The bizarre reason this nurse – who served in Iraq – is facing a career block
Jenna Brown says her time in the ADF set the foundation for her fascination with healthcare and drove her desire to further her learning. Why has she been left disillusioned, and wondering whether she should give up nursing altogether?
Nurses who have ever worked in cosmetic injectables fear they are being routinely rejected from progression to nurse practitioner, even when they are applying for endorsement under different specialties, in what they say is an unjustified overstep by the nation’s top health authorities.
Nurse practitioners are advanced practice registered nurses who have higher education levels and are authorised to prescribe and administer scheduled medicines and order diagnostic investigations, independently from doctors. However, they must first be endorsed by the Australian Health Practitioner Regulation Agency and Nursing and Midwifery Board.
Numerous nurse practitioners and NP candidates have spoken with The Australian, sharing similar experiences and perceptions about what is happening behind firmly closed doors. They perceive the endorsement process as opaque, lacking in procedural fairness, inconsistent in its rulings, and having goalposts that can move in an instant.
Many of those who have spoken have done so on the condition of anonymity out of fear of career reprisal.
One of those is a senior figure who says it is now a given that any nurse who has even a hint of cosmetic experience will have their application for NP endorsement rejected by the Nursing and Midwifery Board.
The Australian College of Nurse Practitioners is aware of the issue and says it has been in urgent discussions with the board to address the concerns of its members.
It comes at a time when the federal government is actively trying to recruit more nurse practitioners and for them to have a greater scope of practice, including in the delivery of women’s and regional health, to help ease pressure on a stressed health system. It is also trying to recruit and retain as many nurses as possible as part of its Nurse Practitioner Workforce Plan.
Instead, nurses say they are investing years of hard work and tens of thousands of dollars chasing their dream of becoming an NP, only to have it collapse in a heap at the finish line with no clarity or obvious avenue for independent recourse.
It has left scores of nurses feeling distressed, angry, and exhausted to the point some are now considering walking away from the healthcare industry entirely. They say change and transparency are desperately needed.
Meet nurse practitioner candidate Jenna Brown
Jenna Brown is an NP candidate, meaning she is seeking endorsement. She and her husband live on the NSW south coast where there is a significant doctor shortage.
The registered nurse works part of her week at a private GP clinic delivering primary care and the rest of it at a cosmetic clinic she runs with another RN.
“Nursing has been an amazing career; certainly mine has,” Brown says.
“It’s one of those professions that can take you anywhere and rapidly evolves and there’s always something new to learn and ways to improve.”
She’s worked as an intensive care nursing officer with the Australian Defence Force – even completing a seven-month deployment to Iraq. After leaving defence she held a number of positions, including with Serco, which had contracts delivering garrison health in a role almost identical to that of when she was in the ADF.
Later, she was a pre-hospital nurse for an aviation company called OPSTAR. During the pandemic, she worked in the overstretched hospital system before relocating to the south coast and working in primary care and aesthetics.
She says her time in the ADF provided her with a greater scope of practice than nurses traditionally have.
“We have a set of drug therapy protocols that align to the primary clinical care manual that allows you to work without direct oversight of a medical officer,” she says.
“So, I was kind of used to that level of autonomy from early on in my career.”
She applied the lessons she learnt in the ADF to future jobs and she says it set the foundation for her fascination with healthcare and drove her desire to continue learning.
“My passion for nursing probably grew in the military.”
Flash forward to today and Brown has grown so disillusioned with nursing that she’s wondering if she should give it all up. Her change of heart happened after she applied for endorsement as NP.
To become an NP, a candidate must complete 5000 hours of what is deemed to be “advanced practice” nursing where they have managed complex patient care with minimal oversight.
The 5000 hours must have been completed in the immediate six years before lodging an application for endorsement.
Then, the applicant needs to attain a Nurse Practitioner Masters degree from an accredited university, and finally be endorsed by the Australian Health Practitioner Regulation Agency and Nursing and Midwifery Board.
Brown was confident she had the hours; in fact, she believed she had completed 6500 hours. So she undertook her Masters degree. At university she didn’t just pass, she excelled.
“I got the School of Nursing and Midwifery prize for academic achievement, which is awarded to the student with the highest graduating marks,” she says.
Finally, she applied for endorsement and lined up two jobs for when it came through. The first was a newly created NP position at the regional GP clinic where she already worked. The second was with a company delivering aged care outreach in nearby Bateman’s Bay.
Then came the hurdles.
