New Nurse Guidelines For Non-Surgical Cosmetic Procedures

Ahpra and national boards are seeking urgent feedback to new guidelines drafted for ‘Regulating registered health practitioners who perform and/or advertise non-surgical cosmetic procedures’. These include a major update to nurse practice guidelines.

The Australian Health Practitioner Regulation Agency (Ahpra) and National Boards have announced an immediate intention to reform the regulation of nurses and registered health practitioners ‘who work in the cosmetics sector in Australia, to improve practice and standards, public safety and informed consumer choice’.

On November 27 Ahpra circulated three draft guidelines seeking public consultation – with a tight 10-week deadline for submissions ending on 2 February 2024.

The three draft documents are titled:

• ‘Guidelines for nurses who perform non-surgical cosmetic procedures’ (nurses practice guidelines);
• ‘Guidelines for registered health practitioners who perform non-surgical cosmetic procedures’ (shared practice guidelines – do not apply to medical practitioners or nurses);
• Guidelines for registered health practitioners who advertise non- surgical cosmetic procedures (advertising guidelines).

Ahpra noted that while the 2022 Independent Review of the regulation of medical practitioners who perform cosmetic surgery made 16 recommendations ‘to improve patient safety in the cosmetic surgery sector’, many of the concerns raised ‘are also relevant for the non-surgical cosmetic sector’.

The Nursing and Midwifery Board of Australia (NMBA) is consulting on the draft ‘nurses practice guidelines’, while other National Boards are consulting on the draft ‘shared practice guidelines’.

Both drafts are based on the Medical Board of Australia’s (MBA) updated ‘Guidelines for registered medical practitioners who perform cosmetic surgery and procedures’ published in 2023; however, the nursing guidelines have differences that reflect the ‘separate roles and scope of practice of enrolled nurses, registered nurses and nurse practitioners in the non-surgical cosmetic procedures sector’.

Ahpra specifically highlighted that ‘there is concern about non-surgical cosmetic procedures, such as cosmetic injectables like botulinum toxin products and dermal fillers, with similar issues for public safety as those found in the cosmetic surgery sector.

‘There are an increasing number of clinics opening in local shopping centres and a growing number of practitioners moving into the industry.’

Draft guidelines for nurses

The draft guidelines for nurses – including enrolled nurses (EN), registered nurses (RN) and nurse practitioners (NP) – have been developed by the NMBA under section 39 of the Health Practitioner Regulation National Law (as in force in each state and territory). They build on NMBA’s position statement ‘Nurses and cosmetic medical procedures’ – first published in July 2016 and most recently updated in April 2023.

The draft guidelines emphasise nurses’ responsibilities around informed consent, including financial consent, and consideration of patient suitability – and ‘take into account the potential vulnerability of patients in this area’.

There is also a ‘focus on the prescribing and administering of prescription-only cosmetic injectables and the necessity for adequate education, training and competence to perform these procedures due to the associated risks’.

The NMBA emphasises these guidelines will be used to assist ‘in its role of protecting the public, by setting and maintaining standards of practice.

‘If a nurse’s professional conduct varies significantly from these guidelines, the nurse should be prepared to explain and justify their decisions and actions. Serious or repeated failure to meet these guidelines may have consequences for a nurse’s registration.’

Conflicts of interest

The new guidelines begin by emphasising that nurse practitioners ‘must recognise that conflicts of interest can arise when providing non-surgical cosmetic procedures’.

This is particularly so ‘given the commercial nature of the industry and the role that advertising and business models play in creating a demand for services’.

Hence, nurses ‘must ensure that the care and wellbeing of the person they are providing care for is their primary consideration’.

Assessment of patient suitability

The guidelines recognise that non- surgical cosmetic procedures may be carried out in different practice arrangements and settings where nurses are working independently (RN or NP), or settings where nurses are working with a medical practitioner, NP and/or other registered health practitioners.

The RN or NP must discuss and assess the person’s ‘reasons and motivation for requesting the procedure’ – including external reasons (for example, a perceived need to please others) and internal reasons (for example, strong feelings about appearance). In addition, the person’s ‘expectations of the procedure must be discussed to ensure they are realistic’.

