Although there has been no firm decision made on what aesthetic nurse education will look like following the proposed licensing scheme for practitioners, there are signs that point towards it being at postgraduate level (Level 7) and open only to registered healthcare practitioners. In this article we will focus on nurses who are already practicing or wish to practice in the field of aesthetics as well as the benefits and challenges that come with a more structured education framework at postgraduate level.
It is fair to say that nurses working in this specialist field of practice wish for a higher and more public recognition of their knowledge and skills. It is also fair to say that while there is no universally recognised qualification for specialist practice in this area, this is not going to happen.
We know the problems that have arisen through failure to regulate this area of practice. The issues, not least safety, that have come from non-medical people being allowed to practice and the prevalence of 1 day ‘courses’ in aesthetics has led to many misconceptions about the levels of knowledge and skills required for safe, high quality and accountable clinical practice in aesthetics. It is therefore not surprising that many nurses leaving these very short and often superficial ‘courses‘ that claim to prepare them for what is in effect a field of specialist practice, end up feeling overwhelmed and experience a dip in confidence.
It often doesn't matter what level of knowledge and skills a person may demonstrate daily in their nursing role. The fact that they are aware of the gaps in their knowledge after taking such a course, which claims to make them a safe and effective practitioner, may lead to them questioning even the most basic aspects of aesthetic practice. We have seen questions on forums for aesthetic nurses asking seemingly simple questions such as ‘is this a bruise’?
This does not mean that a nurse does not recognise a bruise when they see one — it means that they are aware of the many aspects of presenting symptoms in aesthetic interventions that require consideration before a differential diagnosis can be made. It is this care and attention — this ongoing risk assessment and awareness of accountability that makes nurses and other medically qualified people the best and only people to be carrying out practice in this field. Nurses are taught, almost from day one of pre-registration education and practice to act only within their scope of practice and competency.
The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (NMC 2018) states at number 6 – ‘Always practise in line with the best available evidence’ and at number 13 ‘Recognise and work within the limits of your competence’. Neither of these is possible without an appropriate foundation of education and practice experience. Cognitive dissonance is described as the state of having inconsistent thoughts, beliefs or attitudes, especially in relation to behavioural decisions. Nurses know that their practice must be safe, evidence based and that they must be competent before carrying out practice. Aesthetic procedures are largely safe (though never without risk) and evidence based, however, until now, nurses have not had access to the required level of education to make them feel competent.
» A training course which instructs on where and how much to inject to achieve a given outcome, even a course which includes a few hours of e-learning, is bound to set up a degree of cognitive dissonance in nurses «
This is the complete opposite of many non-medical persons carrying out aesthetic treatments without a second thought. Here we can consider the Dunning-Kruger effect (Kruger and Dunning 1999).
The Dunning-Kruger effect is a cognitive bias or psychological phenomenon in which individuals with low ability or knowledge in a particular domain tend to overestimate their own competence or skills. In other words, people who are less skilled or knowledgeable about something often believe they are more skilled or knowledgeable than they are.
This bias is named after social psychologists David Dunning and Justin Kruger, who conducted a series of studies on the subject. Their research found that individuals who lack the expertise or experience to accurately evaluate their own abilities, often exhibit a lack of self-awareness regarding their limitations. In other words, they don't know what they don't know. This bias is often used to describe people who are practising in aesthetics with no medical knowledge or background.
The Dunning-Kruger effect highlights the importance of self-awareness and the need for honest self-assessment in order to make informed decisions and improve one's skills and competence in practice.
Conversely, qualified nurses have this level of self-awareness and ability required to self-assess as it is an integral part of always acting within one's scope of competence.
Nurses want this depth and breadth of knowledge and competency in whatever field of practice they choose, and this should equally be the case in aesthetic nursing.
Now that we have briefly discussed the importance of a pre-registration nursing qualification and the need for appropriate post-registration education, we will focus on the standard of education that is now going to be available, and indeed mandatory, within the new regulatory framework.
