Clinical scope of practice for nurses

There are three distinct groups of nurses in cosmetic medical practice, each with its own scope of practice and clinical governance. Words by Elissa O’Keefe (1), Adjunct Professor Kylie Ward (2), Sharon Griffiths (3) and Suzie Hoitink.

As the cosmetic industry has blossomed over the past decade, there has been a multitude of professionals who have found a scope of practice within the industry – from plastic surgeons, dermatologists, cosmetic physicians and nurses to dermal therapists and beauticians.

While skill mix is essential in an aesthetic/cosmetic medical practice in order to meet client needs and expectations and to maximise the use of clinic room space, stock and equipment, it can be confusing to understand the distinctions between roles – in particular, the various types of nurses.

Nurses are the cornerstone of many practices and it is important that clinic owners, managers and human resource staff have a good understanding of what a usual scope of practice is for a particular nursing role and the clinical governance structures required to support excellence in practice. This enables judicious employment, allocation of resources and the peace of mind that regulatory and legislative requirements are adhered to.

In aesthetic/cosmetic practice, the clinical scope of practice for nurses falls into a few primary domains: assessing the client, planning and delivering appropriate care, administering muscle relaxants and dermal fillers, performing laser, intense pulsed light and other related therapies, and recommending cosmeceuticals.

The nursing process is required for the holistic care and wellbeing of all clients during the therapeutic process. All professional nurses are represented in aesthetic/cosmetic medical practice, including registered nurses, enrolled nurses and nurse practitioners. All three types of nurses are registered health practitioners with the Nursing and Midwifery Board of Australia and as such are required to comply with the relevant professional codes and guidelines set out by the Board.

Registered nurses

The most frequently employed category is that of the registered nurse (RN). Registered nurses hold a Bachelor of Nursing acquired at university (800 clinical placement hours). Registered nurses in aesthetic/cosmetic medical practice administer Schedule 4 medication prescribed by either a medical practitioner or a nurse practitioner, such as topical anaesthetics, dermal fillers and muscle relaxants. In all states and territories, they are able to independently operate all classes of laser with the exception Queensland where when using a Class 4 laser must do so under the supervision of a doctor or in Western Australia where Class 4 is restricted to a medical practitioner or a nurse practitioner.

Enrolled nurses

Enrolled nurses (EN) undertake 12-18 months training including 120 clinical placement hours to achieve a Diploma of Nursing. All endorsed ENs are able to administer medications under the supervision of a registered nurse. But note that not all ENs are endorsed and this lack of endorsement is notated on the register. The EN works with an RN/NP as part of the health care team and demonstrates competence in the provision of person-centred care. Core practice generally requires the EN to work under the direct or indirect supervision of an RN/NP. At all times, the EN retains responsibility for their actions and remains accountable in providing delegated nursing care. The need for the EN to have a named and accessible RN/NP at all times and in all contexts of care for support and guidance is critical to patient safety.

For some levels of care there should be a model of clinical supervision where the registered nurse “is actually present and personally observes, works with, guides and directs” the enrolled nurse who is being supervised.

Indirect supervision is a model of clinical supervision where the registered nurse “works in the same facility or organisation as the supervised” enrolled nurse, “but does not constantly observe their activities”. The registered nurse “must be available for reasonable access”.

What is reasonable will depend on the context of practice, the needs of the patient and the needs of the EN who is being supervised. A governance model where an EN is employed without an RN/NP supervisor is not acceptable and furthermore an RN/NP must be satisfied that the level of supervision offered is adequate to meet the threshold requirement.

Nurse practitioners

Nurse practitioners (NP) have a Master of Nurse Practitioner or equivalent and three years’ full-time experience (5,000 hours) at the clinical advanced nursing practice level.

Nurse practitioners have an individual, unique scope of practice within which they work. They use extended skills, knowledge and experience in the assessment, planning, implementation, diagnosis and evaluation of care required. An NP autonomously performs advanced physical assessment, orders diagnostic tests, interprets the results of these tests, initiates referrals to relevant healthcare providers, and is authorised to obtain, possess, supply, administer, prescribe and dispense medications and other therapies as needed within their scope of practice. NPs can prescribe any medication within their scope of practice and so, as an example, can prescribe muscle relaxants, dermal fillers, local anaesthetic for topical, local or nerve blocks and are able to hold a license to operate Class 4 lasers in all states and territories.

A full discussion of the standards and scope of practice for aesthetic/cosmetic nursing can be found in the document Professional Practice Standards and Scope of Practice for Aesthetic Nursing Practice in Australia (O’Keefe et al, 2015) available on the Australasian College of Cosmetic Surgery website. Professional support for nurses in the aesthetic/cosmetic area of practice can be obtained via the Australian College of Nursing’s Cosmetic Nursing’s Cosmetic Nursing’s Community of Interest.

For information on regulation contact the Australian Nursing and Midwifery Board or for industrial matters the Australian Nursing and Midwifery Federation.

1. Elissa O’Keefe RN NP FFACNP MACN, Managing Director of Bravura Education, Australia’s leading educators for lasers and intense pulsed light (IPL) technologies.
2. Adjunct Professor Kylie Ward FACN, Chief Executive Officer, The Australian College of Nursing.
3. Sharon Griffiths RN RM BSc MSc MNP MACN, Founder and CEO of Finesse Cosmetics.
4. Suzie Hoitink RN, MACN, Founder of the Clear Complexions Clinics

References

Nursing and Midwifery Board of Australia (2015). Standards for Practice: Enrolled Nurses. http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/enrolled-nurse-standards-for-practice.aspx Accessed 17 March 2017

O’Keefe et al, (2015). Professional Practice Standards and Scope of Practice for Aesthetic Nursing Practice in Australia. Australasian College of Cosmetic Surgery http://www.accs.org.au/pdf/FINAL_Professional_Practice_Standards_Scope_Practice_Aesthetic_Nursing_Practice_in_Australia_20150709.pdf

Accessed 17 March 2017