The RN or NP must assess the person ‘using an evidenced-based and validated assessment tool for underlying psychological conditions’ – such as body dysmorphic disorder (BDD), which may make them an unsuitable candidate for the procedure.

If there are indications the person has significant underlying psychological issues that may make them an unsuitable candidate for the cosmetic procedure or prescribed cosmetic injectable, they ‘must be referred for evaluation to a psychologist, psychiatrist, nurse practitioner or medical practitioner, who works independently of the nurse performing the procedure or the NP prescribing the cosmetic injectable’.

The RN or NP must discuss alternative options with the person, including other non-surgical cosmetic procedures or treatments ‘as well as the option of not having the procedure’.

The RN or NP ‘should not recommend a cosmetic procedure proceeding if they believe it is not in the best interests of the person’.

Direct patient consultation

The draft guidelines insist nurses must ensure the medical practitioner or NP who has prescribed the cosmetic injectable ‘has a consultation with the person, either in person or by video, each time they prescribe them a Schedule 4 (prescription only) cosmetic injectable or where otherwise required’.

Remote (bulk) asynchronous prescribing of cosmetic injections by phone or email (or equivalent) is not acceptable practice.

Patients under age 18

The guidelines specify additional responsibilities which ‘must be undertaken’ when providing non- surgical cosmetic procedures for persons under age 18.

Firstly, the RN or the NP ‘must know and comply with relevant legislation of the jurisdiction in which they are practising’ in relation to restrictions on cosmetic procedures.

The RN or NP must also consider the clinical appropriateness of the cosmetic procedure for the person who is under 18; importantly, the NMBA ‘views botulinum toxin and dermal fillers should not be prescribed for persons under 18 for cosmetic purposes’.

The RN or NP who will perform the non-surgical cosmetic procedure or prescribe the cosmetic injectable (NP only) must assess whether, and be satisfied that, the person has the capacity to consent to the procedure.

The RN or NP should, to the extent practicable, have ‘regard for the views of a parent or guardian of the person under 18, including whether the parent or guardian supports the procedure being performed’.

For persons under 18, there must be a cooling-off period of at least seven days between the informed consent and non-surgical cosmetic procedure being performed.

No money should be payable until after the cooling-off period (other than for initial consultations).

The person should be encouraged to talk to their general medical practitioner, nurse practitioner or other relevant registered health practitioner during the cooling-off period ‘about why they want to have the cosmetic procedure’.

Informed consent

Nurses who will perform the non-surgical cosmetic procedure or prescribe the cosmetic injectable (NPs only) ‘must provide the person with enough information for them to make an informed decision about whether to have the procedure’.

Nurses must have a ‘verbal consent discussion’ with the person as well as ‘provide written information in plain language’ (including all practical steps to provide information in a language understood by the person).

Information provided must not: glamorise non-surgical cosmetic procedures; minimise the complexity of a procedure; overstate results or imply persons can achieve outcomes that are not realistic.

It must include information about the risks and benefits associated with the cosmetic procedure and what alternatives may be available.

This includes information about the cosmetic procedure:

• what the procedure involves (including the type of anaesthesia and pain management);
• for injectables, which cosmetic injectable is being prescribed (types and quantity);
• whether the procedure is new or experimental;
• range of possible outcomes of the procedure, in the short and long term (i.e. the longevity of the treatment product and requirements to maintain the desired appearance);
• risks and possible complications associated with the procedure, in the short and long term;
• risks specific to the person including possible impact of any comorbidities the person has;
• possibility of the need for further treatment in the short term (such as treatment for anaphylaxis,
• Hyaluronidase to dissolve dermal filler, antibiotics oral or topical, or the long term such as surgical removal of dermal filler);
• recovery times and specific care requirements during the recovery period;
• alternative options to the cosmetic procedure such as topical products (face creams) and other non-invasive treatments.

It also includes information about the nurse providing the non-surgical cosmetic procedure or NP prescribing the cosmetic injectable:

• the nurse’s registration type (for example, their education, training and experience);
• information about other practitioners who will be involved in the procedure (if applicable).

It includes information about costs:

• total cost;
• costs of maintenance price range and potential variability of costs for future treatments;
• details of deposits and payments required and payment dates;
• refund of deposits;
• costs for follow-up care;
• possible further costs for revision or additional treatment;
• advising that cosmetic procedures are not covered by Medicare.

