Under s 202(1) of the Health Practitioner Regulation National Law (Vic), the respondent's decision of 13 July 2022 refusing the applicant's application for endorsement as a nurse practitioner is set aside and substituted with a decision that the applicant be endorsed as a nurse practitioner under s 95 of the Health Practitioner Regulation National Law (Victoria).

1. On 8 August 2022, Ms Nektaria (Nicky) Tzimas, a registered nurse who has worked in the field of non-surgical cosmetic procedures since 2008, applied to VCAT for review of the 13 July 2022 decision of the Victorian Branch of the Nursing and Midwifery Board of Australia ('Board') refusing her application for endorsement as a nurse practitioner ('Board's Decision').[1] It is relevant to note, at the outset, that this decision followed an earlier decision made by the South Australian branch of the Board on 7 January 2022, but not communicated to Ms Tzimas, to approve her application for endorsement.[2] That decision was subsequently repealed.[3]
2. The object of the Health Practitioner Regulation National Law (Victoria) ('National Law') is to establish a national registration and accreditation scheme for the regulation of health practitioners, including nurses.[4] The objectives of that scheme include:[5]

to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered

...

to facilitate access to services provided by health practitioners in accordance with the public interest; and

to enable the continuous development of a flexible, responsive and sustainable Australian health workforce and to enable innovation in the education of, and service delivery by, health practitioners.

1. The main guiding principle underlying the National Law is the protection of the public and public confidence in the safety of services provided by registered health practitioners.[6] However, it is also a principle that restrictions on the practice of a health profession are to be imposed under the scheme only if it is necessary to ensure health services are provided safely and are of an appropriate quality.[7]
2. Division 6 of the National Law addresses the registration of health practitioners, including providing for general registration or specialist registration,[8] while Division 8 provides for endorsement of registration with endorsements available in respect of scheduled medicines, as a nurse practitioner, for acupuncture and for an approved area of practice (e.g. clinical psychology).[9]
3. Under section 95 of the National Law, the Board 'may' endorse a nurse as being qualified to practise as a nurse practitioner if the nurse holds an 'approved qualification' and complies with any 'approved registration standard'.
4. Ms Tzimas holds a 'Masters of Nursing Practice (Nurse Practitioner)' ('Nurse Practitioner Masters') which she completed at Deakin University between 2016 and 2020. The parties agree that that degree is an approved qualification for these purposes.
5. Registration standards are developed by health practitioner boards under section 38 of the National Law and approved by the 'Ministerial Council' (defined in the National Law as the COAG Health Council or its successor). The approved registration standard in this case is the Registration Standard: Endorsement as a Nurse Practitioner approved by the Ministerial Council on 30 October 2025 and issued by the Board on 1 June 2016 ('Registration Standard').[10] It provides that, when applying for endorsement, a nurse must be able to demonstrate four things:
   1. Current general registration as a registered nurse in Australia with no conditions or undertakings relating to unsatisfactory professional performance or unprofessional conduct.
   2. The equivalent of three years' full-time experience (5,000 hours) at the clinical advanced nursing practice level, within the past six years, from the date when the complete application seeking endorsement as a nurse practitioner is received by the NMBA.
   3. Successful completion of:
      • - an NMBA-approved program of study leading to endorsement as a nurse practitioner, ...
   4. Compliance with the NMBA's Nurse practitioner standards for practice.
6. It appears that this is the first substantive occasion on which the Tribunal has been asked to review an endorsement decision.[11] It is common ground that the role of the Tribunal on this review, as in most review proceedings and certainly in relation to registration decisions under the National Law,[12] is to consider the evidence before the Tribunal[13] with a view to making the correct or preferable decision. Ultimately, after undertaking the review, the Tribunal may confirm, amend or substitute the Board's Decision.[14] It is expressly provided that the Tribunal 'has the same powers' as the Board, at least in cases where the Tribunal determines to substitute another decision for the one under review.[15]
7. Ms Tzimas contends that the Board's Decision should be set aside and substituted with a decision endorsing her registration as being qualified to practise as a nurse practitioner.[16] She relies on three broad contentions:[17]
   • First, on 7 January 2022,[18] the South Australian branch of the Board had determined that she had met the Registration Standard based on the same material.
   • Second, the Board's position regarding nurses involved in non-surgical cosmetic procedures (discussed below at [12]) 'has no statutory force or effect', which the Tribunal is 'entirely free to disregard'. It is suggested 'there is every reason for the Tribunal to do so' given the evidence placed before the Board (including that of Ms Tzimas herself) that her practice satisfies the definition of advanced nursing practice required under the Registration Standard and she 'incorporated professional leadership, education and research into her clinically based practice'.
   • Third, the reports and evidence of Dr Chau Nguyen[19] and Dr Peter Callan[20] 'establishes that [Ms Tzimas'] practice satisfies the definition of "Advanced nursing practice" in the Registration Standard'. While conceding that the opinions of those witnesses are 'not reports by experts without any connection to Ms Tzimas', they 'have a significant advantage' as compared to the Board's expert, Ms Leane Boase, in that 'each has known Ms Tzimas and her practice over many years' and, as such, 'is perfectly placed to provide an opinion on her level of practice'.
8. The Board's position is that its decision ought to be confirmed on the basis that Ms Tzimas has not demonstrated that she meets the second and/or fourth criterion of the Registration Standard (see [7]). In particular, the Board contends that Ms Tzimas has not demonstrated that she has engaged in 'advanced nursing practice' for the requisite number of hours.
9. Advanced nursing practice is defined in the Registration Standard as:

