Considerations for Providing Cosmetic Services

Cosmetic services and procedures have evolved in recent years. Since this is a relatively novel way to deliver nursing services, nurses should understand the unique liability risks when providing cosmetic services.

Regulation of Cosmetic Nursing

Nurses who provide cosmetic services are encouraged to confirm that they are working within their scope of practice as defined by their respective regulatory bodies. For example, as with the administration of any substance, registered nurses (RNs) in every jurisdiction can only administer Botox^® and other fillers when the patient has been initially assessed by a physician or other authorized prescriber and when there is a client-specific order.

A few regulatory bodies have prepared guidelines to inform RNs of their roles and responsibilities in relation to cosmetic services. In some jurisdictions, RNs require additional education and experience to have the necessary competency for performing cosmetic procedures.1 In other jurisdictions, a physician must be present on site for the initial cosmetic injection, but subsequent injections can be administered by the RN via directive if a physician is readily available.2

Regulatory bodies have also taken differing positions on nurse practitioners (NPs) providing cosmetic procedures as part of their practice. In Nova Scotia, NPs are able to prescribe Botox^® and other fillers with additional education and experience, and with the approval of the CRNNS NP Committee. By contrast, the regulatory bodies in British Columbia and New Brunswick have stated that cosmetic procedures are not part of primary health care and therefore should not be ordered or performed as part of NP practice.3

Nurses performing cosmetic services should be aware that some cosmetic services may not be considered to be nursing activities, particularly esthetic services that do not need to be performed by a regulated health professional (e.g. microdermabrasion). Therefore, they are encouraged to contact their regulatory body to confirm that their activities fall within the definition of nursing practice in order to correctly hold themselves out as nurses to clients and others, and that these activities qualify toward the required number of practice hours for maintaining licensure.

Informed Consent

Before providing any cosmetic service to a client, the health-care professional proposing the intervention must obtain valid consent. Performing a procedure on a client without consent is considered battery for which a court can award damages, even if the client does not suffer harm.

In order for consent to be considered valid, it must be voluntary. The client must have had the capacity to consent and must have been properly informed. For consent to be informed, the client must be provided with sufficient information about the nature of the procedure, its anticipated outcome and any material risks. In the context of cosmetic services, the duty of disclosure is even more onerous.

Given the subjective nature of cosmetic outcomes, those who deliver these types of services are more at risk of being subject to complaints and civil actions from their clients. In order to minimize this risk, it is prudent for nurses who perform cosmetic procedures to manage their clients’ expectations about the anticipated results of the procedure.

Consent discussions with the client should always be documented by the health-care professionals involved in providing the cosmetic service.

Record-keeping Requirements

As with nurses in other practice areas, nurses providing cosmetic services have legal and professional obligations to document their encounters with clients. All regulatory bodies have established documentation standards, which are equally applicable to cosmetic services when the nurse is acting in a professional nursing capacity. In some jurisdictions, client records must also be retained for a specified period.4 Failure to comply with these record-keeping requirements may result in disciplinary action.

Proper and thorough documentation is also likely to be a nurse’s best defence in a legal proceeding related to cosmetic services. Records can be used later to reconstruct events, refresh memory, and provide detailed evidence of the care, all of which may minimize legal risk.

We also remind nurses be mindful of their ethical and legal obligations to protect the confidentiality and privacy of their clients’ personal health information. As always, it is important to store all records in a secure manner. Nurses in independent practice providing cosmetic procedures will often be considered the custodian of their clients’ records and subject to the legal requirements imposed by the relevant privacy legislation.

Independent Practice

Nurses who are considering opening a clinic or operating their own independent nursing practice to provide cosmetic procedures face unique challenges because they are also responsible for business management. We encourage nurses in independent practice to consult with their own lawyer: (1) to determine the best business structure for the delivery of their services and (2) to discuss other business-related matters, such as appropriate billing of clients, compensation practices, taxation issues, advertising requirements, compliance with privacy legislation, etc.

Liability Protection

The Canadian Nurses Protective Society (CNPS)’s professional liability protection is structured to protect individual eligible nurses5 from claims for professional liability arising from the provision of professional nursing services. Performing procedures that are not considered professional nursing services may limit the ability of an otherwise eligible nurse from relying upon CNPS professional liability protection. This is yet another reason for nurses providing cosmetic services to consult with their relevant regulatory body to ensure that their activities fall within the definition of nursing practice.

Nurses who are considering opening a clinic or operating their own independent nursing practice to provide cosmetic procedures may also need to consider liability protection for their business entity. CNPS protection does not extend to a business entity.

Business insurance options are available to CNPS beneficiaries.  To learn more, visit “Operating a Business or Independent Practice?” or contact CNPS at 1-800-267-3390.

Nurses who partner with a spa or a clinic to deliver cosmetic nursing services are encouraged to inquire about whether they will be covered under the spa or the clinic’s insurance policies and, if so, the amount of coverage. Alternatively, CNPS beneficiaries may also purchase business liability insurance from the commercial insurance market.

It is prudent for nurses who are working in collaboration with other health-care professionals to provide cosmetic procedures to confirm that each health-care professional has adequate individual professional liability protection.

CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.

1. For example, see the Nurses Association of New Brunswick position statement on “Cosmetic Medical Procedures” (October 2014).
2. For example, see the Nova Scotia College of Nursing’s position statement on “The Role of Registered Nurses in Cosmetic Procedures: BOTOX and Dermal Fillers” (2013).
3. Nurses Association of New Brunswick position statement, Cosmetic Medical Procedures, August 2019; British Columbia College of Nursing Professionals, Scope of Practice for Nurse Practitioners, Cosmetic Treatments.
4. For example, the College of Nurses of Ontario recommends that records of nursing services be retained for a minimum of 10 years after the nurse-client relationship is terminated.
5. Eligible nurses are members in good standing with a CNPS member organization, or who have registered individually for beneficiary status with the CNPS. See cnps.ca/eligibility for details.

Related infoLAWs of interest: Consent to Treatment, Quality Documentation: Your Best Defence.

NOTE: As of June 2019, there is no longer a requirement for Nova Scotia nurse practitioners to obtain approval from their nursing regulator (the Nova Scotia College of Nursing) prior to changing client types (including cosmetic clients) that fall within the client populations for which they were educated and passed an appropriate entry to practice examination.

Volume 23, number 1, May 2016

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.