The specialist area of medical aesthetics originates from aesthetic surgery, which is a branch of plastic surgery (Campion, 2012). There has been a rise in the number of registered nurses practising medical aesthetics (Di-Scala, 2017), and it is the largest area of growth within personal care and wellness (Advertising Standards Agency, 2018). However, statistics show that medical aesthetics treatments are still relatively new in comparison to cosmetic surgery procedures.
The British Association of Aesthetic Plastic Surgeons (BAAPS) (2014) reported that the number of patients undergoing cosmetic surgery had declined by 9%. In 2017, a further audit identified a decrease of 7.9% from 2016 figures for the number of men and women undergoing cosmetic surgical procedures (Cooke, 2018).
Botulinum toxin
The International Society of Aesthetic Plastic Surgery (ISAPS) stated that, in 2019, botulinum toxin remained the most popular non-surgical treatment across the globe. There was an increase of 7.6% in non-surgical procedures compared to the previous year (ISAPS, 2020). In the USA, surgeons reported that 1 712 994 botulinum toxin treatments were performed in 2019 (The Aesthetic Society, 2019).
In the UK, botulinum toxin type A medicines are licensed for several different medical indications, including blepharospasm, cervical dystonia, paediatric upper limb spasticity, axillary hyperhidrosis, bladder dysfunction and chronic migraine (British National Formulary, 2020). In medical aesthetics, botulinum toxin type A brands are licensed for the treatment of the glabella lines, periorbital lines and horizontal forehead lines in patients between the ages of 18 and 65 years (Electronic Medicines Compendium (EMC), 2020a).
Reconstitution of botulinum toxin
All botulinum toxin type A brands require reconstitution into an injectable solution for injection. At the time of the study there were three licensed brands in the UK, produced by Merz, Allergan and Galderma. All three pharmaceutical companies advise that their products should be reconstituted with sterile, unpreserved sodium chloride 0.9%. This information is readily available in each brand's summary of product characteristics (SPC).
The Global Aesthetics Consensus accepts that many clinicians prefer to use bacteriostatic saline off-label to reconstitute botulinum toxin (Signorini et al, 2016). It is unknown how many medical aesthetics nurses choose to reconstitute with bacteriostatic saline, but it appears to be a considerable number (Turner Traill et al, 2012). However, it is unclear as to why, given that this is an off-label use of a prescription-only medicine.
Both bacteriostatic saline and normal saline are prescription-only medications (EMC, 2020b). When bacteriostatic saline is used to reconstitute botulinum toxin type A, this is classed as off-label use, both in terms of the bacteriostatic saline use and the reconstitution of the botulinum toxin type A. Prescribing and administering off-label and unlicensed medicines is recognised as an acceptable practice if it is an appropriate option to a licensed product and is beneficial to the patient (Nursing and Midwifery Council (NMC), 2018).
Treatment complications
Practitioners must be able to deal with any treatment complications (Levy, 2012). Common complications of botulinum toxin type A treatment include bleeding, bruising, discomfort, erythema, headaches and ptosis (EMC, 2020a). Other less common complications can include facial asymmetry, dysphagia, urticaria, dyspnoea and anaphylaxis (EMC, 2020a). Side effects such as pain, redness and localised swelling may occur following the injection of sodium chloride or bacteriostatic saline (WebMD, 2020). Medical aesthetics nurses have a professional responsibility and duty of care to recognise and manage treatment complications (Di-Scala, 2015).
The research question
The research question focuses on the reconstitution of botulinum toxin type A and asks whether medical aesthetics nurses use bacteriostatic saline (preserved sodium chloride 0.9% and benzyl alcohol 0.9%) or normal saline (unpreserved sodium chloride 0.9%) for reconstitution, and what factors influence this decision.
It is thought that medical aesthetics nurses have not previously taken part in this type of research study. Turner Traill et al (2012) were the first nurses to discuss this subject and suggested that a high percentage of medical aesthetics nurses chose to use bacteriostatic saline to reconstitute botulinum toxin type A. It is important to understand the clinical decisions made by medical aesthetics nurses, as they are accountable for all aspects of their patient care, including patient experiences and outcomes (Nibbelink, 2018). Using evidence-based practice enables nurses to use scientifically proven and critically appraised evidence to support their clinical decisions (Majid, 2011). Training, prescribing choices and experience will all influence clinical decisions, but it is important to ensure that medical aesthetics nurses are working autonomously and comply with the NMC's Code of conduct (2018).
