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Fundamental aspects of advanced nursing practice in the field of medical

aesthetics

Article  in  Journal of Aesthetic Nursing · September 2013

DOI: 10.12968/joan.2013.2.7.334

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Fundamental aspects of advanced nursing
practice in the field of medical aesthetics
T
he role of medical aesthetic practitioner is
akin to positions such as the advanced nurse
practitioner in the NHS, where nurses are
working autonomously and making clinical
decisions regarding treatment options based a
comprehensive consultation and physical assessment
(Box 1). However, where advanced nurse practitioners
in the NHS have often had years of experience in their
speciality before reaching the skill level required, most
training programmes for aesthetic nurses comprise
1-2 day courses, after which the nurse is able to administer
non-surgical procedures and make autonomous clinical
decisions. This can often feel daunting for aesthetic
nurses and many may feel isolated.
According to the British Association of Cosmetic
Nurses (BACN) (2013a), all nurses entering the field
of medical aesthetics should have at least three years
of post-registration experience. However, there is a
vast diversity in nurses' academic qualifications, level
of competencies and responsibilities in aesthetic
medicine. In this article, the author explores what
constitutes advanced practice in relation to aesthetic
medicine, discussing assessment, consultation skills,
audit, treatment selection and continuing professional
development.
Developing a nurse-led service
Whether aesthetic nurses are self-employed, working
independently, or practising alongside cosmetic doctors,
setting up and managing a medical aesthetic service
requires skill, specialist knowledge and awareness of the
support, assessment, administration and monitoring
required in supporting patients throughout the
treatment pathway. These elements are in addition
to the acquisition of the business skills needed when
working in private practice (Royal College of Nursing
(RCN), 2007a; 2012).
When developing any nurse-led service, it is
essential that a firm infrastructure is in place for it to
run effectively. This will vary according to local needs
but should include evidence-based protocols for all
procedures undertaken, administration and monitoring
of the treatments, and a system for measuring the
outcomes of aesthetic procedures and capturing this at
regular audit (Nursing and Midwifery Council (NMC),
2008). For the service to run effectively and remain
Volume 2 Issue 7 ► September 2013 ► Journal of Aesthetic Nursing
▼ CLINICAL
Abstract
Not only is there is diversity in qualifications, level of competencies and
responsibilities of nurses in aesthetic medicine, but also there is limited
empirical data to support the role. Being a medical aesthetic practitioner
involves working autonomously, making clinical decisions based on
comprehensive consultations and carrying out physical assessments of
patients. However, owing to the lack of regulations and standards for
education in medical aesthetics, many nurses may feel isolated and
inadequately prepared when entering the field. This article explores the
fundamental aspects of advanced practice and provides practical advice for
nurses to ensure their practice meets requirements.
Key words
► Advanced nursing practice ► Evidence-based practice ► Clinical audit
client-focused, aesthetic nurses should play a key part in
writing protocols, training, educating and establishing
the infrastructure needed.
The BACN's nursing network is a thriving group that
aims to act as an expert resource to inspire, support and
educate nurses to achieve excellence through sharing
best practice (BACN, 2013b). The association's board
is currently in the process of developing protocols on
cosmetic injectables, which will be disseminated to all
association members. Support is also available at regional
meetings and online through the association website
and social networking sites. In the author's experience,
connecting with a regional group will provide essential
support to develop services locally.
Patient assessment and decision-making
Patient assessment starts when patients enter the
consulting room and is a fundamental part of all
aesthetic procedures. However, the expanded role of
physical assessment brings an additional range of legal
and ethical responsibilities that necessitate a more
© 2013 MA Healthcare Ltd
KAY GREVESON
Clinical Nurse Specialist, Royal Free Hospital, London.
e: k.greveson@nhs.net
1
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iStockPhoto\purmar
Connecting with a regional group of aesthetic nurses and sharing best practice
will provide essential support and help to develop services locally
structured approach to diagnosis and a new dimension
to clinical decision-making (While, 2002).
Benner (2001) suggested that decision-making
is dependant on the nurse's stage of professional
development. Whereas the novice has little experience to
guide his or her thinking, relying on analytical methods
of decision-making, the expert will combine this
thinking with knowledge gained from experience. This
idea was reinforced by Banning (2008), who stated that
clinical decision-making is a unique process involving
the interplay between knowledge of pre-existing
conditions, explicit patient information, nursing care
and experiential learning.
For nurses who are inexperienced in medical
aesthetics, structured mentorship programmes and
peer support from experienced colleagues would play a
vital role in developing clinical skills for effective care
(Brennan Thorns, 2013).
Consultation skills
Pendleton et al (2003) and Neighbour (2005)
recommended involving clients in the decision-making
process. An example of this in medical aesthetic
practice was provided by Lockett (2012), who discussed
the use of topical anaesthesia with her patients, but
also extends to more complex interventions.
More specifically, Pendleton et al (2003) suggested
that consultations involving explanations of the benefits
and risks of treatment should be carefully worded.
© 2013 MA Healthcare Ltd
The authors also stressed the importance of conveying
information in a meaningful way without manipulating
the message; for example, ensuring clients are fully
counselled regarding treatment options to provide
informed consent, and managing their expectations by
providing a realistic idea of outcomes.
2
Box 1. Aspects of the nursing
role that constitute advanced
level practice
►► Direct care provision
►► Making professionally autonomous decisions
and being accountable for them
►► Making an assessment of care needs based
on highly developed history-taking
and clinical decision-making skills
►► Evidence-based prescribing
►► Physical assessment and examination
Royal College of Nursing (2012)
Nurse prescribers must also balance evidence-based
prescribing decisions, such as the type of dermal filler
used or the area to be treated, with client preference,
ensuring that they respect clients as partners in their
care and include them in the decision-making process
(NMC, 2008). According to Pendleton et al (2003),
failure to do this can result in damage to the nurse-
patient relationship and a lack of concordance with
treatment. Therefore, a consultation where clients are
fully involved in treatment and management decisions
ultimately increases patient adherence and satisfaction.
Treatment selection
When it comes to treatment planning, choosing between
aesthetic procedures can seem like a minefield to patients.
One of the vital aspects of the aesthetic nurse's role is
to increase client awareness and education by being a
source of expert knowledge and support, empowering
individuals to be active in the decision-making process
(Baird, 2004). Over time, this practice will help nurses to
build a rapport with their patients.
Developing a trusting relationship with patients is key
to understanding their perceptions and care needs (Baird,
2004). It is also important when patients are considering
the array of aesthetic treatments available to them, as
there is not only a choice of modalities to be aware of,
but also the side effect profiles of each treatment.
Non-medical prescribing
All nurses have a legal duty of care, whether working
as a nurse practitioner or a prescriber (Dimond, 2005).
As non-medical prescribers, nurses must ensure that
any decisions made are based on high-quality evidence,
rather than using an anecdotal approach to product
choice (Luker et al, 1998). Clinical decisions that are
not made in this way and fall outside the realm of
competence may result in harm to clients and can be
perceived as negligence (Dimond, 2005). Clear guidance
on prescribing in medical aesthetics was recently
published by the BACN (Rankin et al, 2012).
Journal of Aesthetic Nursing ► September 2013 ► Volume 2 Issue 7

