By Alex R. Thiersch, CEO of the American Med Spa Association (AmSpa)

The recent medical spa related arrests in the Houston, Texas area (see here and here) have raised many questions and concerns in the Texas medical spa community. What is a licensed vocational nurse's role in a medical spa? What are they able to do? How do I not go to jail? Fortunately, the Texas Board of Nursing (BON) provides some helpful guidance and resources on this issue that we will explore below.

Scope of practice

The Texas BON does not maintain lists of approved procedures that LVNs may perform. So don't expect answers to specific treatment questions like, "Can an LVN inject Botox?" Instead, they provide some guidelines that an LVN may use to determine if a particular procedure is within their scope of practice. The scope of practice guidelines are available in full here. It is broken into six steps, which are:

1. Determine if particular procedure is within the statutory definition of "vocational nursing" or if it is covered in a guidance document. Of note anything that requires an LVN to make a medical diagnosis or prescribe a treatment will never be within an LVN's scope of practice
2. Determine if there a valid order or protocol authorizing the procedure. LVNs do not practice independently so everything they do must be authorized by a higher level license.
3. The procedure must be supported by medical evidence.
4. The LVN must personally have the competency and skill to perform the procedure. This competency must be documented by and acquired from their basic, post-basic, or continuing education program.
5. The procedure must be within the accepted "standard of care" that a similarly trained and experienced LVN would find reasonable and prudent.
6. And finally the LVN must be willing to accept the consequences of their actions.

The LVN must be able to answer each of these six points in the affirmative for a procedure to be within their scope of practice. In order for a LVN to be able to expand their scope of practice to include new procedures they will need to acquire the competency and skill through an education program. Position Statement 15.10 highlights some limitations of this additional education. The Board believes that informal and on the job training is useful for expanding a nurse's competency and skills. However only formal education and a higher level of license would allow a nurse to expand their scope past the statutory limits placed on vocational nursing.

Supervision

LVNs do not – and cannot – practice independently. LVNs operate under the supervision of a higher medical licensee, such as an RN, APRN, physician, or physician's assistant. Both the Board of Nursing and the Board of Medicine provide guidance on what supervision LVNs need when performing procedures outside the normal scope of vocational nursing.

The Board of Nursing provides Position Statement 15.11 on Delegated Medical Acts. The statement details that a LVN (or RN) may perform a delegated medical act when they (1) have appropriate education and are competent to perform the act (2) their education and skills are documented (3) there are written policies, procedures, or practice guidelines for the act (4) the procedure was ordered by licensed practitioner, and (5) there is appropriate medical and nursing support. The Statement however stresses that the nurse is still expected to adhere to the Standards of Nursing Practice no matter if they are performing a nursing function or a delegated medical act. And that neither RNs nor LVNs are permitted to make medical diagnoses or prescribe "therapeutic or corrective measures".

These general rules with some additional requirements apply to laser procedures as detailed in Position Statement 15.9. To perform non-ablative laser treatments the LVN/RN must acquire education in safety and use of lasers for medical purposes and document it in their personal record. Further the procedures must have been ordered by a physician, podiatrist, dentist, or a APRN or physician assistant working in collaboration with the prior stated licensees. Since treating adverse reactions will be outside the nurse's scope there must also be sufficient medical and nursing support. And the nurse will need to comply with any additional requirements from the Texas Dept. of Licensing and Regulation for laser hair removal, if any apply to their situation.

The Board of Medicine has adopted an administrative rule for the supervision of nonsurgical medical cosmetic procedures known as Rule §193.17. We've reviewed Rule 193.17 previously here. It is written as the set of rules a physician must adhere to in providing sufficient supervision and delegation for these procedures. It stresses that it is the physician or midlevel practitioner who performs the initial examination, makes the diagnosis, and develops the treatment plan.

Continuing Duty

Although the practice of nursing (including licensed vocational nursing) does not include diagnosing or forming courses of treatment, every licensed nurse is required to apply their nursing knowledge in all practice settings in order to fulfill their responsibility to provide safe, effective nursing care to the patient. This duty is detailed in the Board of Nursing's Position Statement 15.14. In the statement the Board stresses that protocols, policies, and supervisor orders do not surmount the nurse's duty to act in the best interests of the patient and provide safe and effective nursing care. According to Position Statement 15.15 this duty applies whether the nurse is performing traditional nursing functions or functioning in a different role.

Licensed Vocational Nurses can be useful and valuable members of a medical spa team. But the LVN license does not have the same scope and authority of midlevel licensees such and physician's assistants or advanced practice registered nurses. It is critical that the limitations of their license be considered when directing them to perform any delegated medical procedures in the spa. Above you can see that there are numerous considerations for performing any type of procedure, the major points being neither LVNs nor RNs are permitted to make medical diagnoses or prescribe courses of treatment. Additionally, RNs and LVNs must have documented training, education, and written protocols in whatever task they are going to perform and at all times are responsible for providing effective nursing care. The Texas Board of Nursing provides many other FAQs on nursing practice and Position Statements that may prove helpful in developing protocols and supervision arrangements for LVNs in Texas medical spas.