirements and considerations, NURSES and NURSE PRACTITIONERS MUST: 


• administer, prescribe and/or delegate within the limits of their scope for practice and have a referral pathway 

• understand the regulation of prescriptions and standing orders in the jurisdiction they work 

• have the education and demonstrated knowledge required to undertake education, screening, assessment and management of cosmetic procedures 

• have recommended protocols and procedures manuals for procedures including identification and management of adverse events 

• have thorough knowledge of the potential dangers and contraindications of injecting in certain areas of the facial anatomy and how to identify risk and respond to adverse outcome event 

• ensure the well-being of patients and discuss and advise all patients of the specific risks associated with the injecting procedures 

• provide accessible and accurate clinical information and an appropriate care pathway 

• in all settings, ensure patient records are kept in accordance with the law. 


Spotlight on Scheduled Medicines

When working with Scheduled medicines, in addition to other key requirements and considerations, NURSES and NURSE PRACTITIONERS MUST:

• work, prescribe and/or delegate within the limits of their scope for practice 

• understand the classification and regulatory controls of medicines and chemicals being used in cosmetic procedures in the state or territory in which they work 

• in all settings, ensure patient records are kept in accordance with the law 

• apply Quality Use of Medicines (QUM) principles as outlined in Australia’s National Strategy for Quality Use of Medicines.(5) 


Spotlight on ethical practice: 


• apply knowledge of state and territory legislation and health service policies governing the possession, administration and supply of medications in clinical practice including remote and isolated areas 

• administer appropriate medication under the direct supervision of a medical practitioner, scheduled treatment protocols integrating comprehensive assessment and best practice guidelines
• apply clinical reasoning skills to identify factors that impact on selecting, monitoring and individualising treatment 

• understand the principles of pharmacology; pharmacokinetics, pharmacodynamics, contraindications and precautions of the commonly prescribed and administered medicines within the individuals scope of practice, and how these principles relate to the treatment of individual patients 

• access up-to-date evidence, best practice guidelines and recommended evidence-based reference material for drug therapies 

• engage in effective communication in a respectful manner, with patients, and other health providers, to ensure optimum health outcomes 

• implement strategies that maximise treatment adherence and therapeutic relationships 

• demonstrate professional and ethical practice in the possession, administration and supply of scheduled medicines 

• provide clinical treatment within your scope of practice at all times. 


Example Snapshot - NSW:

In NSW nurses working in the area of cosmetic procedures may be required to know that:

Both botulinum toxin and hyaluronic acid and its polymers (dermal filler) are restricted substances listed in Schedule 4 of the NSW Poisons List.

Regarding supply:

There is no provision under Section 11 of the New South Wales Poisons and Therapeutic Goods Act 1966 (the Act) for a wholesaler to supply a registered nurse or other unauthorised persons with restricted substances. The Act and the Poisons and Therapeutic Goods Regulation 2008 (the Regulation) allows for a medical practitioner to be supplied by wholesale with restricted substances.

Section 10 (4) of the Act allows for the supply of a restricted substance by a medical practitioner in the lawful practice of his or her profession. Supply is interpreted to also include administration to a patient.

The re-supply by some medical practitioners of restricted substances to registered nurses for therapeutic use in circumstances where the registered nurse is not under the direct supervision of the medical practitioner, prima facie is considered to be wholesaling, contrary to Section 9 of the Act.

Regarding controlled substance administration:

There is no provision under the New South Wales Poisons and Therapeutic Goods Act 1966 (the Act) for a registered nurse to administer restricted substances, outside of a hospital or designated institution (and then only when authorised on the prescription of a medical practitioner), or unless the nurse is a patient carer 
(and then only when authorised on the prescription of a medical practitioner).

The form of a prescription is mandated in Clause 35 of the Poisons and Therapeutic Goods Regulation 2008.

Regarding Standing Orders:

Although Standing Orders are an accepted protocol for authorising the administration of restricted substances within hospitals, in accord with Section 10(4)(c) of the Act and Clause 58 of the Regulation, subject to strict conditions specified in the Ministry of Health’s Policy Directive for the Handling of Medications in NSW Public Health Facilities (PD2013-043), there is no equivalent provision in the legislation for the use of Standing Orders in beauty clinics or salons by registered nurses.

Administration of Medications

Nurses and midwives must practise in accord with legislation, with standards and guidelines provided by the Nursing and Midwifery Board of Australia, policy directives of the NSW Health Department where these policies are applicable, and policies of individual employers.

The storage, supply etc, of medications is governed by legislation. The relevant legislation is the Poisons and Therapeutic Goods Act 1966 and the Poisons and Therapeutic Goods Regulation 2002. Implementation of this legislation is delegated to the NSW Health Department’s Pharmaceutical Services Branch which issues directives and guidelines to assist health personnel in complying with the requirements of legislation.

Some specific documents that may be relevant and applicable to ENs, RNs and NPs, depending on their practice settings are shown below.

Public Hospitals:

-Medication Handling in New South Wales Public Hospitals

-The Administration of Medication by Endorsed Enrolled Nurses

Private Hospitals and Day Procedure Centres:

-Guide to the Poisons and Therapeutic Goods Legislation in Private Hospitals and Day Procedure Centres – TG115

Nursing Homes:

-Nursing Homes - ‘Guide to Handling of Medications in NSW’ Information Bulletin 2003/10

Community-Based Health Services & Residential Facilities:

-Community-Based Health Services and Residential Facilities - Guidelines for the Handling of Medication

References:

1. S. Newberry D. Urban, C. Lawrence, J. Javornisczky, A. Lynam, S. Critchley, B. Cassels, ‘Analysis of Public Submissions Consultation Regulatory Impact Statement in the use of Intense Pulsed Light (IPLs) Sources and Lasers for Cosmetic or Beauty Therapy, Technical Report 177, March 2017’ (2017) <https://www.arpansa.gov.au/ sites/g/ les/net3086/f/tr177.pdf

2. Australian Health Practitioner Regulation Agency, ‘National Board Guidelines for Registered Health Practitioners Guidelines for Mandatory Notifications’ (2016). <http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines/Guidelines-for-mandatory-noti cations.aspx>.
3. Nursing and Midwifery Board of Australia [NMBA], ‘Position Statement - Nurses and Cosmetic Procedures’ (2016) http://www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Position-Statements/nurses-and-cosmetic-procedures.aspx
4. O’Keefe EJ, Griffiths S, Hoitink SJP, Knoop SL, Murphy KI, Taylor AL (2015) Professional Practice Standards and Scope of Practice for Aesthetic Nursing Practice in Australia. Australasian College of Cosmetic Surgery, Sydney
5. Commonwealth of Australia, ‘The National Strategy for Quality Use of Medicines’ (2002), http://www.health.gov.au/internet/main/ publishing.nsf/content/8ECD6705203E01BFCA257BF0001F5172/$File/natstrateng.pdf

Additional article

https://defenceupdate.mdanational.com.au/Articles/schedule- 4-injections

There is no provision for “prescriptions” or “standing orders” for restricted substances to be prepared by an unauthorised person and then signed by a medical practitioner. Clause 32 of the Regulation is specific, allowing a medical practitioner to issue a prescription for a restricted substance. There is no allowance for another person to “issue” a prescription or part of a prescription, to be signed by a medical practitioner.