Qualified nurses in Australia, Canada, and the United Kingdom (UK) are permitted to perform minimally-invasive treatments on patients, but not in Asia. Why is this so? And is Asia ready to take this leap?
Nurses play an integral role in patient care and recovery, whether they are based in a primary care facility or aesthetic medicine practice.
Nurses in aesthetic clinics support aesthetic physicians by recording patients’ medical history and vital statistics such as height and weight, and preparing physicians and patients for treatment. Post-treatment, nurses follow up with patients on treatment outcomes and dispense tips and advice on how to manage side effects if and when they arise. Registered nurses (RNs) who work in the operating theatre — also known as perioperative nurses — work alongside surgeons, anesthesiologists and other allied healthcare professionals, and their patients and their families, to plan, implement, and evaluate surgical treatments.
In Asia, there is a clear distinction between what doctors and nurses do. While aesthetic physicians rely on nurses to support patients who are undergoing minimally-invasive treatments and surgery, they are generally prohibited from performing minimally-invasive treatments.
By contrast, in countries such as Australia, Canada and the United Kingdom (UK), a nurse’s role can extend to include performing a full range of minimally-invasive aesthetic treatments from neurotoxin and dermal filler injections, and threadlifts, to light- and energy-based treatments, microneedling, and dermabrasion treatments.
While this might seem insignificant to the patient, enabling nurses to perform minimally-invasive aesthetic treatments could potentially reduce the rate at which they are dropping out of the profession, which has led to a critical shortage of nurses not just in Asia, but across the globe.
Burnout, lack of career progression leading to nurse shortage in Asia
There is a global shortage of nurses supporting primary healthcare facilities, leave alone private aesthetic practices. According to the International Council of Nurses (ICN), up to 13 million nurses will be needed to fill the global nurse shortage gap by 2030.
The lack of career progression, low pay and long hours, and burnout have been flagged as the main reasons nurses are dropping out of their profession.
A survey of healthcare workers involving government nurses and doctors in Malaysia found 73% of respondents considered quitting their jobs due to burnout and career uncertainty in public health. In Singapore, the proportion of nurses who resigned from public hospitals in 2021 reached a five-year high, with 7.4% local and 14.8% foreign workers leaving their nursing jobs, mainly due to fatigue from providing acute care during the COVID-19 pandemic and the lure of higher salaries overseas.
“There are factors that underpin the global shortage of nurses which have to do with how nursing as a vocation is perceived by society, and how institutions determine their pay structure, etc., which are not within the control of private practices, leave alone those providing aesthetic treatments,” says Dr Johnathan Hopkirk, Global Medical Director of Laser Clinics, which owns and operates over 200 clinics across Australia, New Zealand, Canada, UK, and Singapore.
“But what aesthetic practices can do to retain nurses is to provide avenues within the practice to empower them. I have found that enabling nurses to perform treatments, even on a part-time basis, could help with increasing their sense of job satisfaction.”
This notion is underscored by the American Association of Aesthetic Medicine and Surgery, who stated on their website that enabling nurses to practice aesthetic medicine can potentially offset the routine and challenges of bedside nursing, promote a renewed sense of satisfaction in caring for patients, offer better work-life balance, higher job satisfaction, more autonomy, and even open up new entrepreneurial possibilities.
Case study: Australia
In Australia, RNs are able to perform minimally-invasive treatments on patients, for as long as they are authorised by a supervising doctor or nurse practitioner (NP). Up to 70% of all aesthetic medicine practitioners in Australia are nurses, while the remaining 30% are doctors or dentists.
NPs with advanced qualifications, including a Masters of Nurse Practitioner and a minimum of three years’ full time experience of the last six years as an RN, are also authorised by the Australian Health Practitioner Agency (APHRA) to prescribe treatments as well as diagnose, treat and refer patients within the aesthetic medicine scope, provided they are adequately trained in that area.
“Qualified NPs are allowed to make autonomous decisions with regards to patients’ treatments and permitted to perform consultations, diagnose skin conditions and even manage adverse events, unlike RNs who are only authorised to perform minimally-invasive treatments on patients,” explains Sarah Ford, a Nurse Practitioner in Australia with 13 years of experience in aesthetic medicine.
She adds, “The role of NPs does not overlap with specialists such as dermatologists or plastic surgeons who perform surgical procedures.”
Australian nurses are subject to rigorous training, closer supervision
“As well as the stringent requirement for nurses in Australia to qualify as RNs and NPs, nurses are often subjected to close scrutiny by governing bodies,” Sarah explains.