Insurance and record keeping
Many nurses employed by an aesthetic clinic are covered
by vicarious liability, where the employer is held liable for
nurses' actions if the individual is appropriately qualified
and practises with consent (Department of Health,
2006). However, this is not the case with self-employed
nurses, who must ensure they have indemnity insurance
to prepare for future cases of litigation (Hooker, 2012).
Record keeping is also an integral part of nursing
practice and acts as the mark of a skilled, safe
health professional (NMC, 2005). Details of patient
consultations, including any treatment decisions made
and explanations given must be documented in note
form (Department of Health, 1998). This is not only
a legal requirement, but also aides recall for future
consultations or in the case of litigation.
Audit and research
Given that the field receives a significant level of negative
attention in the media, it is essential that the aesthetic
nursing community unites to show a high standard of
professionalism and evidence-based practice. Very few
nurses undertake clinical audit or original research
(Cheater and Keane, 1998; Collis, 2006); however,
despite regular clinical audit not being mandatory in
the private sector, it is essential for service evaluation,
benchmarking against national standards, improving
quality and enhancing patient outcomes (National
Patient Safety Agency, 2007; Patel, 2010). Local clinical
audits to assess whether practice is in line with current
benchmarks and national guidelines should also take
place (RCN, 2007b; BACN 2013b).
There could be several reasons for a lack of audit and
research in nursing, including expertise, resources or
perceived benefits. Patel (2010) provided an excellent
review of the stages and support needed for clinical
audit. Attendance at local study days, or even group
project collaboration at local BACN meetings, where
peers share their expertise, can help to get the voice
of aesthetic nurses heard. For example, the north
west BACN group are currently proposing an annual
prescribing audit. This example of good practice
should be followed by aesthetic nurses around the UK
and highlights the excellent role the BACN plays in
providing a platform for best practice and professional
development.
Continuing professional development
Registered nurses have an obligation to continue their
professional development and ensure their knowledge
and skills are up to date (NMC, 2011). It is essential that
all nurses keep a portfolio of the evidence supporting
their practice and professional development to identify
developmental needs and assess progress against
personal development plans (RCN, 2009; NMC,
2011). Non-medical prescribers also have professional
Volume 2 Issue 7 ► September 2013 ► Journal of Aesthetic Nursing
▼ CLINICAL
» Although clinical audit is not
mandatory in the private sector,
it is essential for service evaluation,
benchmarking against national
standards, improving quality
and enhancing patient outcomes «
accountability for prescribing decisions and so
must ensure that they practice within their level of
competence and read up on the latest evidence and best
practice for managing the conditions or indications for
which they prescribe (Department of Health, 2006a).
Continuing professional development is also
essential for aesthetic nurses to maintain competence
in their field (Department of Health, 1999; Peate,
2012). This can be attained through attending regular
training updates, conferences and study days, as
well as undergoing structured clinical supervision,
reflective practice or mentorship with experienced
nurse colleagues (Soutter-Green, 2013). Systems used
in the NHS, such as knowledge and skills frameworks,
although not mandatory in private practice, are also
vital for personal development and performance.
More importantly, this can also help with the NMC's
revalidation process (RCN, 2009).
The RCN (2006; 2009) has also provided a competency
framework mapped against the NHS Knowledge and
Skills Framework, and skills for health competencies
and can be used for nurses working outside the NHS.
Conclusion
Moving forward, aesthetic nurses need to make their
presence heard and work towards providing empirical
evidence to support their role. The development of high-
quality national audit and competencies for best practice
is needed in the field and should identify the necessary
skills, knowledge, educational preparation and ongoing
training and developmental needs.
The RCN (2007b) competency document was recently
developed by the BACN to measure practice against
agreed benchmarks and highlight areas of strength
and weakness. There have also been discussions
surrounding the development of a clearly defined
standard of education and accredited qualifications for
© 2013 MA Healthcare Ltd
providers of non-surgical cosmetic interventions, with
some establishments already introducing dedicated
modules that aim to provide a theoretical underpinning
for aesthetic practice (Bardsley, 2013). It is hoped that
future regulation will not only strengthen the aesthetics
industry, but also improve safety and quality.
3
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4 Journal of Aesthetic Nursing ► September 2013 ► Volume 2 Issue 7

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