... a continuum along which nurses develop their professional knowledge, clinical reasoning and judgement, skills and behaviours to higher levels of capability (that is recognisable).

Nurses practising at an advanced level incorporate professional leadership, education and research into their clinically based practice. Their practice is effective and safe. They work within a generalist or specialist context and they are responsible and accountable in managing people who have complex health care requirements.

Advanced nursing practice is a level of practice and not a role. It is acknowledged that advanced nursing practice is individually attributed within a regulated nursing scope (enrolled nurse, registered nurse or nurse practitioner). Advanced nursing practice for the purpose of the 5,000 hours required is not related to a job title or remuneration.

1. The Board's Decision, and its position before the Tribunal, reflects a position statement (approved by the Board on 16 December 2021 and which commenced on 4 January 2022) in relation to 'Nurses and cosmetic medical procedures' ('Position Statement').[21] The Position Statement indicates that:

[registered nurses] that are intending to progress towards endorsement as a [nurse practitioner] working solely in the area of cosmetic medical procedures are unlikely to meet the requirements for endorsement as [a nurse practitioner], as the [Board] considers that practising in the area of cosmetic medical procedures, such as cosmetic injecting, is not working at the advanced practice level (in line with the definition provided).

Advanced practice in nursing is demonstrated by a level of practice and is not by a job title or level of remuneration, or a set of procedural skills. Owning and running a health and/or nursing related business for example is not by itself an indication of advanced practice.

1. While the Board concedes that the Position Statement is not an approved registration standard, it submits that it is 'within the scope of the Board's statutory functions to provide guidance'[22] and, on review, the Tribunal should give those views 'considerable weight' because of the Board's 'specialist expertise and unique experience as the administrator of the legislative scheme in relation to nurses'.[23]
2. The Board also relies on the opinion and evidence of its expert, Ms Boase, who is a nurse practitioner and a lecturer in the Master of Nursing (Nurse Practitioner) at Latrobe University.[24] In essence, Ms Boase's opinion was that Ms Tzimas had 'not presented evidence of advanced nursing practice in order to meet the requirements for endorsement as a nurse practitioner'. Ms Boase maintained that position in her evidence before the Tribunal.[25]
3. For the more detailed reasons which follow, we are satisfied that Ms Tzimas has met the Registration Standard and should be endorsed as a nurse practitioner, notwithstanding that her recent practice is limited to non-surgical cosmetic procedures. While not every hour of the 8,893 hours she has claimed as 'evidence of advanced clinical practice' between 2017 and 2021[26] necessarily meets the definition, we are satisfied on the evidence (at the civil standard, namely the balance of probabilities) that she spent at least 5,000 hours over the last six years in clinical practice and that this practice was 'recognisably' at a 'higher level of capability' in the specialist field of non-surgical cosmetic procedures and incorporated professional leadership, education and research in that clinical practice as required. Further, we accept that she was 'responsible and accountable in managing people who have complex health care requirements'.
4. As foreshadowed towards the end of the hearing, we gave some consideration as to whether it might be appropriate to impose a condition or conditions on Ms Tzimas' endorsement as a nurse practitioner under sections 95(2)(b) and 103 of the National Law to reflect her area of specialty.
5. In our view, and contrary to the submissions of the parties, the type or nature of conditions that may be imposed by the Board under those sections (or the Tribunal on review) is not constrained. For example, it is conceivable that a condition could limit the field of practise as a nurse practitioner to non-surgical cosmetic procedures.[27] Another possible condition would be a limitation as to the drugs that a nurse practitioner could prescribe (e.g. limited to those relevant to non-surgical cosmetic procedures or for treating common complications of such procedures).[28]
6. However, in the present case, we have determined that it is inappropriate to impose any condition on the endorsement in circumstances where:
   • both parties had argued the case on a 'binary' basis, i.e. that Ms Tzimas either met the Registration Standard (and should be endorsed) or failed to meet that standard (and the decision to refuse endorsement should be affirmed);
   • neither party considered that conditions could or should be imposed; and
   • it would be difficult for the Tribunal to fashion an appropriate condition(s) without input from the parties.

