An increased consumer demand for nonsurgical aesthetics treatments has created opportunities for nurses in the field of medical aesthetics. Nurses have been providing aesthetic injections in Canada since the 1990s. Initially, they were trained in core specialists' clinics and through companies that distributed the products. However, as this field of nursing gained momentum, consistent standards of professional and structured training became needed and required.

Medical aesthetics is defined as minimally invasive procedures such as neuromodulator and hyaluronic acid injections. As the field, and its treatments, has become more socially acceptable, this has given rise to increased consumer market awareness. This, in turn, has led to industry growth. The American Society of Aesthetic Plastic Surgery (ASAPS) estimates that almost 2.7 million injection procedures were performed in the United States in 2018, which represents an increase of 13.9% over the previous year (ASAPS, 2020). Because these statistics are only reported by core specialty physicians (plastic surgeons, dermatologists, otolaryngologists, and oculoplastic surgeons), it can be assumed that the numbers are even greater as medical aesthetics procedures are commonly performed by noncore practitioners (Mckee et al., 2019).

A study in 2010 by Spears showed that medical aesthetics practitioners are not educated in a consistent manner in regard to injection techniques, clinical assessments, contraindications, and complications. This gap in education has created a fragmented field of nursing concerning the level of quality assurance (Spears, 2010). If health professionals are not properly educated, then the advanced clinical knowledge, skill, judgment, and patient safety required to practice proficiently could be minimized, impacting the quality of the patient care (Spears, 2010).

All medical aesthetics practitioners must work within their scope of practice and show that they have the appropriate education requirements expected to ensure professional competency (Regulated Health Professions Act [RHPA], 2020). Nurses in medical aesthetics should align their practices with the principles of their provincial college standards and independent practice guidelines, noting that regulations may differ from province to province. Educational requirements that are recognized as essential to a medical aesthetics practice include a knowledge of facial anatomy, physiology, pharmacology, injection techniques, and complication management (Canadian Society of Aesthetic Specialty Nurses [CSASN], 2015). This extensive knowledge is critical for patient health history assessments, treatment plans and interventions, as well as patient follow-ups and outcome analysis. All of these critical educational elements are key components to the infrastructure of a medical aesthetics program that ensures excellent clinical care and patient safety (Mckee et al., 2019).

The growing field of medical aesthetics has resulted in varying educational programs in terms of the depth and quality required to meet educational needs, practice limitations, and medical directive responsibilities. Basic nursing education is built on evidence-based science and nursing theory. Nursing competency models, focusing on assessment methods and validation of practice outcomes, are an excellent framework for the practice of medical aesthetics (Lenburg, 1999; Spears, 2010). Nursing competencies can be defined as measurable conducts for skills and practices (Zhang, Luk, Arthur, & Wong, 2000).

Historically, physicians trained and nurtured the medical aesthetics nurses. Education originated from the research and academic literature produced in dermatology and plastic surgical medicine. Physicians recognized that training nurses to provide the medical aesthetic injections would provide patients with better access to these treatments. Those nurses would be employed to improve clinic flow, permit a continuity of patient care, and allow physicians the flexibility to maintain hospital duties or operating room schedules. The only way nurses could inject was through direct delegation under the nursing scope of practice guidelines (RHPA, 2020). As this specialized role developed, many nurses became proficient in the integration of aesthetic physiology, product knowledge, injecting techniques, and clinical decision-making. They were also encouraged to use their acquired expertise to train and mentor other nurses in the field.

As a result of the development of nursing clinical expertise, medical aesthetics has recently undergone an incremental growth in independent nursing practice clinics. Independent registered nurses and registered practical nurses function under a medical directive-driven care model that fully supports their ability to function independently in a clinical practice (RHPA, 2020). Even with this advanced clinical expertise and college practice guidelines, nurses must utilize the evidence-based medical/nursing literature that supports all nurses in a standardized manner (Spears, 2010).

NURSING PRACTICE GUIDELINES IN MEDICAL AESTHETICS

Although registered nurses are able to practice independently, they are governed by practice regulations set forth through the RHPA and their provincial college of nurses. Nurses are able to perform 5 of the 14 controlled acts that require a directive from an Authorizer of Ordering Authority (AOA). The AOA is also referred to as a medical director (RHPA, 2020).

