1. Epstein, Iris RN, PhD


I am a registered nurse, working for more than a decade. In the last few years, I decided to pursue my passion in the field of medical aesthetics. I invested in learning new skills through training and certification programs and was excited to attain employment in my chosen field. Yet, despite my qualifications, many employers were measuring my competency as an aesthetic nurse on the number of neuromodulators and dermal fillers I was able to inject or, to put it bluntly, able to sell. Many asked me to role-play exactly how and what I would say to "close the sale." These experiences caused me to reflect "Should nurses sell?" and "Is it ethical for nurses to sell?" In this article, I set out to explore these dilemmas and their implications on the role of the aesthetic nurse, using diverse perspectives in the current literature.


Article Content

After working for over a decade in the nursing profession, I found myself seeking another passion: aesthetic medicine. Yet, the journey of searching for this work experience has provided me with the opportunity to reflect again, on who is a nurse. As I was seeking a position as an aesthetic nurse in a medical aesthetic or plastic surgery environment, it seemed to me that according to the employer, my efficiency in selling products was the main skill required. In fact, many of these reputable medical aesthetic establishments measured my competence by the number of neuromodulators and dermal fillers that I was able to inject or sell. Their ultimate premise was twofold: the more you inject reflects your ability to sell, and the more you sell, the more competent you are.


During my interviews, several staff inquired how many units on average I injected and asked me to role-play about how I would sell a particular filler. Some of these role-play scenarios measured the time that it took for me to do the sale. It appears from these experiences that the ultimate measure of a competent registered nurse in a medical aesthetic facility is the ability to quantify one's skills. However, these experiences beg the question: Is selling part of a nurse's role and is it safe or ethical for nurses to participate in this practice? In the last decade, with the increased popularity of nonsurgical aesthetic procedures in plastic surgeons' and family doctors' offices, a pivotal question concerning nurses and other health care practitioners has become whether health care providers should be involved in selling products (Hornstein, 2009,2013). The purpose of this article is to begin a conversation, as Beauchamp and Childress (2001) argue, that the first step in addressing an ethical dilemma is recognizing, acknowledging, and naming it. I will also explore different implications and approaches suggested by the literature to address this ethical dilemma.


A great place to start answering this question is to refer to the guidelines of the Colleges of Nurses from various provinces within Canada. The selling of products has been addressed in many areas of the Colleges' publications, illustrating the current relevance of the question. The role of the College of Nurses is to primarily protect the public; thus, in a recent question-and-answer posting on their website, the College of Registered Nurses of British Columbia (2016) argued that if nurses are asked by their employer to sell products for money, they should consider removing the use of their RN credential. On the other hand, in 2014, when a nurse practitioner asked about charging clients' fees for services, the College of Nurses of Ontario (CNO, 2014) advised the nurse practitioner to have consistent standards and ensure that he/she is paid by salary as opposed to fees for service. Several nurse practitioners who inject neuromodulators and fillers charge by area rather than by units or syringes. This strategy is believed to minimize a salesmanship position, promoting a more holistic care approach. However, for nurses electing to work autonomously in private practice, the CNO (2014) has set a practice guideline for independent practice. For instance, in the section regarding the sale of product(s), the guidelines highlight that when a nurse's private practice entails the selling of product, the nurse "must provide objective, evidence-based health education to clients about factors to consider when selecting a product, discuss evidence-based options and other products if available" (p. 4). Yet, several authors have discussed the lack of evidence in the sale of nonprescribed cosmetics (Canto, 2011; Gold, 2010). Bercovitch (2009), a clinical professor of dermatology, argued that virtually all nonprescription cosmetic products sold through medical spas and physicians' offices lack conclusive evidence of clinical efficacy. Most are not Food and Drug Administration approved: "lending one's status as a physician to the sale of clinically unproven products in a medical setting, even a medical spa, is ethically questionable, since patients and consumers place their trust in health care professionals to provide medically sound advice and to protect their interests" (Bercovitch, 2009, p. 2).


There are several opponents against nurses or other health care providers being involved in any direct selling for profit. Most of their arguments focus on the ethical principle of veracity and fidelity -being honest, transparent, and truthful, and on the duty that nurses and other health care professional owe to their patients in a fiduciary relationship. The latter is a legal term and "refers to someone who has ethical duty to act in the best interests of patients ... put aside the agendas and competing priorities of practitioner in favor of the patient's immediate and long term needs" (Burkhardt, Nathaniel, & Walton, 2010, p. 191). Hornstein (2013), a family physician, wrote, "those already there [in the health care field], please take a long, hard look in the mirror, and think about what you are really selling" (p. 1).