Informed consent must be obtained ‘by the nurse who will perform the cosmetic procedure or the NP prescribing the cosmetic injectable’ – and ‘must take reasonable steps to ensure the person understands the information provided’.

Consent forms & images

Informed consent ‘must be documented appropriately, and a copy of the signed consent form must be given to the person’.

The consent form should reflect that in some circumstances – if a nurse is compelled by law to give evidence, for example – that information regarding the person may need to be provided which may progress without the person’s consent.

Consent must be requested for any photographs or videos the nurse, or any other practitioner, proposes to take of a person in a consultation or during the cosmetic procedure.

The person must be given information about the proposed use of any such images, including:

• the purpose (for example, for medical record only, for advertising);
• how the images will be used (for example, stored in the medical record, shown to prospective persons in consultations, published on website and posted on social media);
• where they will be stored and who will have access.

Images of the person receiving care must be stored on a secure device. Nurses must not store images of person/s on a personal device.

People must be given an opportunity to view images before consenting to their use in advertising. They have the right to refuse use of their images – and a person ‘cannot be required to agree’ to their images being used. in advertising. Consent for the use of images in advertising must be separate from consent to the procedure.

People must be allowed to withdraw their consent to use of their images and the nurse must promptly stop using images (for example, not show to others seeking services and delete them from advertising) if a person withdraws consent.

A person’s consent for the taking, using and storing images of them must be documented.

Schedule 4 injectables

Nurses must know and comply with the requirements of their state or territory drugs and poisons (or equivalent) legislation for Schedule 4 (prescription only) cosmetic injectables – for example, requirements relating to permits, prescribing, records, supply, storage and transport.

Nurses must comply with Therapeutic Goods Administration (TGA) requirements by ensuring products they administer are registered; administering and/or advertising unapproved and/or unregistered products is unlawful.

NPs are authorised to prescribe medicines in accordance with state and territory legislation and their context of practice, supported by their education, skills and knowledge.

RNs and ENs cannot prescribe Schedule 4 cosmetic injectables.

Patient management & responsibility

Nurses who will perform the non-surgical cosmetic procedure or prescribe the cosmetic injectable (NP only) are responsible for the management of the person, ‘including ensuring the person receives appropriate post-procedure care’.

If the ‘prescription only’ cosmetic injectable is administered by another nurse (who is not an NP), the prescribing medical practitioner or nurse practitioner remains responsible for the management of the person, including ensuring the person receives appropriate post-procedure care.

The nurse who administers the injectables is responsible for informing the prescriber of any concerns relating to the administration.

If the nurse who performed the non-surgical cosmetic procedure or prescribed the injectable (NP only) is not personally available to provide post-procedure care, formal alternative arrangements ‘must be in place including nominating a person who is a suitably qualified health practitioner; these arrangements ‘must be made in advance, documented, and made known to the person and other treating practitioners’.

There must be protocols in place for managing complications and emergencies that may arise during the procedure or in the immediate post- procedure phase.

In the event of complications requiring hospital admission, the medical practitioner or NP who performed the non-surgical cosmetic procedure or prescribed the injectable

is responsible for coordinating care until the person is under the management of the nominated health practitioner or hospital.

Written instructions must be given to the person after the non-surgical cosmetic procedure including:

• contact details for the medical practitioner or NP who performed the non-surgical cosmetic procedure or prescribed the cosmetic injectable, nurse who performed the procedure (if applicable) and nominated delegate health practitioner in case the nurse who performed the cosmetic procedure or prescribed the injectable (NP only) is not available;
• details of the procedures performed and any anaesthesia used;
• name and details of the products used;
• the usual range of post-procedure symptoms;
• instructions for the person if they experience unusual pain or symptoms (escalation points and who to contact and when);
• instructions for medication, activity restrictions and self-care dates and details of follow-up visits (if applicable).

Medical records must include the non-surgical cosmetic procedure performed, ‘described in enough detail to enable another health practitioner to take over post-procedure care with an adequate understanding of what has been done’; all relevant medical records need to be accessible and transferrable to another health practitioner.