What is a specialist practitioner in nursing? As long ago as 2014, the Royal College of Nursing (RCN) discussed the role and purpose of specialist practitioners as those who work alone or as part of a multi-disciplinary team providing high quality, patient centred, tailored, timely and cost-effective care. The RCN also discussed the education, clinical and research focused activities of this advanced role.
The 2014 Document Specialist Nursing in the UK (RCN, 2014) promoted the idea of a specialist nurse having a grounding in nursing, being a qualified Registered Nurse and in some cases having experience in professional practice of ‘sufficient length’ before embarking on a specialist programme. In the case of Specialist Community Public Health Nurses (SCPHN) this period of post registration professional practice is flexible, however it was suggested that the consensus was the nurses must complete a minimum of 12 months of professional practice before moving into a specialist role.
A later RCN document (RCN, 2018) discusses the four pillars of advanced practice. The complete document is referenced below but the main factors to consider are the nurse's role in: management and leadership, education, research and advanced clinical practice.
In some way, this new regulation and standardisation of aesthetic practice education for nurses represents the beginning of a journey towards the recognition of aesthetic nursing as a specialist practice area. The field is therefore too new (in that sense) for us to have a practice framework in place that will support the development of management and leadership roles in the manner that is intended by the RCN document. We have ‘leaders’ in the aesthetic field, we have Key Opinion Leaders (KOLs) but we do not, through the education of aesthetic practitioners, actively encourage them to identify need for change, lead innovation and manage change.
» The autonomy, clinical decision making and accountability for own practice are supremely evident in the work of the aesthetic nurse «
Similarly, we do not yet have the infrastructure to place education and development at the heart of practice. Aesthetic education programmes do not include principles of teaching and learning, or how to support others to develop knowledge and skills, promote learning/create a learning environment, service user teaching and information giving, teaching, mentorship and coaching.
It could be argued that pre-registration education and experience give us this knowledge, and while that may be true to some extent, it is still the case that specialised or advanced practice requires us to formalise and standardise the quality of this education.
In terms of research and advanced clinical practice, aesthetic nurses are well placed to demonstrate these aspects at the higher level required for specialist practice. The autonomy, clinical decision making and accountability for own practice are supremely evident in the work of the aesthetic nurse. And yet, until now, we have not addressed the knowledge and skills required for this in post-registration education programmes for aesthetic nurses.
In addition to the RCN guidance, in 2001, the Nursing and Midwifery Council (NMC) published Standards for Specialist Education and Practice, (NMC, 2018) which will remain current until August 2024. Within this document they define specialist practice as practice which demonstrates higher levels of clinical decision making, monitoring and improvement of standards, the development of practice through research, teaching and support of professional colleagues and provision of skilled professional leadership.
At the time, the NMC concluded that the programme of preparation for the specialist practitioner role should be at no less than first degree level, be no less than 32 weeks in length and made up of 50% theory and 50% practice. The programme would be modular; having internal integrity and the capacity to be linked to other modules to form a coherent programme; have flexible modes of delivery; linkage to a higher education accreditation system; and give credit for appropriate prior (experiential) learning.
In most higher education institutions approved by the NMC, the specialist nurse programme is at postgraduate level and ranges from a postgraduate diploma to a full masters qualification. A postgraduate diploma in higher education equates to 120 credits at level 7 and a masters to 180 credits at level 7. The last 60 credits are usually achieved by way of a dissertation.
The proposed level 7 qualification for aesthetic practitioners to obtain their licence comprises of 60 credits at level 7. We are aware that this is subject to further consultation next year, but there are strong indications that this will not change in any major way regarding level at least.