Nurse prescribers must follow the code of conduct (NMC, 2018) and limit their prescribing to their scope of practice (NMC, 2019). Since 2018, the NMC has used the competency framework of the Royal Pharmaceutical Society (RPS). Nurse prescribers must ‘adhere to the RPS competency framework as standards for safe and effective practice to ensure patient safety’ (NMC, 2018). The NMC (2018) states that a nurse prescriber must be ‘satisfied that it would better serve the patient's needs’ when deciding to prescribe off-label. Rankin et al (2012) state that, ultimately, the prescribing decision lies with the prescriber. Autonomous practice requires the nurse to take charge in clinical situations where they have responsibility, which may include improving care and patient satisfaction and reducing adverse events.
There is diversity in the qualifications and levels of competency of medical aesthetics nurses (Greveson et al, 2013). As nurses with a full scope of skillsets and working in private practice, medical aesthetics nurses need to be fully prepared when dealing with treatment complications and adverse events (Fukada, 2018).
The purpose of this study is to answer the research question and to understand the influences on the clinical decisions made by medical aesthetics nurses when reconstituting botulinum toxin type A. This will incorporate factors that may influence their clinical practice, such as level of qualification, location, workplace setting, employment status, whether the participants are independent prescribers, frequency of training updates and attendance of peer-to-peer British Association of Cosmetic Nurses (BACN) regional group meetings. Other influences, such as cost, patient comfort, peer recommendations and level of training, will also be discussed.
Reconstitution of botulinum toxin type A and pain reduction upon injection
There appears to be a direct link between reconstitution with bacteriostatic saline and pain reduction when botulinum toxin type A is injected. Alam et al (2002) conducted a double-blind randomised controlled trial (RCT). The study found that injection pain was reduced in 90% of patients when preserved saline was used, and it had no effect on efficacy.
Some 15 patients participated in a double-blind RCT that was conducted by Van Laborde et al (2003). Patients were treated on one side of their face with botulinum toxin that was reconstituted with bacteriostatic saline. The other side was treated with botulinum toxin reconstituted with unpreserved saline. Some 87% of patients reported less pain on the side that used bacteriostatic saline. Although the study was small, the findings support other research, which suggests bacteriostatic saline has an analgesic effect.
Van Labore et al (2003) also commented that neither the investigators nor the participants detected any difference in clinical effect between the two sides. This suggestion adds to the established knowledge that bacteriostatic saline has no impact on the efficacy of botulinum toxin.
Kwiat et al (2004) performed trials on 20 patients who had previously received botulinum toxin type A treatments. The patients underwent bilateral injection of botulinum toxin type A, reconstituted with either bacteriostatic or unpreserved saline. The patients and researchers were blinded for the trial. The clinical outcome was assessed using verbal scales.
The study found that using bacteriostatic saline to reconstitute the botulinum toxin type A made the treatment less painful. The key benefits of this double-blind study are that it is considered to be the most reliable type of study, minimising the placebo effect and bias. These findings add to the existing work carried out by previous researchers, contributing further to the established understanding of the analgesic effects of bacteriostatic saline. It could be argued that the study was only small and subjective to the opinions of the patients and physicians. Pain tolerance will vary from one patient to the next, and the reliability of the verbal scale could be questioned.
Carruthers et al (2004) published the first global consensus, recommending protocols for botulinum toxin type A treatments. The members of the consensus panel agreed that bacteriostatic saline could be used to reconstitute botulinum toxin type A (Carruthers et al, 2004). In a bilateral, comparative prospective study, 100% of patients reported less pain when bacteriostatic saline was used instead of unpreserved saline. Some 20 patients who were injected with botulinum toxin type A reconstituted with bacteriostatic saline were asked to make a comparison with previous injections using unpreserved saline. Reduced pain with bacteriostatic saline was reported in 90% of those patients.