Recent scholars have argued that valuing nurses' competency by how many injections and treatments they perform and sell could also be an unsafe and dangerous practice, as these measurements of the nurse's competence are located within the nurse (Doane & Varcoe, 2015). As nurses in medical aesthetics always relate to people, including, the patient, family, other health care professionals, in various environments such as the doctor's office or the medical spa, competency is relational practice; and is dependent and determined by what transpires in a particular relational situation. Dr. Linda McGillis-Hall, a nurse researcher from the University of Toronto, has dedicated her career to demonstrating the value of nurses' work and their image (McGillis-Hall, Wodchis, Johnson, Ma, & Pringle, 2013). She argued that although several nursing tasks, for example, injections, bed making, vital signs, and wound care, have been delegated to other unregulated professionals, for example to personal support workers, sitters, or family members, there is still a major improvement in patients' health outcomes when nurses care for these patients from admission to discharge in acute care settings (McGillis-Hall et al., 2013). Nurses' work does not focus on the care of the body alone, but rather the entire person and his or her relationship in different places and times. Measuring nurses' competence only by how many neuromodulator and filler injections and products they sell might hurt the nurses' image but more importantly will put patients' safety at risk. Instead of measuring competency by how many injections, and product units, competency should be measured in context. For example, hiring personnel should focus on various nursing knowledge and skills, including how the nurse relates to patients and family; how side effects are addressed and communicated to others; how patients' problems are solved, and as a result how future care is or is not modified; how teaching and empowering patients is done; what options for continuity of care are considered or provided; how ethical issues are addressed; and whether new knowledge is actively sought. Doane and Varcoe (2005, 2015) highlight that nurses' competence might be highly dependent on power and the interests and concerns that dominate a situation and that is an important context to consider when nurses' competence is valued by quantifying their skills.


The ethical concepts of paternalism versus autonomy have also been linked in the literature to the question: Is it ethical for health care providers to sell? The importance of the context of selling will now be highlighted. For example, on the one hand, selling can be done in a paternalist way, such as when a nurse decides and then persuades a patient's preferences on a particular treatment decision. Paternalism has a negative connotation in nursing (Burkhardt et al., 2010, p. 55); thus, selling that involves paternalism can be viewed as unethical practice for nurses. Alternatively, the importance of informing patients about their medical health and their options for care are just one way to forge a patient's autonomy. Through support, guidance, and repetition, patients are empowered to make their own decisions for achieving medical health and wellness. Through the nursing role of advocacy, the legal rights and the ethical concerns of patients are addressed. Perhaps the nonprescription cosmetic products sold through medical spas and physicians' offices lack conclusive evidence of clinical efficacy, but there are other prescription medications that have gone through the rigors of randomized control trials. When nurses support their patients' autonomy and educate patients about these medications and their purpose, they do not really sell but rather advocate and support the patients' decisions. Nevertheless, Zomorodi and Foley (2009) warn nurses that there is a thin line between being paternalistic and supporting patients' autonomy through advocacy. They argue that strategies, such as knowing the patient, clarifying information, and educating, are initial steps in distinguishing advocacy from paternalism.


In conclusion, the advances in technology, pharmaceuticals, and the restructuring of health care and nursing have resulted in role ambiguity for nurses. Health care has become a complexity of medicalized systems, with a business mindset, hierarchically driven, and often in competition with the social-justice values of nursing. What was once considered nursing work has been delegated to others and, as a result, describing the nurse's role has become blurred (Doane & Varcoe 2015). Although the College of Nurses from various provinces from within Canada provides general guidance on the question-Should nurses sell?-much ambiguity remains, leading to a deeper discussion of what constitutes nurses' competency. Some opponents are against the notion that nurses should sell, emphasizing the fiduciary duty nurses have to their patients, families, and each other. Others argue that selling should be explored in the context in which it is delivered in. Thorne (2011) assists us to better articulate the paradox of nursing as "a professional practice discipline at once so mundane that some of its technical aspects can be performed by almost anyone, yet so cognitively sophisticated and mysterious that its excellent application requires advance education, extensive reflective clinical practice and an ongoing commitment to inquiry" (p. 86).




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