INJECTABLE AESTHETIC THERAPIES
Document Contents
The purpose of this document is to inform nurses of their professional responsibilities and accountabilities related to injectable aesthetic therapies. Injectable aesthetic therapies may include treatments such as injections of neuromodulators, dermal fillers, and platelet-rich plasma for the purpose of enhancing, preserving, or altering a client's appearance.
This Practice Advice was developed collaboratively by the College of Licensed Practical Nurses of Alberta (CLPNA), the College of Registered Psychiatric Nurses of Alberta (CRPNA), and the College of Registered Nurses of Alberta (CRNA). Nurses of these regulatory colleges should contact their respective organizations if they have any questions about the information in this document.
Nurses must be aware of and follow all applicable legislation and regulations when providing injectable aesthetic therapies. An injectable aesthetic therapy may be either a personal service or a health service[1], depending on the purpose for and the setting in which the therapy is performed. The Personal Services Regulation (Alta Reg 1/2020, s 1) defines personal services as “activities performed on, in, or to a person’s skin, hair, nails or teeth, or other parts of the body of a person, for the primary purpose of enhancing, preserving or altering the person’s appearance” and includes injecting cosmetic products.
A nurse who performs an injectable aesthetic therapy as a personal service must comply with the Personal Services Regulation (Alta Reg 1/2020) and Personal Services Standards (Alberta Health, Government of Alberta, 2020), as these provide the minimum health and safety requirements for the personal services industry. Nurses providing aesthetic procedures and treatments must be aware of all the requirements relevant to their practice, as outlined in the Personal Services Regulation (Alta Reg 1/2020) and Personal Services Standards (Alberta Health, Government of Alberta, 2020).
If an aesthetic procedure performed is considered a nursing or health service, nurses are required to follow their regulatory college's standards. The Personal Services Regulation (Alta Reg 1/2020) and Personal Services Standards (Alberta Health, Government of Alberta, 2020) apply in any setting where personal services are provided, with the following exemptions:
“(b) a service provided in
(i) an area within an approved hospital, as defined in the Hospitals Act,
(A) in which health services are provided, and
(B) that is subject to auditing for hospital accreditation purposes,
(ii) a facility accredited under Schedule 21 of the Health Professions Act, by the Medical Facility Assessment Committee continued under that Schedule or by the Council of the College of Physicians and Surgeons of Alberta, or
(iii) the premises in which a dentist carries on the practice of dentistry.”
(Personal Services Regulation, 2020, s 2)
Any other setting where a personal service is provided is subject to the Personal Services Regulation (Alta Reg 1/2020) and Personal Services Standards (Alberta Health, Government of Alberta, 2020).
[1] Health service – a service provided to people: (i) to protect, promote or maintain their health, (ii) to prevent illness, (iii) to diagnose, treat or rehabilitate, or (iv) to take care of the health needs of the ill, disabled, injured, or dying (HPA, 2000).
Scope of practice refers to the interventions that nurses are authorized, educated, and competent to perform. Set out in provincial legislation and regulations, scope of practice is complemented by standards of practice, code of ethics, guidelines, and other regulatory documents. Nurses must follow all applicable legislation, regulations, and standards associated with the provision of injectable aesthetic therapies.
Nurses are authorized under the Health Professions Restricted Activity Regulation (Alta Reg 22/2023) and have the education to administer drugs and substances by injection. To provide safe, competent, and ethical care in providing injectable aesthetic therapies, nurses must have additional education. It is the responsibility of the nurse to ensure that any initial and ongoing education and training they undertake provides essential competencies to integrate the knowledge, skills, abilities, and judgment to perform aesthetic procedures safely. At entry-to-practice, nurses do not have the competencies or education to perform injectable aesthetic therapies, this includes determining indications for the procedure, identifying when reassessment is required, and managing complications that arise. Nurses must ensure the education and training they take meets industry standards, is evidence-informed, and demonstrates best practices. Nurses are accountable for meeting the minimum expectations outlined in their regulatory college's standards of practice, code of ethics, and guidelines related to providing safe, competent, ethical care.
Nurses using a protected title are required to meet the expectations outlined in legislation, standards of practice, and the code of ethics. Nurses will be held to their regulatory college's standard regarding the use of title in a setting that is outside of health services involving injectable aesthetic therapies.
Nurses are responsible for ensuring they have the appropriate professional liability insurance for performing injectable aesthetics therapies and should contact their insurance provider for further information.
Nurses are legally required to document all nursing care provided, including the provision of aesthetic procedures and treatments. Nurses must adhere to documentation requirements outlined by their regulatory college. 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 client-focused care, including relevant components of the nursing process: assessment, nursing diagnosis, plan, implementation, and evaluation.
Privacy and management of health information requirements are outlined in legislation, regulations, and standards of practice. Nurses must meet the minimum expectations as outlined in their regulatory college's standards.
Clients need to understand the risks, benefits, and expected outcomes for any injectable aesthetic therapy. Nurses should ensure they have obtained informed consent from their clients prior to providing any aesthetic therapy. If prior to starting treatment, there is a change in the treatment plan or client condition, the consent must be renewed to ensure valid consent.
For consent to be informed, the nurse must explain the intervention, including alternative options, as well as 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, 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 (person under 18 years old) when the parent/legal guardian consent is obtained, and treatment is mutually agreed upon between parent/legal guardian and minor. In situations where the client is a minor, the nurse should identify appropriate actions to take during the informed consent process by following employer requirements or contacting their regulatory college;
- obtain consent in an ethical manner and document accordingly;
- renew consent if there are changes to the client’s initial care plan; and
- obtain consent each time the intervention or procedure is provided.