In their consensus recommendations for Bocouture, Kane et al (2010) reported that using bacteriostatic saline to reconstitute botulinum toxin type A did not alter the potency. It was also reported that using bacteriostatic saline for reconstitution made the botulinum toxin type A injections less painful. Their comments confirm the existing thoughts that bacteriostatic saline does not affect the efficacy or longevity of botulinum toxin type A and supports the research that suggests bacteriostatic saline has an analgesic effect.
Liu et al (2012) used an online survey to analyse the practices of doctors who administered botulinum toxin type A treatments and were members of the American Society of Dermatologic Surgery. Surveying members of an association may be beneficial, as it provides immediate access to the membership. Some 77.9% of the doctors chose to use bacteriostatic saline to reconstitute botulinum toxin type A to reduce the pain associated with injections (Liu et al, 2012). One downfall of this study is that the survey only had a 32.2% response rate. According to Fincham (2008), researchers should be achieving response rates of approximately 60%. The low response rate may impact the validity of the results, but it does add to the other research discussed, which has suggested the same.
Turner Traill et al (2012) recognised that it is common practice among nurses and doctors to use bacteriostatic saline off-license to reconstitute botulinum toxin type A. They were the first medical aesthetic nurses to research bacteriostatic saline and its use within medical aesthetics. Their work discusses the finding of research involving doctors, where the general consensus is that using bacteriostatic saline for reconstitution reduces the patient's pain. Turner Traill et al (2012) also acknowledged the guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) (2014), NMC (2018) and General Medical Council (GMC) (2018) in their recognition that ‘the prescribing and administration of off-label and unlicensed medicines is accepted practice when it is in the best interest of the patient’. Despite being written in 2012, Turner Traill et al have a valid discussion that can be applied to medical aesthetics nursing today. As no further research has been carried out by medical aesthetic nurses since this article was written, it provides an opportunity to expand upon their work, which is often the case with research.
Some of the published studies demonstrate that pain during injection can be reduced by reconstituting with bacteriostatic saline (Kwiat et al, 2004; Allen and Goldenberg, 2012). There are several publications stating that bacteriostatic saline has an anaesthetic quality (Carruthers et al, 1992, 2004).
Training of medical aesthetic nurses
Training in medical aesthetics procedures such as dermal fillers and botulinum toxin injections also remains unregulated. Tan (2007) identified that there was an international need for statutory governance of aesthetic medicine. He commented that, in many countries, procedures were only marginally regulated.
Greveson (2013) wrote that, with a ‘lack of regulation and standards for education, many aesthetic nurses feel isolated and inadequately prepared’. Medical aesthetics nursing is a highly skilled specialism that needs to continue to develop and evolve. Baker (2018) states that, to establish and develop their role as a specialist medical aesthetics nurse, nurses need to engage with education and training opportunities. This common theme highlights an area of medical aesthetics nursing that needs to be addressed.
Guinan (2019) states that continuous professional development is essential for safe clinical practice and goes on to mention that attending conferences ‘not only enhances practice but aids in continuous professional development and post-registration education’.
Holmberg et al (2019) used semi-structured interviews in their qualitative study of 13 medical aesthetics nurses, investigating the professional, clinical and patient needs of participants. The research found that all participants were motivated to build professional networks and ‘create local medical and ethical guidelines until more robust mandatory regulations are in place’. Although the small sample may not represent all attitudes, it does identify and discuss the need for professional networking and education within medical aesthetics.
Financial decisions
Collier (2018) advises that practitioners must provide further evidence to support their clinical decision-making. Collier concludes that the clinical decisions around administering an aesthetic treatment should never be based on financial gain. Prescribers should recognise factors that might unduly influence prescribing.
For many years, those providing training courses in medical aesthetics have not been assessed, and the standard of education and experience has varied greatly from one training academy to the next. Franks (2016) suggested that ‘practitioners should focus on the quality of teaching and educational content, rather than how convenient and cheap the courses are’. This appears to support Collier's views on financial decisions.
Methodology
A mono-quantitative approach was the most suitable method for addressing the research question, obtaining primary data by using a systematic approach to obtain numerical data (Quick and Hall, 2015).