Overview of evidence before the Tribunal as to Ms Tzima's practice

1. When Ms Tzimas applied for her endorsement, she provided the Board with a number of case studies to establish her claims of engaging in advanced nursing practice during the relevant period between 2016 and 2021.[29] In summary, these related to:
   • A 56-year-old female patient ('Patient A') who presented with 'painful hardened lumps and swelling to the mid malar area of her face along with several days of heat [after being] treated with dermal fillers four weeks ago by a nurse from a different clinic' ('Case Study 1').
   • A 43-year-old female patient ('Patient B') who presented in January 2016 with 'concerns about her skin integrity, namely her loose and thin skin' ('Case Study 2').
   • A patient ('Patient C') who presented in July 2017 with 'suspected vascular occlusion of the lower lip' ('Case Study 3').
   • A patient ('Patient D') who presented in July 2018 for anti-ageing medicine with contradicting co morbidities' ("Case Study 4').
2. Case Study 1 is headed 'Clinical Supervision Research Task' and was prepared by Ms Tzimas for her Nursing Practitioner Masters degree and includes reference to research publications supporting the analysis it contains. The document records:
   • Patient A's health history and medications, including recent dental treatment a week before receiving the dermal filler.
   • Patient A's vital signs and the area of reported pain, noting that her heart rate of 120 was 'an indication of infective process'.
   • The physical examination conducted, including an examination of Patient A's mouth looking for any 'abnormalities, changes, discoloration or oozing from mouth or gums' and palpation of her face 'looking for possible signs of skin changes, skin breaks or areas of necrotic tissue and signs of cellulitis'.
   • The plan for assessment of Patient A's previous cosmetic procedures, noting she had not experienced swelling following prior filler treatments, but there had been a change in the dermal filler she had received in recent times.
   • A differential diagnosis as to the possible conditions impacting Patient A. This included vascular occlusion, erythema (or redness of the skin), swelling from the filler due to post inflammatory filler syndrome or an infection (and setting out the considerations for each).
   • The likely diagnosis that Patient A was 'showing sign[s] of increasing infection', ruling out vascular occlusion based on research suggesting that this 'would be expected to be present immediately and within 1-7 days' (rather than a few weeks after dermal filler treatment).
   • That hyaluronidase operates to dissolve the filler and can 'help with management of inflammation', but it is 'imperative to ascertain the cause of the inflammation' as this treatment could lead to the infection spreading.
   • That it is 'imperative that collaboration with the patient's health practitioner is done to be informed of most current pathology and test results'.
3. Case Studies 2 to 4 are headed 'Clinical Supervisor Meeting Notes' and record discussions about the cases between Ms Tzimas and her clinical supervisors during her studies, being Dr Rob Weiss (in the case of Case Studies 2 and 3) and Dr Nguyen (in the case of Case Study 4). They are briefly summarised below:
   • Case Study 2: It is noted that Patient B reported that she suffered from an auto immune disease, namely rheumatoid arthritis, which is managed through use of a steroid. It is suggested that Patient B was negative and critical of various health practitioners when asked about previous treatments. The document observes that a 'red flag' is raised by reason of (a) Patient B's dissatisfaction with prior treatment when she is seeking further treatment, and (b) her desire to look like a celebrity (apparently Kylie Jenner). In the notes for discussion, Ms Tzimas records that Patient B 'showed signs of body dysmorphic behaviours' and that she would discuss the option of referral to a psychologist with Dr Weiss, as well as discuss alternative treatments for addressing the patient's concerns about her skin. The agreed actions included dissolution of the existing dermal filler, refusal of further dermal filler treatment and discussion with the patient about the 'observations and concerns of body dysmorphic presentation and possible referral to psychologist', discussion of skin strengthening treatments and referral to the supervising doctor for a review and further recommendation.
   • Case Study 3: It is noted that Patient C's 'upper lip area developed what initially seemed like a bruise, immediately after the needle was withdrawn'. However, the bruise 'did not have a regular pattern, it was irregular in shape blue, grey, white and pink presentation' and, based on her studies, Ms Tzimas believed that 'the "mottled effect" [was] consistent with a potential blockage of vessels/vasculature' and she 'immediately suspected a vascular occlusion'. Ms Tzimas records that, 'to avoid any further complications [she] proceeded to treat the patient with HYLASE (hyaluronidase)' and the bruise-like presentation subsided. The notes go on to record Ms Tzimas' discussions with Dr Weiss about the matter.
   • Case Study 4: This note concerned a patient that presented for anti-ageing medicine with contradicting comorbidities. Following the topic header, there is some suggestion of Patient D presenting 'with a medical history of cancer' and having 'recently completed her cancer treatment medication'. However, the body of the note instead refers to a 'history of autoimmune condition', an increase in Patient D's symptoms due to stress and the likelihood that her steroid medication would be increased. The note records that Ms Tzimas discussed with Dr Nguyen how she managed the presentation and how she 'could have better provided care as an advanced nurse practitioner candidate'. The note records various considerations with respect to the presentation and the actions as being to advise Patient D to 'see her doctor and specialist' and to '[s]eek permission [from Patient D] to collaborate with her doctor and specialist'.
4. On 8 December 2021, Ms Tzimas provided some further case studies to the Board in a document entitled 'Mapping Advanced Nursing Practice against the NMBA Nurse practitioner standards for practice (2021)' ('Mapping Document').[30] In summary, these related to:
   • 'Patient E', a '36-year-old female patient [who] presented to [Ms Tzimas'] clinic with a non-fluctuant delayed inflammatory nodule post dermal filler injection for nasolabial fold augmentation 2 years earlier' ('Case Study 5').

