Aesthetic nursing

The scope of practice of a nurse in Alberta is outlined in the legislative framework and is further defined by each respective regulatory body. Performing procedures that are not within a nurse’s scope of practice can result in significant professional and legal consequences.

Administering neuromodulators such as Botox and dermal fillers are post entry-level competencies and are not taught in the entry to practice nursing programs. Neuromodulators require a client specific order following an initial assessment by an authorized prescriber such as a physician, dentist or nurse practitioner. As aesthetic nursing procedures pose potential risk to the client, appropriate emergency support should be readily available.

The nurse providing an aesthetic procedure uses a skill set comprised of the following competencies:

• a sensitive and respectful manner of communication, a positive non-judgmental attitude and caring behaviors
• thorough knowledge of anatomy and physiology of the skin and underlying tissue
• thorough understanding of the medications and substances to be used
• strong analytical skills and clinical competence in this practice area
• provision of honest and factual counselling and advertising

In Alberta, RPNs, RNs, and LPNs are authorized under regulation and have the education to administer medications and substances by injection. An order by an authorized prescriber is required before any nurse can administer schedule 1 medications and/or substances (e.g. neuromodulators and dermal fillers). The nurse is responsible and accountable to have the required education and experience to carry out the order.

In addition, The College of Licensed Practical Nurses of Alberta requires that LPNs providing aesthetic nursing procedures within their defined scope of practice must have direct or indirect supervision by a physician or nurse practitioner. The physician or nurse practitioner must be trained in dermatology, on-site, and available to assist as necessary when aesthetic procedures and treatments are being performed.

Yes. Many esthetic procedures do not need to be performed by a regulated health professional (e.g. facials, waxing, piercings, tattooing including semi-permanent makeup etc.). These would not fall within the definition of nursing or health services but are included in the Personal Services Regulation under the Public Health Act. The individual performing these personal services could not use the protected title “nurse” and these hours would not qualify as practice hours.

Yes. Nurses must have the additional education to practise competently and ensure public safety. At entry to practice, nurses do not have the competencies or education to administer dermal fillers, volume enhancers, collagen stimulators and neuromodulators (e.g. Botox). Nurses must be sure the education and training they take provides core competencies including infection prevention and control best practices. On the job training may not provide the necessary competencies to practise aesthetic nursing safely as this requires specific education in anatomy and physiology of the skin and underlying tissue, assessment, and knowledge of neuromodulators and dermal fillers. Each nurse is responsible and accountable to ensure they have the knowledge to practice safely, competently and ethically.

Yes. Nurses are required to document the care they provide accurately and in a timely, factual, complete and confidential manner. All documentation and record keeping must adhere to the documentation and privacy requirements as defined by their regulatory body, employer policy and provincial legislation. These documentation expectations are the same across all practice settings.

Documentation is not separate from care and is not optional. It is an integral part of the nurse’s practice, and an important tool that nurses use to ensure high-quality client care. Nurses document holistic, patient focused-care including relevant components of the nursing process:

• assessment
• nursing diagnosis
• plan
• implementation
• evaluation

Documentation is evidence that care has been provided and is necessary for:

• communication between health-care providers
• meeting professional and legal requirements
• quality improvement
• research

Yes. It is very important that the client understand risks, benefits and expected outcomes of treatment. Before providing any aesthetic nursing procedures, the nurse must obtain informed consent from the client for the specific procedure. Consent must be valid and current, and not have been retracted or withdrawn at the time of the procedure or treatment. Performing a procedure on a client without informed consent is considered unlawful and can result in professional conduct investigations and/or criminal charges regardless of whether the client is harmed or not.

For consent to be ‘informed’, the nurse must explain the intervention, including alternative options, as well as the disclosure of risks and complications. Consent must be voluntary and cannot be coerced from the client through undue influence or intentional misrepresentation. It is the responsibility of the nurse providing the service to:

• Assess the client’s ability to understand the nature of the proposed procedure, any risks and complications, and the right of refusal. Consent is only considered valid if the client fully understands what they are consenting to.
• Ensure that the proposed procedure is only provided to a minor (under 18) when parent/legal guardian consent is also obtained prior and treatment is mutually agreed upon between parent/legal guardian and minor.
• Obtain consent in an ethical manner and document accordingly. Re-establish consent if there are changes to the client’s initial care plan or the client has changed their mind.
• Consent to the proposed procedure needs to be obtained each time the intervention is provided.

It is important that the nurse mitigate the risk of complaints and legal action by ensuring that consent is informed and addresses the client’s expectations regarding outcomes before any procedure is performed.

Nurses must ensure client safety which includes preventing health care-acquired infections. If you are practising in a clinic or have a self-employed practice it is important to use IP&C best practices and follow IP&C policies.

The following routine practices are an important component of IP&C and should be used at all times:

• There should be dedicated hand-washing sinks and hand sanitizer stations.
• Follow the four moments of hand hygiene.
• Ensure the appropriate personal protective equipment is used for the procedure performed.
• Surfaces and equipment must be cleaned, disinfected and/or sterilized appropriately.
• Single-use devices must only be used once. 
• Any waste, whether general or biomedical, must be disposed of safely and appropriately.

There are many IP&C resources available to help ensure the safety of the client and the nurse.

The Canadian Nurses Protective Society (CNPS) provides CARNA members with professional liability protection, as well as offers legal advice, risk management services and legal assistance. CNPS will only provide liability protection if you are providing professional nursing services.  When working in collaboration with other health care professionals you should confirm each health care professional has adequate liability protection.

RNs or NPs who engage in independent nursing practice by themselves, in partnership with other practitioners, or by employing others are considered to be self-employed.

Medication listed on Health Canada’s prescription drug list can only be prescribed by authorized regulated health professionals. In Alberta, these health professionals include:

• physicians
• nurse practitioners
• dentists
• pharmacists who have been granted prescribing authority by the Alberta College of Pharmacy

Neuromodulators, such as botulinum toxin, are Schedule 1 medications and can only be prescribed by an authorized prescriber as outlined in the Government Organization Act and respective regulation for each health profession. Some dermal fillers are classified as Schedule 2 medications and do not need a client specific order unless required by employer policy. 

Nurses must be satisfied that the practitioner prescribing the neuromodulator or dermal filler is authorized by their college to engage in this practice.

Authorized prescribers must abide by the standards of practice developed by their regulatory college. The standards of practice governing physicians and nurse practitioners require them to personally assess a client prior to providing a prescription. Physicians and nurse practitioners can only prescribe neuromodulators and other medication on Health Canada’s Prescription Drug list when a client assessment has been performed. Physicians can only provide a prescription for “office use” when they personally will be attending the patients for whom they will provide an order for injection. An office use medication (i.e. a multi dose vial) can be used for more than one patient attending a clinic.

Medications and substances for administration by injection (prescription or otherwise) must be procured through legitimate means (i.e. through a pharmacy or the pharmaceutical company).  Medications and substances procured by other means may not be the correct substance, may be beyond expiration date, or may have been stored inappropriately, thereby altering composition, safety and efficacy. Pharmaceutical companies may have restrictions on who may procure medications and substances. A nurse should not use another health-care professional purely for the purposes of procurement. Nurses need to follow the manufacturer recommendations for storage and handling as outlined in standards, best practice guidelines and manufacturer recommendations.