“Nursing has been an amazing career; certainly mine has. It’s one of those professions that can take you anywhere and rapidly evolves and there’s always something new to learn and ways to improve”
The first was after an initial assessment from an AHPRA adviser who was responsible for reviewing her application and recommending if the nursing board should endorse her.
After a preliminary review, it was suggested only three of Brown’s jobs were likely to meet the threshold for “advanced practice”, but questions remained over the hours.
“The initial assessment shows that your submitted advanced practice hours for the Defence Force and Serco and Opstar do not reach the required 5000 hours over the previous six years,” the AHPRA reviewer wrote in an email.
Brown wasn’t overly concerned as she was confident she still had the required hours just from those three jobs. She re-documented and submitted the proof of hours equating to more than 5000.
Weeks later, a voicemail was left on Brown’s mobile by the AHPRA reviewer. It was followed by an email, where the person raised several concerns, starting with the fact Brown’s message bank mentioned her aesthetics business. The reviewer then looked Brown up online.
“Your submitted CV omitted to list your role as a cosmetic injecting nurse and this could be seen as withholding relevant information in light of the NMBA’s Position Statement – Nurses and Cosmetic medical procedures (2022),” the adviser wrote.
“On review of your application it appears that there is insufficient evidence to demonstrate completion of 5000 hours at an advanced practice level, as per the NMBA’S definition of advanced practice.”
Since around 2023, the NMBA has declared non-surgical cosmetics work is “unlikely” to be recognised as “advanced practice”. Brown says she was aware of this, which is why she did not include those hours. She did, however, include on her CV a position she holds with the Cosmetic Nurses Association, which alludes to her experience.
She was given two options. The first was to withdraw her application.
The second: “You may wish to continue with your application. If so, your application will be considered by the board and we will recommend that the board refuse your application.
“However if the board was to see the application and assessment with the above mentioned anomalies it may decide to proceed with an own motion notification of the anomalies’,” the email states.
Brown took that as a veiled threat that her registration as an RN could be at risk if she continued to push for endorsement.
Brown sought legal advice, collected almost 2000 pages of supporting documents, including evidence of advanced practice, letters from past employers including senior doctors and two lieutenant colonels who validated her responsibilities and hours worked.
She found the selection criteria for advanced practice nursing and provided examples of how she met each, then she approached someone connected to the Australian College of Nurse Practitioners to review her application and analyse her hours and work standard independently. Finally, she bundled all of the information together with a cover letter and updated CV.
Brown also wrote that she was concerned she was being targeted for her work in aesthetics, due to stigma surrounding the field.
A spokeswoman for AHPRA and the NMBA told The Australian: “Any applications are assessed in line with the published guidelines.”
When asked if there was any legislation restricting nurses with cosmetics experience from being endorsed as NP or if either regulator blocks applications for those who work in cosmetics, the spokeswoman said “no”.
Despite having legal representation, Brown continued receiving conflicting information about what hours were or were not counted and why. At her insistence, she was granted a video call with the board, which is the body ultimately responsible for assessing her application and deciding her outcome.
“I asked for specific examples about where my application had fallen down and where activities I had submitted had failed to meet the threshold for advanced practice,” Brown says.
She alleges nobody from the board could answer her question.
“One would think that if (they had reviewed it), it would be inherent upon them to understand the intricacies of my application.”
Instead, she says her questions were referred back to the original AHPRA reviewer who was also present.
That person was concerned Brown had been hired in roles that were part-time or casual, and they found it difficult to believe she would therefore have the autonomy required for advanced practice. It’s a premise Brown disagrees with.
It is unclear if that is an official stance and if it applies to people returning from parental leave.
“I asked for specific examples about where my application had fallen down and where activities I had submitted had failed to meet the threshold for advanced practice”
Brown says the only thing the board did seem well versed in was her cosmetics experience. She alleges that, rather than asking about her advanced practice experience, she was probed about whether she uses filler in her cosmetic clinic.
Her application was officially refused earlier this year.
When Brown told other candidates of her rejection, she started hearing from others. She says while all of them worked in mainstream fields of nursing, they also had cosmetics experience.
According to AHPRA and the NMBA, 208 new applications for NP endorsement were made between June 2024 and February. Of those, 10 have been refused and 66 withdrawn.
That compares to 210 applications in the entire fiscal year from 2020. Of those, none were refused and 15 were withdrawn.
A spokeswoman from AHPRA and the NMBA says it does not store data on a practitioner’s experience, so could not say how many refused or withdrawn applications were from nurses who had cosmetics experience.
