NSG/397 Week 2: Scope of Practice and the Professional Code, sample paper

A Standing Order at a Med Spa: Applying the Scope of Nursing Practice Decision-Making Framework to Cosmetic Injections by a Registered Nurse

[Student Name]

University of Phoenix

NSG/397: Professional Nursing Role

Week 2 Assignment

[Instructor Name]

[Date]

The nurse, business and state rules described are a composite written for a model paper.

A composite registered nurse with six years of emergency department experience received an offer from a medical spa: two weekend days a month, well paid, giving botulinum toxin injections for facial wrinkles. The spa's owner, who is not a clinician, explained that a physician in another city had signed a standing order, that clients would be assessed by the nurse and that the physician was available by phone. The offer raised a question every nurse eventually faces: the fact that someone will pay me to do something does not tell me whether my license allows it. This paper applies the scope of nursing practice decision-making framework to the offer and considers the professional code and standards.

The Framework

The national council of nursing regulators, working with several state boards, built a scope of practice decision-making framework to help nurses decide whether a task is within their scope (Ballard et al., 2016). It asks a sequence of questions: whether the activity is expressly permitted or prohibited by the nurse practice act, rules or board opinions; whether it is consistent with evidence-based practice; whether there are organizational policies and procedures supporting it; whether the nurse has the education and documented competence; whether a reasonable and prudent nurse would perform it in this setting; and whether the nurse is prepared to accept accountability for the activity and its outcomes. A "no" at any step means the nurse should not perform the activity.

Step 1: The Law

The nurse practice act of the composite state defines registered nursing to include administering medications on the order of an authorized prescriber, but it does not allow registered nurses to diagnose or to establish a medical plan of care. The board of nursing has issued an advisory opinion on cosmetic procedures. It states that a registered nurse may administer botulinum toxin for cosmetic purposes only after a physician, physician assistant or nurse practitioner has performed a good faith examination of the client and written a client-specific order, that the prescriber must be available for consultation and that the nurse must have documented training and competence.

The spa's arrangement fails this step. A standing order that allows the nurse to assess each client and decide on treatment effectively asks the nurse to perform the medical examination and establish the plan, which the advisory opinion reserves to prescribers. Under the board's position, a registered nurse cannot perform the initial evaluation that makes an injection appropriate for a particular client.

Step 2: Evidence and Safety

Even if the law were satisfied, the framework asks whether the practice is consistent with evidence and safe. Botulinum toxin is a prescription drug with a boxed warning about distant spread of toxin effect, and complications of cosmetic injection include eyelid drooping, asymmetry and, rarely, serious systemic effects. Safe practice depends on a proper evaluation of the client's medical history, medications and anatomy and on the ability to manage complications. The spa had no emergency equipment and no protocol for adverse events.

Step 3: Organizational Policy

The framework asks whether the facility has policies and procedures supporting the activity. The spa had no written policies, no credentialing process and no mechanism for the physician to review the nurse's work. A standing order signed by someone who never sees the clients and never reviews the charts is not the kind of organizational structure the framework contemplates.

Step 4: Education and Competence

The nurse had never received training in cosmetic injection. Emergency department experience with intramuscular injections does not transfer to facial anatomy, dosing by muscle group or recognition of complications specific to these procedures. The board's advisory opinion requires documented training, which she would need to complete before performing any injection even in a compliant setting.

Steps 5 and 6: Prudence and Accountability

A reasonable and prudent nurse, knowing the board's opinion, the absence of an on-site prescriber and her own lack of training, would not accept the role. And the nurse is accountable for her own practice regardless of what an employer or a remote physician authorizes. The ANA Code of Ethics states that the nurse is responsible and accountable for individual nursing practice and makes decisions consistent with the obligation to promote health and provide optimal care (American Nurses Association [ANA], 2015). A standing order does not transfer that accountability to the physician.

The Standards of Practice

The ANA standards of practice describe the registered nurse's role in assessment, diagnosis in the nursing sense, outcome identification, planning, implementation and evaluation, along with professional performance expectations such as ethical conduct, maintained competence and use of evidence (ANA, 2021). Administering a cosmetic injection after a prescriber's evaluation fits within implementation. Deciding whether a client should receive the drug, and in what dose and where, is a medical evaluation outside the registered nurse's standards.

The Decision

The nurse declined the offer as structured. She told the owner that she could consider the role only if a physician, physician assistant or nurse practitioner examined each client and wrote a client-specific order, emergency equipment and protocols were in place, the practice had written policies and she completed accredited training. She also checked the board's website for the current advisory opinion rather than relying on the owner's assurance, and she kept a copy for her records.

What the Case Teaches About Scope

Scope of practice is not defined by what an employer asks, what a physician is willing to sign or what a nurse is technically able to do. It is defined by the law, shaped by evidence, supported by organizational structure, limited by individual competence and anchored in personal accountability. The decision-making framework makes those layers explicit, and the Code of Ethics explains why the nurse, not the employer, answers for the result.

Conclusion

A well-paid offer to give cosmetic injections under a remote standing order failed the first step of the scope decision-making framework because the state's advisory opinion requires a prescriber's examination and client-specific order, and it failed several later steps as well. The Code of Ethics and the ANA standards confirm that the registered nurse administers treatments ordered after a proper medical evaluation and remains accountable for her own practice. Applying the framework turned an attractive offer into a clear, defensible decision.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Publishing.

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.

Ballard, K., Haagenson, D., Christiansen, L., Damgaard, G., Halstead, J. A., Jason, R. R., Joyner, J. C., O'Sullivan, A. M., Silvestre, J., Cahill, M., Radtke, B., & Alexander, M. (2016). Scope of nursing practice decision-making framework. Journal of Nursing Regulation, 7(3), 19-21. https://doi.org/10.1016/S2155-8256(16)32316-X