The survey aimed to collect quantitative data that was striving to avoid bias, while enabling the researcher to access the participants' attitudes and thoughts on the research question and wider issues covered by the survey. An online questionnaire in the form of a survey was used to gather data.
» Nurses have a professional responsibility and identity (NMC, 2018). This means doing things correctly and being an advocate for patients, yet many medical aesthetics nurses regularly prescribe bacteriostatic saline off-license, which goes against manufacturers' guidelines and the summaries of product characteristics «
Sampling methods
The population of interest in this study are medical aesthetic nurses. Although the exact number of nurses specialising in medical aesthetics is unknown, it is thought that 70% of medical aesthetics treatments carried out in the UK are administered by nurses. Convenience sampling, a type of non-probability sampling was used. The objective was to generalise the results of the study to the general population.
A large sample size is important in quantitative research, so the aim was to reach the largest sample size possible. As the total population of medical aesthetics nurses is unknown, the decision was made to sample the membership of the BACN. As the largest known organisation of medical aesthetics nurses in the UK, with (at the time of the study) 944 members, the aim was to reach all members and obtain representation from them.
Results and discussion
Descriptive and inferential statistics are used to discuss the research data analysis and how the analysis links back to the research question (Ali and Bhaskar, 2016). Data visualisation provides a graphical display of information, which is useful for data analysis and in describing the research findings (Pearson, 2010).
Highest level of nursing qualification
The highest level of nursing qualification can be seen in Table 1. In recent years, there has been a rise in the number of qualified nurses choosing to enrol in postgraduate education (Havenga and Sengane, 2018). A postgraduate degree in nursing or medical aesthetics appeared to be the most common level of nursing qualification among the participants, with a total of 25% (11 participants). Some 52.8% of participants who were prescribers were educated to postgraduate level, while 40.9% of participants (state registered nurse, registered nurse/midwife, diploma and degree level) had not undertaken any postgraduate education. There are several barriers that may affect a nurse's ability to commit to education, including access, workplace culture, time and financial constraints.
Table 1. Highest level of nursing qualification
| Rank value | Option | Count |
|---|---|---|
| 1 | Enrolled nurse | 0 |
| 2 | State registered nurse | 1 |
| 3 | Registered nurse | 7 |
| 4 | Registered midwife | 1 |
| 5 | Diploma in nursing | 3 |
| 6 | Degree in nursing | 6 |
| 7 | Postgraduate certificate | 8 |
| 8 | Postgraduate diploma | 6 |
| 9 | Masters in nursing or aesthetics | 11 |
| 10 | PhD | 1 |
Nurse independent prescribers
More nurse independent prescribers participated in the research in comparison to those who were not prescribers (Table 2). Creedon et al (2015) stated that nurse prescribing has been a positive addition to clinical practice for nurses. It has been suggested that all medical aesthetics nurses should obtain a prescribing qualification to ‘comply with the law, and NMC standards and guidance’ (Ford et al, 2011). More prescribers participated (n=39) than non-prescribers (n=5), although one of those participants was studying towards a qualification.
Table 2. Nurse independent prescribers
| Rank value | Option | Count |
|---|---|---|
| 1 | Yes | 39 |
| 2 | No | 4 |
| 3 | Currently studying on a V300 module | 1 |
Workplace
The majority of participants (94.4%) were self-employed, either full-time or part-time (Table 3). The other four categories, which were for those employed within clinics, equate to 4.6% or two participants. Both dominant categories were self-employed. Vilas (2016) commented that many medical aesthetics nurses enter the specialism with the intention of working for themselves in this private health sector, which is indicated in this data.
Table 3. Workplace
| Rank value | Option | Count |
|---|---|---|
| 1 | Self-employed aesthetic nurse (full-time) | 24 |
| 2 | Self-employed aesthetic nurse (part-time) | 18 |
| 3 | Employed in an aesthetic nurse-led clinic (full-time) | 1 |
| 4 | Employed in an aesthetic nurse-led clinic (part-time) | 1 |
| 5 | Employed in a doctor-led clinic (full-time) | 0 |
| 6 | Employed in a doctor-led clinic (part-time) | 0 |
Geographical location
There was a mixed spread of results in terms of geographical location (Table 4), which is to be expected as medical aesthetics treatments are available UK-wide (National Hair and Beauty Federation, 2020). Of the 11 geographical locations, 50% are based in the two regions of the Northwest (25%) and the Southeast of England (25%). This is also representative of nurse prescribers.