“All RNs and NPs undergo random audits to ensure compliance. RNs and NPs must complete 20 and 35 hours of Continuous Performance Development (CPD), respectively per year, which involves a combination of formal or self-initiated training, to maintain our registrations, which is why in some cases, the training that nurses undergo can appear more rigorous than training for physicians,” she adds.
Although RNs are enabled to perform treatments on patients in Australia, doctors still have the final say in whether a patient undergoes a treatment or not.
“Before undergoing any treatment, the patient must first consult with a doctor, who will assess and evaluate if the patient is suitable for the procedure based on his or her needs, medical history, and health status. The doctor will also counsel the patient to ensure he or she is aware of the risks involved in the procedure. Only then will the doctor authorise the treatment,” explains Dr Hopkirk.
Enabling nurses to treat patients can elevate aesthetic practices
Dr Hopkirk believes enabling nurses to perform minimally-invasive procedures does not only enhance the patient’s experience but benefits the practice in the long run.
“Nurses are trained to be caregivers and typically have more empathy and better bedside manners compared to doctors. This enhances the patient’s overall experience, which only helps the practice; patients who have had a good experience with a clinic are more likely to return, and refer their family and friends.”
“By enabling nurses to perform more routine treatments, specialists such as dermatologists and plastic surgeons are freed up to take on and perform more invasive and complex procedures, and tend to patients needing more critical care. This not only helps doctors perfect their skills, but generates more revenue for the practice in the long run,” says Dr Hopkirk.
Is Southeast Asia ready?
Currently RNs in Southeast Asian countries are not offered additional training programmes or pathways to specialise in aesthetic medicine, and doctors appear hesitant to consider their benefits, leave alone work with the authorities to institute them.
Shila Das, Regional Trainer with Novoxel and former Lead Nurse at Woffles Wu Aesthetic Surgery and Laser Centre in Singapore, believes doctors’ hesitancy can be attributed to stiff competition arising from the industry’s rapid growth. In 2020, the beauty and cosmetics segment in Southeast Asia was valued at US$25,449 billion, with a compound annual growth rate (CAGR) of 5.3% between 2020 to 2023.
Relatively lax regulatory frameworks have created loopholes or grey areas which are vulnerable to exploitation by practitioners, and when combined with stiff competition, encourage unscrupulous practices within the industry,
“Aesthetic clinics, especially the newer ones, are slashing prices in the hope of driving demand up. In some countries, aesthetic physicians perform procedures only plastic surgeons and dermatologists are allowed to perform. There are instances where although the clinic is registered in a physician’s name, personnel who are not medically trained such as beauticians are allowed to perform minimally-invasive treatments. Malpractices are rarely brought to the attention of the health authorities who tend to put aesthetic treatments on low priority compared to issues of public health concern, such as the outbreak of infectious diseases,” she offers.
“In an industry where competition is stiff, I can see why aesthetic physicians would be reluctant to share the same slice of pie with more players,” she opines.
Dr Somasundaram Sathappan, veteran Consultant Plastic and Reconstructive Surgeon from Soma Plastic Surgery is hesitant to enable nurses to perform minimally-invasive aesthetic treatments.
“While nurses may be skilled at using needles to insert intravenous lines and for drawing blood, they may not have the in-depth understanding or knowledge of anatomy, medicine, and treatment protocols to safely introduce foreign substances into the body, as well as manage the potentially deadly complications that may occur,” he offers.
“On one hand, enabling nurses to perform more invasive treatments can put a practice and its doctor at risk of expensive and lengthy legal proceedings that can damage the practice’s reputation. On the other hand, with sufficient training, nurses should be enabled to perform superficial treatments which do not go deeper than the epidermis, under the supervision of a qualified physician, as the likelihood of permanent and irreversible damage from these treatments is low.”
In Malaysia, there is a surplus of doctors in need of permanent jobs, and competing with nurses in the aesthetic medicine space could make it more challenging for doctors to secure permanent positions. Dr Soma elaborates, “Our country is facing a crisis where over 30,000 medical graduates are expected to remain contract doctors by 2025. I don’t think we should be taking away opportunities from physicians who have already undergone years of medical training.”
Shila is more upbeat about the possibility of nurses and doctors working together to benefit the patients and the aesthetic medicine industry as a whole. “I think it boils down to establishing and enforcing a regulatory framework where plastic surgeons, dermatologists and aesthetic physicians clearly determine who can perform what sort of treatments based on what sort of training, and in what situations, and then work with the authorities to establish a minimum training for nurses to deliver some treatments.”
“By providing recognised and comprehensive training courses for nurses to perform minimally-invasive treatments, doctors and nurses can work together to benefit patients based on their strengths and the most appropriate allocation of their time and resources. This way, everyone wins,” she says.