Rejection of nurses a known problem
The Australian has heard from three other candidates who share similar stories.
One works for a plastic surgeon and says her hours were not counted as advanced practice. The nurse says she is the clinic’s head nurse, performs advanced procedural interventions, and has worked for the same surgeon for a decade.
While it must be acknowledged that not every application will be appropriate for endorsement, candidates say their quest to understand more about their refusal is often confusing, with conflicting or vague advice provided to them.
Therein lies the problem; candidates say they are left with the impossible task of trying to argue with subjectivity.
“There appears to be clear guidelines and criteria that need to be met upon application,” Brown says. “However, when you really scrutinise the documents, they’re really quite subjective which then leaves room for interpretation. And when such subjectivity exists, there really need to be checks and balances in place to ensure that doctrine is then applied in a way that is both equitable and impartial, and I just haven’t seen evidence of those processes existing. And I think that’s really problematic.”
The Australian College of Nurse Practitioners has met with the NMBA to discuss the problem.
The college’s chief executive is Leanne Boase.
“We’re not fully aware of how widespread it is, but it is something we’ve heard on multiple occasions,” the NP says.
She is not necessarily convinced the problem is related to bias, instead suggesting there appears to be a myriad of issues at play.
“It does concern me how these applications are being assessed … just because they work in cosmetics a few hours a week, that they’re still able to have their advanced practice in primary care recognised,” Boase says.
“It’s important that if someone works in two different areas they’re still able to have their advanced practice in primary care recognised. That’s really important.”
Boase says the college’s discussions with the board have been constructive and says she is optimistic improvements will follow.
“I don’t think significant changes need to be made,” she says.
“I wouldn’t know whether there needs to be internal changes made within the assessment process. But I can say we have wonderful relationships with all the key stakeholders involved. Systems everywhere need regular review, so that’s probably something that needs to be looked at.”
A spokeswoman from AHPRA and the NMBA says all decision-making is unbiased.
“Procedural fairness is a guiding principle that supports fair, transparent decision making by the NMBA when a practitioner’s interests are affected,” the spokeswoman says.
“The NMBA or its delegate ensure that the decision-making process is unbiased and impartial, is based on relevant evidence that logically supports the findings, and allows the practitioner an opportunity to be heard before any adverse decision is made.”
Nonetheless, Boase says it’s critical that endorsement issues are resolved quickly to ensure the process is not a traumatic for nurses, and so Australia reaps the benefit of more advanced nurses.
“These nurses work to the absolute maximum of their abilities and skills and experience and training, and they’re absolutely necessary,” Boase says.
“We know they’re under-utilised now, and that’s why the government’s been working to try and maximise the use of nurse practitioners; they’re recognising the importance of them.”
Health Minister Mark Butler did not answer questions about whether he was aware of the issue. Instead, The Australian’s questions were referred back to the Health Department, which said decisions made by the NMBA and AHPRA can be appealed through a tribunal.
“There are options to make a complaint via AHPRA complaints and feedback process and the National Health Practitioner Ombudsman.”
Questions over stance against cosmetics
All of this is happening amid a crackdown on the broader cosmetics industry. New guidelines, to come into effect from September, will require registered nurses to complete 12 months’ industry training before being able to switch to cosmetics.
Practitioners wanting to work in cosmetics will also need to prove they have training in facial asymmetry. However, no minimum training standards have been set, much to the horror of many in the industry.
Another anomaly is the decision to bar nurses who work only in cosmetics from being endorsed as an NP. It comes as Queensland states that only clinics with a doctor or NP on-site will be allowed to store the restricted medications needed to administer the most popular cosmetic injectables.
Nicky Tzimas is a registered nurse and founder of what’s known as the Cosmetic Professional Development Institute of Australia. She worries the stance will deter nurses from furthering their education and thinks it is illogical at a time when health agencies are wanting to improve the training and standards of nurses in cosmetics.
“It’s absolutely negligent and absolutely punitive,” she says of the restriction on nurses who only work in cosmetics to become NPs.
“It’s appalling that they’ve punished health practitioners who have raised their hand, given time and money to advance themselves, to be a better version of themselves, and to help the industry.
“The irony is that we do a lot of training and education of doctors, nurses and dentists, and we have nurse practitioners coming across to be trained by us.
“Support nurses. Have a great education program for them. Elevate them. Elevate the industry.”
Contact the National Health Practitioner Ombudsman here.
Know more about this story? Contact the reporter: pennytimms@protonmail.com
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