Table 4. Geographical location
| Rank value | Option | Count |
|---|---|---|
| 1 | North west England | 11 |
| 2 | North east England | 4 |
| 3 | South west England | 6 |
| 4 | South east England | 11 |
| 5 | East midlands | 4 |
| 6 | West midlands | 2 |
| 7 | North Wales | 0 |
| 8 | South Wales | 3 |
| 9 | Scotland | 2 |
| 10 | Northern Ireland | 0 |
A total of 50% of the participants were spread over nine geographical areas. There was no correlation between postgraduate qualification and geographical location.
Botulinum toxin type A treatments each week
There is no published data regarding the total number of weekly botulinum toxin type A treatments carried out by UK-based medical aesthetics nurses. As there is no regulation for medical aesthetics, there is no formal data collection on treatments. Some 31.8% (14 participants) were found to treat one to five patients per week with botulinum toxin type A, while 20 of the 44 participants (45.4%) treated six to 20 patients per week (Table 5). This equates to 77.3% (34 participants) treating between one and 20 patients per week with a brand of botulinum toxin type A. The median number of patients treated per week was six to 10. Only one surveyed participant treated 91–100 patients per week with botulinum toxin type A, equating to 2.3% of the total sample.
Table 5. Botulinum toxin type A treatments each week
| Rank value | Option | Count |
|---|---|---|
| 1 | 0 | 0 |
| 2 | 1–5 | 14 |
| 3 | 6–10 | 10 |
| 4 | 11–20 | 10 |
| 5 | 21–30 | 7 |
| 6 | 31–40 | 1 |
| 7 | 41–50 | 1 |
| 8 | 51–70 | 0 |
| 9 | 71–80 | 0 |
| 10 | 81–90 | 0 |
| 11 | 91–100 | 1 |
| 12 | Over 100 | 0 |
Training
Some 20 participants trained either 10–13 or over 13 years ago, while 6.8% (three participants) had less than 1 year's experience (Table 6). The remaining 21 participants had anywhere between 1 to 10 years' experience since first training. Cross-tabulation showed that 100% of nurses who had trained in botulinum toxin type A 10–13 years ago update at least once per year, while 90% of those who trained over 13 years ago update annually. This indicates that those participants are adhering to the NMC code of conduct (2018), which requires registrants to remain trained and competent.
Table 6. Training
| Rank value | Option | Count |
|---|---|---|
| 1 | Within the past year | 3 |
| 2 | 1–3 years ago | 8 |
| 3 | 3–6 years ago | 6 |
| 4 | 6–10 years ago | 7 |
| 5 | 10–13 years ago | 10 |
| 6 | Over 13 years ago | 10 |
Brands of botulinum toxin used in practice
At the time of the study there were eight brands of botulinum toxin type A that are commercially available in the UK. Based on the responses of the 44 participants surveyed, 98 answers were provided, indicating that participants used multiple brands of botulinum toxin type A (Table 7).
Table 7. Brands of botulinum toxin used in practice
| Rank value | Option | Count |
|---|---|---|
| 1 | Botox 50 | 24 |
| 2 | Botox 100 | 25 |
| 3 | Bocouture 50 | 14 |
| 4 | Bocouture 100 | 10 |
| 5 | Xeomin | 1 |
| 6 | Azzalure | 24 |
| 7 | Dysport | 0 |
| 8 | Other | 0 |
Form of saline used
Turner Traill et al (2012) first suggested that a high percentage of medical aesthetics nurses used bacteriostatic saline to reconstitute botulinum toxin type A. The study found that 93.2% (41 nurses) of participants stated that they reconstitute with botulinum toxin type A, rather than normal saline (Table 8). These findings support the views of the global aesthetics consensus (Signorini et al, 2016), in that the majority of clinicians prefer to use bacteriostatic saline to reconstitute botulinum toxin type A.