Care & treatment

The RN/NP is responsible for ensuring any other person participating in the person’s care and/or treatment has appropriate education, training and competence ‘and is adequately supervised as required’.

When an RN/NP is assisted by another registered health practitioner or assigns an aspect of a non-surgical cosmetic procedure or care to another registered health practitioner, the nurse who performed the procedure or prescribed the cosmetic injectable (NP only) retains primary responsibility for the person’s care.

This does not apply when the nurse has formally referred the person supported by relevant therapeutic communications to another registered health practitioner.

Complaints

Before a procedure, the nurse must provide all people receiving care with information about the range of complaints mechanisms available.

These include:

• raising and resolving the complaint directly with the practitioner who provided the procedure;
• accessing the clinic or facility’s complaint process;
• making a complaint to the health complaints entity in the state or territory where the procedure was performed;
• making a complaint to Ahpra, the Health Care Complaints Commission or the Nursing and Midwifery Council of NSW (in NSW) or the Office of the Health Ombudsman (in Queensland).

Nurses must ensure any non-disclosure agreement (NDA) they use makes clear that a person, or someone on behalf of the person, can still make a complaint to Ahpra, the HCCC, the NMC in NSW or OHO in Queensland.

Education & experience

Non-surgical cosmetic procedures or prescribed cosmetic injectables (NP only), must only be provided by nurses with the appropriate education, training and competence in the specific cosmetic procedures being offered.

These nurses must have the experience to perform the procedure and deal with ‘all routine aspects of care and any likely complications’.

A nurse who is changing their scope of practice to include non-surgical cosmetic procedures is expected to undertake the necessary education, training and competence before providing the procedures or prescribing cosmetic injectables (NP only).

All nurses must participate regularly in continuing professional development (CPD) relevant to their scope of practice; all nurses whose scope of practice includes cosmetic procedures must undertake CPD that includes activities related to non-surgical cosmetic procedures – including planning their learning goals and activities, and reflecting on their learning.

Nurses must not make claims about their qualifications, experience or expertise that could mislead people by implying the practitioner is more skilled or more experienced than is the case; to do so is a breach of the National Law.

Nurses must clearly inform people of their registration details, including type, profession (for example, EN, RN or NP) and where relevant division or endorsement on their registration.

Nurses must not use a protected title unless they hold the related registration type.

Advertising & marketing

Advertising material – including practice and practitioner websites and social media – must comply with National Boards’ ‘Guidelines for advertising of regulated health services’ and the current Therapeutic Goods Advertising Code. It must also comply with any TGA guidance on advertising non-surgical cosmetic procedures, as well as the advertising requirements of section 133 of the National Law.

Advertising should not glamorise cosmetic procedures, minimise the complexity of a procedure, overstate results or imply outcomes that are not realistic.

Facilities

Nurses must know and comply with relevant (including local council, state, territory and Commonwealth) legislation, regulations and standards of the jurisdiction in which they are practising in relation to facilities where the non-surgical cosmetic procedure will be performed.

Nurses who provide or prescribe (NP only) cosmetic injectables or any non-surgical cosmetic procedures that include injecting, piercing the skin or incisions, are encouraged to provide procedures in a facility accredited by an Australian Commission on Safety and Quality in Health Care (ACSQHC), an approved agency to the current addition of the ACSQHC’s National Safety and Quality Primary and Community Healthcare Standards, or the ACSQHC’s National Safety and Quality Health Service (NSQHS) Standards, whichever is most applicable.

Non-surgical cosmetic procedures must be performed in a facility appropriate for the level of risk involved in the procedure and the risk profile of the person.

Facilities must be appropriately staffed and equipped to manage possible complications and emergencies.

Financial arrangements

Nurses must not provide or offer to provide financial inducements (such as a commission) to agents for recruitment of patients.

Nurses must not provide or offer to provide free or discounted procedures to prospective or existing people receiving care (including social media influencers or users) for promotion of cosmetic procedures or services.

Nurses must not offer, promote or recommend financing schemes to people, either directly or through a third party, such as loans or commercial payment plans, as part of the cosmetic procedure.

This does not preclude a nurse from informing people of accepted payment methods such as credit cards (such as Visa, Mastercard), or buy now, pay later products (such as Afterpay, Openpay, Zip Pay) or from offering the option to pay for a procedure in instalments in a non-commercial payment arrangement between the nurse and the person receiving care.

