Issues in Medical Aesthetics

Many state nursing boards and NPs are seeking to define exactly what fits within the scope of professional practice.

by Renee H. Martin, JD

Consumer demand for minimally invasive cosmetic procedures is rising dramatically. In 2004 alone, spending on these services increased 57%. Almost half of cosmetic procedures in 2004 were performed in office settings.

In response to the growing demand, NPs are finding and creating many opportunities to provide medical aesthetic services. It is an exciting and evolving practice focus, it is a service people want, and it does not involve third-party payer headaches because patients pay out of pocket.

With the proliferation of these new noninvasive cosmetic services, many state nursing boards and nurse practitioners are seeking to define exactly what fits within the scope of professional practice and how best to protect the public from providers who are not adequately and appropriately trained. To date, only a handful of states have put forth specific guidance or advisory opinions on cosmetic procedures. Although not an exhaustive list, below are some of the state pronouncements to date:

• In Massachusetts, Botox can be administered by a registered nurse as directed by a physician or NP, but only after the physician or NP has performed a medical examination of the patient.

• In Rhode Island, the administration of Botox is considered the practice of medicine and may be performed only under the supervision of an appropriately trained physician or advanced practice provider such as an NP.

• In Connecticut, the following procedures are considered within the acceptable practice of RNs as long as they are ordered by a physician: laser removal of hair, age spots, sun spots and broken capillaries; collagen injections; microdermabrasion; glycolic treatments; and Botox administration.

• In New Hampshire, the use of any laser to alter human tissue is deemed to be surgery, and therefore laser treatment is regulated by the board of medicine. Surgery may only be performed by a physician or a physician assistant.

• The Nebraska Board of Nursing has decided that registered nurses may perform collagen injections for cosmetic dermatology purposes, as well as sclerotherapy of small varicosities.

• The South Dakota Board of Nursing has decided that dermatologic procedures such as microdermabrasion, Botox injections, sclerotherapy, laser hair removal, collagen injections, and chemical peels are not within the scope of RN practice.

Most NPs are governed by their respective state board of nursing and function independently, but collaboratively, with physicians to provide patient care. Obviously, if a state board of nursing determines that a registered nurse can engage in certain activities, NPs can also engage in them by virtue of their basic RN licensure. However, in many instances, a state board of nursing may not offer a specific determination about whether NPs can engage in a particular practice. The best course of action is to contact your state's NP professional association, as well as your state board of nursing, to determine whether the issue of cosmetic procedures by NPs has been addressed.

Risk Management Strategies

Even when you are permitted under state law to perform a nonsurgical cosmetic procedure, be sure to adhere to certain basic risk management standards.

Obtain proper and thorough training to perform the cosmetic procedure. Decide for yourself whether the training is sufficient to allow you to practice at the standard of care you will be held accountable for in the event of a claim or lawsuit. Clearly, you will be expected to select the patient, obtain informed consent, perform the procedure and recognize and treat the complications or emergencies that may occur as a result of or in the course of the procedure.

If you are permitted to delegate the performance of any procedure to another health care professional, determine whether the people you employ or supervise are suitable to perform nonsurgical cosmetic procedures. Ideally, such people should be certified in the chosen procedure. Where no certification exists, such as in the case of Botox, written evidence of training in a nationally or regionally accepted program should be required and kept in the employee's personnel file. For some procedures, most notably laser treatment, you must mentor personnel in the performance of a set number of procedures before allowing them to provide the service independently.

Select your patients carefully. Patients may not always have realistic expectations about results. Not every patient who requests or wants a nonsurgical cosmetic procedure is an appropriate candidate for one. Prospective patients should undergo a prescreening that includes a visit with you, a thorough history, and a physical examination to determine the suitability of the proposed treatment. Ask them to define their expectations of the procedure. Patients with medical contraindications or unrealistic expectations should not be accepted.

Renee H. Martin is an attorney with a master's degree in nursing. She practices health care law at Tsoules, Sweeney and Martin in Exton, Pa.