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Nurses and Cosmetic Procedures: Registered Nurses.

The Board frequently receives questions about whether cosmetic procedures are within the scope of practice for a registered nurse (RN). Because each nurse has a different background, knowledge, and level of competence, the Board does not have an all-purpose list of tasks that every nurse can or cannot perform, and it is up to each individual nurse to use sound judgment when deciding whether or not to perform any particular procedure or act.

However, the following resources are intended to provide you guidance in determining if cosmetic procedures are within your scope of practice.

What is the RN scope of practice specific cosmetic procedures?

Registered nursing, also known as professional nursing, is the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

Professional nursing involves:

A. the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes;

B. the maintenance of health or prevention of illness;

C. the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist;

D. the supervision or teaching of nursing;

E. the administration, supervision, and evaluation of nursing practices, policies, and procedures;

F. the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157;

G. the performance of an act delegated by a physician under Tex. Occ. Code [section][section]157.0512, 157.054, 157.058, or 157.059; and

H. the development of the nursing care plan [Tex. Occ. Code [section]301.002(2)].

Professional nursing requires the tasks/procedures/acts being performed be within the scope of the RN's practice and appropriate orders be in place. While the Nursing Practice Act (NPA) and board rules do not specifically address cosmetic procedures, when appropriately ordered for a specific client by a provider who is authorized to prescribe such treatments, each RN would need to individually determine whether or not that specific act is within his/her scope of practice. Each RN would need to individually apply the Board's Six-Step Decision-Making Model for Determining Nursing Scope of Practice, a step-by-step tool designed to assist a nurse in determining whether a task/procedure/act is within his/her scope of practice. Note that two RNs could both utilize the Six-Step Model and come to differing answers of whether or not the same given task/procedure/act is within their respective scopes of practice because each nurse has his/her own individual knowledge, experience, training, etc.

Below are some examples of what you should consider when evaluating whether a cosmetic procedure is within your scope of practice:

1. Whether you have the necessary educational preparation and knowledge to perform the task safely.

a. Was the procedure taught to you as a part of your formal educational curriculum in a school of professional nursing?

b. Do you know what complications and/or untoward effects may result from the task or procedure?

c. Does the task or procedure require a higher level of licensure or a different level of authorization?

2. Whether you have the competency and skill to safely perform the task or procedure.

a. Have you obtained additional training or continuing education specific to the cosmetic procedure?

i. Keep in mind that continuing education and on-the-job training may expand competency at the current level of licensure but CANNOT qualify a RN to perform the same level of care as an APRN.

b. In the event of complications and/or untoward effects, are you able to respond appropriately?

3. Whether there is an appropriate order from a provider authorized to prescribe such treatments.

a. For administration of drugs, such as Botox, does the order contain all pertinent information, such as dose, strength, route, etc.?

b. Do you have a standing delegation order, if applicable?

4. Whether there is appropriate medical supervision available.

a. Is the ordering provider on-site?

An RN should not perform a cosmetic procedure if the RN lacks the necessary educational preparation, knowledge, competency, or skill to safely perform the procedure; lacks an order for the procedure; or lacks appropriate supervision.

To further assist you in evaluating whether a cosmetic procedure is within your scope of practice, Board Staff recommend review of several resources available on the Texas BON website. These resources include:

* Tex. Admin. Code [section]217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all licensure levels [Licensed Vocational Nurse (LVN), RN, Advanced Practice Registered Nurse (APRN)]. Specific subsections of this rule can be directly applied to this situation and should be considered. All nurses must:

[check] (1)(A)- know and conform to the Texas NPA and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

[check] (1)(B)-implement measures to promote a safe environment for clients and others;

[check] (1)(C)- know the rationale for and the effects of medications and treatments and correctly administer the same;

[check] (1)(G)-obtain instruction and supervision as necessary when implementing nursing procedures or practices;

[check] (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;

[check] (1)(M)- institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;

[check] (1)(0)- implement measures to prevent exposure to infectious pathogens and communicable conditions;

[check] (1)(R)-be responsible for one's own continuing competence in nursing practice and individual professional growth; and

[check] (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability.

* Position Statement 15.9 (Performance of Laser Therapy by RNs or LVNs)

* Position Statement 15.23 (The Use of Complementary Modalities by the LVN or RN)

* Position Statement 15.11 (Delegated Medical Acts) - specifically addresses the nurse's role with delegated medical acts. Board Staff recommend caution when performing a delegated medical act, as delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, Tex. Admin. Code [section]217.11. Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations; nurses do not practice under a physician's license.

* Position Statement 15.14 (Duty of a Nurse in any Practice Setting) - discusses a landmark court case which demonstrates how every nurse has a duty to promote patient safety and that duty to a patient supersedes any physician order or facility policy.

* Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) - clarifies that expansion of an individual nurse's scope of practice has licensure-related limitations and that informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/Iicensure or authorization.

Board Staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable guidance related to the practice setting; e.g., a private physician office might have specialty specific guidelines from the American Board of Medical Specialties. Beyond following all applicable laws, rules, and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer's policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).

If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed 'off duty' or in another setting [Tex. Occ. Code [section]301.004(a) (5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board's Jurisdiction Over a Nurse's Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code [section]217.11(1)(A)].

Food for Thought

It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided.
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Publication:Texas Board of Nursing Bulletin
Date:Jan 1, 2019
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