Nurses must not offer people additional products or services that could act as an incentive to cosmetic procedures.

Nurses must:

• ensure they do not have a financial conflict of interest that influences the advice they provide to the person;
• disclose any financial interests that could be perceived as influencing the advice they provide to the person they are providing care to.

Nurse Practitioners (NPs)

The draft guidelines note that NPs provide ‘high levels of clinically focused nursing care’.

The NP role ‘builds on, and expands upon, those required of an RN’; this role is an ‘advanced practice role and is autonomous and independent’.

NPs use professional knowledge when prescribing indicated pharmaceutical interventions and demonstrate ‘professional integrity and ethical conduct’ in relation to therapeutic product manufacturers and pharmaceutical organisations.

Registered Nurses (RNs)

The NMBA expects RNs first practise for a minimum of one-year full-time equivalent post initial registration ‘to consolidate the foundational skills and knowledge as an RN in a general or specialist area of nursing practice’ (not in the area of non-surgical cosmetic procedures).

RNs who perform non-surgical cosmetic procedures are required to undertake detailed assessment and planning of care, have complex anatomical and physiology knowledge as well as decision-making relating to pharmacodynamics and pharmacokinetics.

RNs are responsible and accountable for the ‘supervision and delegation’ of nursing activities to ENs and other healthcare workers.

RNs intending to progress towards endorsement as an NP working solely in the area of non-surgical cosmetic procedures are ‘unlikely to meet the requirements for endorsement as
an NP’ – as the NMBA considers practising in the area of non-surgical cosmetic procedures, such as cosmetic injecting, ‘is not working at the advanced practice level’ (in line with the definition provided).

Enrolled Nurses (ENs)

The foundational education entry requirement for ENs ‘is not at a level that adequately prepares an EN for the risk and complexities associated with non-surgical cosmetic procedures’ – including the administration of cosmetic injectables.

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

• is directly, or has been directly, supervised and assessed by an RN for a minimum of 75 hours for cosmetic injections, until competence is demonstrated and documented;
• does not undertake the administration of dermal filler injectables to very high- risk areas (that includes the glabella, nose and forehead);
• only undertakes the administration of dermal filler injectables to high-risk areas, including temples, nasolabial folds, peri-orbital and medial cheek, in a clinical setting with immediate access to a medical practitioner, a nurse practitioner or an RN;
• only performs laser skin resurfacing with direct supervision of an RN to check the laser settings before use.

If an EN ceases employment in the area of non-surgical cosmetic procedures and later seeks to return to this area of practice, the EN must meet the requirements of the NMBA’s Registration standard: Recency of practice (RoP); that is, they have practised in the area of non-surgical cosmetic procedures for a minimum of 450 hours in the past five years.

Where an EN has ceased practising in the area of non-surgical cosmetic procedures and does not meet the RoP requirements, they must then fulfill the entry to practice requirements outlined below.

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

• practise for a minimum one-year full-time equivalent post initial registration to consolidate the foundational skills and knowledge as 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 non-surgical cosmetic procedures;
• and completed formal education relevant to practise in the area of non-surgical cosmetic procedures.

EN supervision

ENs must work under the direct or indirect supervision of an RN; this is a ‘fundamental requirement that applies to the practice of all ENs’. 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.

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 EN’s activities; it is generally expected in the case of indirect supervision, that the RN and the EN have the same employer.

There may be situations where the RN and EN may not have the same employer but work in the same facility or organisation; in these situations, clearly documented arrangements between the employers, supported by the RN and the EN, must be in place.

These documented arrangements should include details of all aspects of the supervision arrangements (including insurance) and describe how the RN will be available for reasonable access to ensure ‘effective timely direction and supervision of the EN so the delegated practice is safe and correct and public safety is ensured’.

RN ‘sole qualification’ bans

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 non-surgical cosmetic procedures.

If RNs with this notation want to change their context of practice to work in the area of non-surgical cosmetic procedures, they must complete an NMBA-approved entry to practice program of study leading to general registration in order to have the notation removed.

All sole qualified RNs, with or without a notation, need to ensure they have the appropriate education and experience to work in a different context of practice. AMP