Performance of aesthetic procedures have heightened requirements for informed consent due to risks associated with this type of procedure. Nurses should communicate the realistic expectations of results with the client, as well as the potential risks.
Nurses have a responsibility to conduct themselves according to the ethical principles outlined within their regulatory college's practice standards and code of ethics and must practice in an honest and factual manner. 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.
Nurses have an ethical responsibility to identify and address conflicts of interest. Both actual and potential conflicts of interest that arise in professional relationships should be disclosed, this includes personal relationships, affiliations, and financial or personal interests. The conflict should be resolved in the interest of the needs and concerns of the client (Canadian Nurses Association, 2017). Examples of conflicts of interest include, but are not limited to,
· compensation arrangements based on selling higher volumes of injections;
· office space rentals based on revenues;
· requirement to reimburse employer or owner in the event of a complication;
· paying kickbacks or referral fees; and
· advertising offering volume discounts or promotional offers on injectables.
Nurses "…shall not engage in advertising that is untruthful, inaccurate, or otherwise capable of misleading or misinforming the public" (Health Professions Act, 2000, s 102) and should not use their professional title to endorse or promote one treatment option over another. Nurses should develop strategies that mitigate risks in situations where their interactions with industry (e.g., pharmaceutical companies), or employers, may interfere with evidence-informed decision-making. The Food and Drug Act (1985) requires that a person advertising prescription drugs to the general public, shall not make any representation with respect to the brand name, the proper name, the common name, and the price and quantity of the drug.
Nurses need to follow best practices for preventing health care acquired infections. This includes meeting the minimum expectations as outlined in legislation, regulations, and standards. The following routine practices are an important component of infection prevention and control (IP&C) and should always be used:
· dedicated hand-washing sinks and hand sanitizer stations;
· follow the Hand hygiene: A guide to clean hands (Alberta Health Services, 2020);
· 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.
The Personal Services Standards (Alberta Health, Government of Alberta, 2020) provides additional guidance for IP&C for individuals working in a personal services setting.
Schedule 1 Drugs
Drugs listed on The Prescription Drug List (Health Canada, Government of Canada, 2022) can only be prescribed by an authorized regulated health professional. All Schedule 1 drugs require a client specific order from an authorized prescriber for a nurse to be able to administer the drug, in accordance with the Pharmacy and Drug Act (2000). Nurses must meet the minimum expectations as outlined in their regulatory college medication standards or policies.
Procurement and Storage
Drugs and substances for administration by injection must be procured through legitimate means (i.e., through the pharmaceutical company or pharmacy). Drugs and substances procured by other means may not be the correct substance, may be beyond expiration date, counterfeit, or may have been stored inappropriately, thereby altering composition, safety, and efficacy. Nurses have no authority to order drugs directly from a drug manufacturer and then store and sell those drugs if they are not doing so in conjunction with a licensed pharmacy.
Section 3 of the Pharmacy and Drug Act (2000) prohibits a person from providing a pharmacy service (which includes storing and selling drugs) unless they are doing so from a licensed pharmacy and in accordance with the Pharmacy and Drug Act and its accompanying regulations, the Standards for the Operation of Licensed Pharmacies and the code of ethics that governs the profession. A nurse should not use the services of another health-care professional purely for the purposes of procurement. Only an authorized prescriber can procure drugs, and the prescription provided should align with pharmacy standards and regulations.
Nurses must follow standards and best practice guidelines for the storage and handling of drugs and substances. Additionally, nurses must follow manufacturer recommendations for safe storing to maintain the quality and efficacy of the drug, such as temperature and light requirements. Nurses should refer to their regulatory college's standards and guidelines for medication management when using or storing single or multi-use medication vials.
Nurse practitioners (NPs) should follow the guidance as outlined above in addition to the responsibilities and accountabilities of their advanced scope.
NP Prescribing
NPs are responsible and accountable for ensuring safe, competent, and ethical prescribing practices including, but not limited to,
· developing a holistic and individualized plan of care with the client (in the context of a therapeutic nurse-client relationship), family, and other members of the health-care team;
· ensuring they have completed an assessment of the client prior to ordering any medications or recommending any therapies;
· ensuring appropriate follow up and evaluations; and
· acting in a reasonable and prudent manner for any urgent, emergent, or adverse events.
NPs must meet the minimum expectations outlined in the Prescribing Standards for Nurse Practitioners (CRNA, 2022) when prescribing for injectable aesthetic therapies.
Alberta Health, Government of Alberta. (2020). Personal services standards. https://open.alberta.ca/dataset/71d9b238-0ec3-4f2d-8ac7-5510b46900a0/resource/6d224d18-1c63-4f5d-8ba5-d71b98ef5c83/download/health-personal-services-standards.pdf
Alberta Health Services. (2020, November 30). Hand hygiene: A guide to clean hands.
Retrieved August 18, 2023, from
https://myhealth.alberta.ca/Health/pages/conditions.aspx?Hwid=custom.ab_handhygiene_inst
Canadian Nurses Association. (2017). Code of ethics for registered nurses.
https://cna-aiic.ca/en/home
https://www.cnaaiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethic
College of Registered Nurses of Alberta. (2022). Prescribing standards for nurse practitioners.
Food and Drug Act, RSC 1985, c F-27.
Health Canada, Government of Canada. (2022, May). The prescription drug list. https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/prescription-drug-list.html
Health Professions Act, RSA 2000, c H-7.
Health Professions Restricted Activity Regulation, Alta Reg 22/2023.
Personal Services Regulation, Alta Reg 1/2020.
Pharmacy and Drug Act, RSA 2000, c P-13.
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