Both the nurse and the AOA should share an understanding of the roles and responsibilities of all the elements involved in the facial assessment, diagnosis, prescribing of a treatment plan, and the legal responsibilities related to clinical consent and documentation. They must collaboratively follow the practice guidelines in all clinical areas and adhere to the stipulations of the controlled acts and directives without assumption or deviation (Jones, 2009).

Controlled acts relevant to medical aesthetics include the following:

* Performing a prescribed procedure below the dermis or a mucous membrane;

* Administering a substance by injection or inhalation;

* Putting an instrument, hand, or finger beyond a body orifice;

* Dispensing a drug; and

* Treating by means of psychotherapy.

Provincial colleges of nursing outline how nurses must follow signed medical directives to support the delivery of an order to a group of patients, provided that circumstances are the same in each case. Medical directives are often used to provide nurses with the necessary ordering structure for their clinical practice. Even with a medical directive to guide the delivery of care, nurses must show both cognitive and technical competency in the performance of the procedure prior to the care (College of Nurses of Ontario, 2020).

Educational programs for nurses must adhere to the standards of practice of provincial colleges. It is essential that academic and practical education programs in medical aesthetics incorporate a full understanding of both the RHPA and the provincial college standards of practice.

PROFESSIONAL NATIONAL ASSOCIATION GUIDELINES

The CSASN was formed more than 10 years ago to support medical aesthetic nurses in their practices throughout Canada. The mission of the CSASN describes a commitment to ensuring current, relevant evidence-based education at the highest standards to protect public safety and promote professional growth for nurses in aesthetic medicine (College of Nurses of Ontario, 2020).

In 2014, the CSASN board of directors created a taskforce that developed "Canadian Guidelines and Practice Standards for Nurses and Nurse Practitioners in Medical Aesthetics." This national document is scheduled for a review and update in 2020.

The current guidelines and standards incorporate evidence-based principles of medical aesthetics and with a consideration of all provincial nursing guidelines for practices in Canada. It is recommended that all nurses have at least 2 years of nursing experience before initiating extensive course training in medical aesthetics. Specialized training includes both basic and advanced training in treatments that include neuromodulators, dermal fillers (including hyaluronic acid and other volume enhancers), collagen stimulators, and lipolysis.

The CSASN guidelines and standards were formulated to be consistent with the Nursing Act 1991, the Health Care Consent Act, and the Regulated Health Professions Act (1991). The CSASN is formally recognized as a specialty network group by the Canadian Nurses Association (CNA). The CNA accepted the guidelines and standards in 2018.

The document outlines the key components of the required skills and the education that is critical for a nursing medical aesthetics practice (Nursing Act, 1991; Nursing Health Consent Act, 2020; RHPA, 2020).

Nurses in medical aesthetics are expected to practice in an environment that follows national standards and maintains practice competencies (CSASN, 2015; RHPA, 2020). These competencies should also be in accordance with their provincial scope of practice and quality assurance expectations. Unfortunately, current educational programs in medical aesthetics have not always included the evidence-based research required to ensure a proficient and safe practice.

ACADEMIC PREPARATION IN MEDICAL AESTHETICS

The CSASN guidelines on the requirements for nurses in this area of practice should be used as a mechanism to raise the bar for all medical aesthetics nursing practices. Utilizing the outline in this document ensures that nurses are educated with the highest level of clinical technical and legal knowledge, which would include the following:

* Facial anatomy and physiology with didactic and hands-on reviews of muscle, vessels, and important facial structures;

* Pharmacology that includes the mechanism of action, indications, and contraindication;

* Clinical assessment, differential diagnosis, and knowledge of anticipated outcomes;

* Management and treatment of potential complications or adverse events; and

* The role and responsibilities of the AOA in ordering medical directives.

Practitioners would greatly benefit from full knowledge of these educational criteria and practical hands-on mentoring performed under the guidance of a clinical expert. Preceptorship and mentorship should continue for as long as the nurse requires confidence to provide a safe practice (CSASN, 2015).

CONCLUSION

Medical aesthetics is a burgeoning independent nursing practice that requires evidence-based education and mentorship as recommended by the CSASN. The national guidelines and practice standards should be used to train nursing practitioners and enhance patient safety.

Nurses considering a practice in medical aesthetics should review educational programs that integrate the critical components of the national guidelines. Nurses already in medical aesthetics should review the national and college guidelines to ensure that their practices meet all standards for safe and proficient patient care.

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