In higher education terms, 60 credits at level 7 equates to a postgraduate certificate. Although the JCCP approved awarding bodies for the Level 7 qualification call their qualifications a level 7 Diploma in Aesthetic Injectable therapies, we should perhaps not get too caught up in titles at the moment. It is post graduate level and the stipulated curriculum, as matched against the JCCP Competency Framework means that these programmes will be significantly longer than has previously been the case.
It is also important to note that the Joint Council for Cosmetic Practitioners (JCCP) currently only approves two awarding bodies for the level 7 qualification - these are Organisation for Tourism and Hospitality Management (OTHM) and the Vocational Training and Charitable Trust (VTCT), both of which are Office of Qualifications and Examinations Regulation (Ofqual) regulated.
Ofqual regulates many awarding bodies but only these two have been approved by the JCCP to offer level 7 programmes in aesthetic injectable treatments. It is not enough for a programme to be Ofqual regulated — it must also be awarded by either OTHM or VTCT. It is easy to cause confusion, as at the moment there are many ‘level 7’ programmes out there, some of which will not meet the level criteria or the curriculum and assessment criteria of a JCCP approved programme.
The term ‘credit’ in relation to higher education and the level 7 programmes from approved awarding bodies is a measurement of learning in terms of hours of study required to obtain X number of credits. This is regardless of level. One credit equates to 10 hours of learning and so a 60-credit programme requires 600 hours of learning. This is sometimes referred to as the Total Qualification Time (TQT). These learning hours must be accounted for within a programme and will be made up of practice learning hours, guided study, taught hours, self-directed learning and time to prepare for and undertake assessments.
It is important to note that Continuing Professional Development (CPD) points do not equate to credits. Manufacturers or non-regulated training providers do not have the power to apply academic credits to their courses. The JCCP also rightly states that CPD should be delivered to those with prior demonstrable qualifications and experience in the applied area for which they are seeking to undertake CPD short courses. CPD courses should be designed to enhance, refresh and update knowledge and skills and not replace primary qualifications.
Constructing a curriculum for postgraduate nurses requires some understanding of adult learning theories. The goals of learning at postgraduate level are to develop and encourage collaborative learning, critical thinking and problem-solving. Reflection on experiences is a key component of the learning process. Students are challenged to critically examine their assumptions and beliefs which can lead to personal and professional growth. In postgraduate education, students are expected to take responsibility for their own learning, manage their time effectively, and seek out resources to meet their educational objectives. This is a far cry from the traditional ‘training’ that has been the field of preparation for aesthetic practice.
Assessment schemes at post-graduate level should be designed to enhance the critical thinking and reflection skills of practitioners. We need to assess clinical competence not merely through the performance of a task but through demonstrating proficiency to conduct assessments, develop and implement evidence-based treatment plans, recognise and manage complex and rapidly changing patient situations and the ability to apply analytical and problem-solving abilities to make informed clinical decisions. We must assess knowledge of theory but also the application of theory to practice.
Registered healthcare practitioners will bring much to the programme in terms of the knowledge and skills gained throughout pre-registration education and practice experience. They will expect a programme of study that takes this into account, but also considers the need for new learning. This new learning will be founded on the underpinning knowledge that makes a safe and competent practitioner. It will be founded on the support and guidance to help adapt and hone existing skills to new areas of practice to make a confident practitioner. It will be developed around increasing and focussing the skills of evaluation and reflection on practice to create a critical and innovative practitioner. It will develop aesthetic nurses who are able and excited to further develop their education and research in this field of practice.
There is no doubt that a structured and, to some extent, standardised approach to post registration education in aesthetic nursing, much as it is done within the NMC frameworks for pre and post-registration nurse education, will dispel the misconceptions surrounding aesthetic practice. It will bring post registration aesthetic practice nearer to being recognised as a speciality of nursing in its own right. The landscape is changing and the concept of a viable career pathway for nurses in aesthetic practice can only be welcomed. Perhaps it will take us a step closer to having NMC recognition of the post-registration qualification of Specialist Practitioner in Aesthetic Nursing.