Table 8. Form of saline used
| Rank value | Option | Count |
|---|---|---|
| 1 | Normal saline (unpreserved) | 3 |
| 2 | Bacteriostatic saline (preserved) | 41 |
| 3 | Other | 0 |
What influences choice
Out of six available categories, there were a total of 73 responses from the 44 participants, indicating that there are multiple reasons for selecting bacteriostatic saline for reconstitution (Table 9). Bacteriostatic saline is more expensive than normal saline, but cost was not an important factor to the large majority of participants. Four participants considered cost when deciding which saline to reconstitute botulinum toxin type A with. As Collier (2018) commented, cost should not influence clinical decisions for medical aesthetics nurses.
Table 9. What influences choice
| Rank value | Option | Count |
|---|---|---|
| 1 | Cost | 4 |
| 2 | Patient comfort | 34 |
| 3 | How I was trained | 23 |
| 4 | Employer preference | 1 |
| 5 | Evidence-based decision | 10 |
| 6 | Other | 1 |
Patient comfort was a priority for 77.3% (34) of participants. This included those participants who treated under 10 patients per week, where it would be more cost-effective to use normal saline. One participant answered ‘other’ and commented that, ‘diluted in saline is painful for the patient … hence bacteriostatic saline is my choice’. Therefore, this participant's response falls under the ‘patient comfort’ category. This changes the percentage to 79.5%.
This is very similar to the 77.9% of doctors who were found to use bacteriostatic saline to reconstitute botulinum toxin type A to reduce pain (Liu et al, 2012). Some 23 of those 34 participants had over 6 years' experience in administering botulinum toxin type A treatments. This may suggest that experience influences clinical decisions for medical aesthetics nurses. Despite only 10 participants stating that evidence-based practice was an influence, there must be a reason why the majority favour bacteriostatic saline because of patient comfort. This would suggest that evidence-based practice does have an influence. As discussed in the literature review, there are several studies available that suggest bacteriostatic saline has an analgesic effect (Carruthers et al, 2004; Kwiat et al, 2004; Kane et al, 2010).
Obtaining information relating to the reconstitution of botulinum toxin type A
It is important to recognise that a variety of information is required in evidence-based clinical practice (World Health Organization (WHO), 2017). The participants used a variety of resources to obtain information regarding the reconstitution of botulinum toxin type A. There were a total of 161 responses from the 44 participants, suggesting that participants use multiple resources to access information (Table 10). Evidence-based education is essential for any nurse practising medical aesthetics (Harrison and Hotta, 2020). The four main resources were summaries of product characteristics (SPC) (63.3%); training updates (59.1%); peers/colleagues (50%); and product representatives (47.7%).
Table 10. Obtaining information relating to the reconstitution of botulinum toxin type A
| Rank value | Option | Count |
|---|---|---|
| 1 | Product representatives | 21 |
| 2 | Medical information department of manufacturer | 10 |
| 3 | Product SPC | 28 |
| 4 | Electronic Medicines Compendium | 9 |
| 5 | Patient information leaflet | 8 |
| 6 | Pharmacy I order from | 5 |
| 7 | Training updates | 26 |
| 8 | Journals | 10 |
| 9 | Conferences | 11 |
| 10 | Peers and colleagues | 22 |
| 11 | Internet | 4 |
| 12 | Online forums | 7 |
| 13 | Other | 0 |
Reading journals
It is essential that nurses access up-to-date information and knowledge by reading journals (Huang et al, 2017). Some 81.8% of participants read medical aesthetic journals every month, while 98% of participants read an aesthetics journal at least every 2–3 months (Table 11). Many participants who were nurse prescribers (n=33) read journals every month. Participants with postgraduate qualifications read journals more frequently than other participants. One participant responded with ‘once per year’. This participant trained in botulinum toxin in the past 1–3 years and treats one to five patients per week. Although 36 participants answered that they read aesthetic journals every month, this may not be accurate, as only 10 participants stated that they obtain information on reconstitution from journals.
