Introduction During the last 25 years nurses have been at the forefront in the treatment of non-surgical aesthetic procedures. These include the use of dermal fillers, the botulinum type A toxin cosmetically, chemical peels, and laser treatments. As well as treating patients many are instructing and mentoring their medical colleagues.
Recognising that a new specialty brought with it responsibilities, a group of entrepreneurial nurses established a forum for aesthetic nurses. This afforded nurses networking and educational opportunities. They also published guidance for best practice, and the internationally acclaimed accredited competencies.
Because their professional organisation felt that aesthetics was not part of mainstream healthcare, we founded the British Association of Cosmetic Nurses (BACN). Part of its remit is to educate and foster good practice so that patient safety in this new specialty may be safeguarded. The medicalisation of ageing and beauty There are many examples of conditions other than disease processes per se, which attract the attention of the medical and nursing professions, obesity and the menopause being the most obvious. Now the ageing process and the enhancement of beauty can be added to the list.
It was during the Enlightenment that the idea of perfecting health began[1]. The Georgian public self-medicated, bought manuals and purchased products[2]which they hoped would help restore health. The 18th Century also saw the advent of marketing including advertising and product distribution. As the nation became more prosperous through an improved market economy, so people became more wealthy with an increase in disposable income.
In addition to these factors anti-ageing treatments were crossing from America to the UK. Collagen which was used in the treatment of burns was found to restore skin integrity, and Drs A and A Carruthers were developing the use of the botulinum type A toxin cosmetically. Initially treatments were taken up by celebrities, and encouraged by the results, it was not long before the media promoted many of these treatments as ‘lunch time’ fixes.
Alongside this was the realisation among some that physical appearance mattered in order to improve self-confidence, and secure a job or a partner. This too was encouraged by the media, and has become more potent with the advent of social media and the popularity of ‘selfies’.
Although the public were initially cautious about anti-ageing treatments, the momentum rapidly increased resulting in the popularity of non-surgical treatments we are familiar with today. To cope with the increase in demand more practitioners are entering this field. There is therefore a requirement for education and training which is not delivered in the National Health Service. Education and training Currently education and training undertaken by doctors and nurses is product based, a format that seems set to change.
The legal test for doctors and nurses is competence judged by the Bolam[3] /Bolitho[4] standard and underpinned by education and training. The BACN have updated their competency framework[5] which recognises the requirement for specialist knowledge and skills at different levels of practice[6]. The document provides a benchmark for good practice and is being used in the structuring of an educational framework for Higher Education Institutions in line with Department of Heath recommendations.
As recommended in the Keogh report[7], Heath Education England (HEE) is reviewing the qualifications required for non-surgical cosmetic procedures. Phase one established a proposed qualifications framework for five treatment modalities including non-surgical treatments. All practitioners will be expected to take part and there will be a range of entry points including accredited prior learning. A range of common themes including consent and ethics[8] will form part of the curriculum ranging from foundation to PhD level. Training will be competence based.
The Department of Health will support HEE with legislation as at present non-medical personnel are undertaking these treatments. The legislation will ensure that all consultations for dermal filler treatments are undertaken by a member of the NMC or GMC. The treatment can then be undertaken ‘under supervision’ by an appropriately qualified practitioner[9]. It is hoped that this more formal model of education will reduce the high level of litigation in this specialty, currently running at 20%. Avoiding litigation While aiming to relieve distress medical treatments can cause iatrogenic harm. Non-surgical treatments are no exception and carry risks as well as benefits. In this field many clinical negligence cases which come before the courts do so because not enough attention has been paid to the consultation and the consent process. Many patients are vulnerable and can suffer from low self-esteem which adds to the pressure medical practitioners face in wanting to help them. Although these patients self refer, patient selection is key to a successful cosmetic outcome, and not everyone is suitable for treatment.
Obtaining valid consent is an ethical, clinical and legal requirement. It must be free from coercion and the patient must have the ability to understand the information given. All risks must be explained and recently the importance of patient autonomy in a competent patient was clarified in Montgomery[10]. Although ignorance is no excuse in law, many practitioners are ignorant of the legal requirements of the consent process.
Two way communication is key and practitioners have a responsibility to give as much information that patients need to make a decision. The amount of information is a matter for clinical judgement while respecting patient autonomy. Practitioners must also make every reasonable effort to ensure the patient has understood what has been said and it is helpful to give him a written information sheet.
The signature on the consent form records the patient’s decision and that a discussion has taken place. It is not proof that consent is valid, neither does it take away legal liability if all aspects of the consent process are not covered. Finally it is advisable to check the medical history and obtain fresh consent before each treatment episode. Conclusion For nearly a quarter of a century nurses have led the way in the use of non-surgical procedures with a group of pioneering nurses being responsible for raising the profile of education and setting standards.
Many factors have contributed to the medicalisation of the ageing process including those which directly impact on ageing and the way we approach it. These in turn have made people more aware of their appearance and the way others regard them. The way in which education is undertaken is changing. Training will be competence based and legislation will ensure all consultations are undertaken by medical or nursing staff.
Finally, in order to reduce the incidence of litigation, those who are responsible for consultations and the consent process must be mindful of the legal requirements. [1] Porter R. Health for Sale. Quackery in England 1660-1850, (1989). Manchester University Press, p39. [2] Porter R and Porter D. Patients’ Progress, (1989), Stanford University Press. Chapter 3. [3] Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 at 587-588. [4] Bolitho v City & Hackney Health Authority [1998] AC 232 HL. [5] British Association of Cosmetic Nurses. An integrated career and competency framework for nurses in aesthetic medicine, (2014) RCN Accredited. [6] Ibid. pp20-21. [7] Department of Health. Review of the Regulation of Cosmetic Interventions, (2013), London. p7. [8] Spicer P. HEE, personal email 19/06/2014. [9] Rankin A. Working with Health Education England to change the future of the industry. Journal of Aesthetic Nursing, (2014), 3 (5), pp248-249. [10] Montgomery v Lanarkshire Health Board (Scotland) [2015] UKSC 11.
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