Table 11. Reading journals
| Rank value | Option | Count |
|---|---|---|
| 1 | Every month | 36 |
| 2 | Every 2–3 months | 7 |
| 3 | Every 4–6 months | 0 |
| 4 | Twice a year | 0 |
| 5 | Once a year | 1 |
| 6 | Never | 0 |
Attending aesthetic training updates on botulinum toxin
There is a need for nurses to demonstrate fitness to practice and maintain their continuing professional development (CPD) (Karas et al, 2020). Greveson (2013) states that there is diversity in the training and competency of nurses working in medical aesthetics. Some 63.6% (28 participants) answered that they undertake annual training on botulinum toxin type A (Table 12). The remaining 36.4% of participants are split over the remaining six categories where four of those categories have a result and the other two indicate no training. The participants with postgraduate qualifications participated more frequently in training updates. Those participants may do so because they are more academically inclined or seeking evidence-based practice and have prioritised their learning needs (Lee, 2011).
Table 12. Attending aesthetic training updates on botulinum toxin
| Rank value | Option | Count |
|---|---|---|
| 1 | Once a year | 28 |
| 2 | Twice a year | 5 |
| 3 | Three times a year | 5 |
| 4 | Four times a year | 0 |
| 5 | More than four times a year | 0 |
| 6 | Never | 4 |
| 7 | Other | 2 |
Conclusions
The study sought to explore the clinical decisions and influences on medical aesthetics nurses when reconstituting botulinum toxin type A. The research question asked whether medical aesthetics nurses use bacteriostatic saline (preserved sodium chloride 0.9% and benzyl alcohol 0.9%) or normal saline (unpreserved sodium chloride 0.9%) for reconstitution and what factors influence this decision.
The key findings were that the majority (93.2%) of medical aesthetics nurses reconstitute botulinum toxin type A with bacteriostatic saline. This is aligned with the global consensus (Signorini et al, 2016), which states that many clinicians chose to reconstitute with bacteriostatic saline rather than normal saline. As previously discussed, Turner Traill et al (2012) first suggested that this was common practice among nurses administering botulinum toxin type A treatments.
The study found that the primary reason for making this clinical decision was because of its analgesic effects, according to 79.5% of participants. This supports the research by Liu et at (2012), who found that 77.9% of doctors reconstituted with bacteriostatic saline because of patient comfort.
The study suggests that most participants were self-employed. Medical aesthetics nurses are highly unusual, as they provide nursing independent healthcare in established private practices. This requires an enterprising skillset and the expertise and competency to sustain high levels of patient satisfaction. Postgraduate education was important to participants, and 86.8% held a prescribing qualification.
Those who completed the survey are also those who engage in training and are cognisant of treatment complications, with 81.8% of the sample being members of Aesthetic Complications Expert (ACE) Group. For these reasons, the sample may not represent the larger population. Further development is required to sample non-BACN members and to be able to reach more nurses. However, the research has provided some insight into the working culture and innovations of medical aesthetics nurses. Specialist perspectives, case studies, reflection and clinical audit trials are essential for a medical aesthetics nurse.
Nurses have a professional responsibility and identity (NMC, 2018). This means doing things correctly and being an advocate for patients, yet many medical aesthetics nurses regularly prescribe bacteriostatic saline off-license, which goes against manufacturers' guidelines and the product SPC. The RPS competency framework for prescribing (2016) should be adhered to. When using a medicine off-license, prescribers must be satisfied that there is suitable evidence and/or experience to support the efficacy and safety for the indication (MHRA, 2014). Any prescribing decision must be in the best interest of patients (MHRA, 2014).
There is limited research available on many areas within aesthetic medicine and, as an evolving specialist branch of medicine, there is a need for empirical research to guide effective practice. As regulated healthcare professionals, medical aesthetics nurses must be competent and take responsibility for their clinical decisions and practice (NMC, 2018).
Key points
- The majority of aesthetic nurses use bacteriostatic saline when reconstructing botulinum toxin type A
- The main reason aesthetics nurses choose to prescribe bacteriostatic saline is for its analgesic effect and patient comfort
- When prescribing bacteriostatic saline for off-license use, the nurse prescriber must be satisfied that the decision to do so is in the best interest of the patient and evidence-based
CPD reflective questions
- What is the Global Aesthetics Consensus on the off-label use of bacteriostatic saline to reconstitute botulinum toxin?
- Why was convenience sampling well suited to this study?
- What are the benefits of using a large sample size in quantitative research?