It is recorded that the patient was referred for an ultrasound which revealed two 'benign nodules ... indicating infective cysts'. The patient was prescribed anti-biotics for a duration of 15 days and 'monitored closely for 3 weeks, [during which] the inflammation, erythema and pain subsided'. Hyaluronidase was then 'injected into the nodule to help clear the filler'. Patient E was 'monitored closely over 4 weeks' but, as 'significant improvement was observed[,] ... no further intervention [was] required'.

• 'Patient F', 'a female patient, 39 years old, [who] presented to clinic for dermal filler treatment to the lips ... [and] had never had past cosmetic procedures ...[and] stated they have no known allergies' ('Case Study 6').

It is recorded that 'approximately 5 minutes post anaesthetic application [being a topical numbing cream approved by the clinic doctor], the patient began to complain of feeling lightheaded, severe swelling to the lips, rash and shortness of breath, and an inability to remain upright in treatment chair'. The note goes on to record that an '[a]mbulance was called by a colleague as per [Ms Tzimas'] direction' and as the patient's difficulty breathing 'was worsening', an Epi Pen was administered. However, as there was 'no change to [the patient's] condition after 5 minutes', adrenaline was injected and Patient F then improved and was transferred by ambulance to the hospital 'for monitoring'. Ms Tzimas states that she followed up with Patient F the next day and describes her as 'well and fully recovered'.

• 'Patient G', a patient 'presenting with body dysmorphic symptoms, unrealistic expectations and high risk for adverse reactions' ('Case Study 7').

It is recorded that Ms Tzimas 'formulated a plan for her prescribed aesthetic treatments, intended treatment outcomes and post care information', ensuring that it was 'appropriate for her clinical presentation, and utilised theory-based education, such as hand out post care information and follow up appointments with myself and her psychologist'.

• 'Patient H', a patient who 'presented with polymyalgia ... seeking dermal filler treatment' ('Case Study 8').

Ms Tzimas explains that, following a 'comprehensive consultation and assessment, [she] discovered that the patient also had acute, current, symptoms of pain'. She 'recommended that treatment not ... proceed until symptoms subside and clearance was provided by the patients Rheumatologist'.

• 'Patient I' who was 'a female patient, 40 years old, who presented to clinic with fever, localised heat, pain and swelling to the left mid cheek 10 days post dermal filler treatment ('Case Study 9')'.

Ms Tzimas records that in assessing the patient she identified that the patient's 'left mid cheek [was] warm to touch [and] painful on palpation'. Following assessment, a 'fluctuant abscess is diagnosed' and Patient I was 'referred to a plastic surgeon for incision and drainage of the abscess', while 'aerobic and anaerobic cultures were taken [and] antibiotics were commenced' with the patient being 'monitored daily over the next three weeks whilst being treated at home'.

1. Dr Nguyen included three further case studies in her report,[31] concerning:
   • A 42-year-old female ('Patient J') who 'received a skin needling treatment [and] presents with an asymmetric lump in the right cheek one week later' ('Case Study 10').

In her report, Dr Nguyen sets out the differentials identified, namely an abscess, haematoma, filler complication or underlying immune disorder and granuloma. Dr Nguyen records that, following discussions with Ms Tzimas, an ultrasound was arranged which confirmed an abscess. As this was 'very unusual' and 'extremely rare', Patient J was asked to attend for evaluation by a plastic surgeon. The abscess was then drained and the patient was given antibiotics.

• - 'appeared to have a body dysmorphic disorder' and 'she was asked to see a psychologist prior to any further [cosmetic] treatment'; and
• - was due to fly to Bali in a week but was 'advised not to travel until her symptoms have resolved'.

• A 62-year-old female ('Patient K') who 'presented for cheek filler injections [which she had] in the past without significant complications' and then '[t]wo weeks post her injection, the patient experiences tenderness in the right cheek' ('Case Study 11').

In her report, Dr Nguyen sets out the differentials identified, namely subcutaneous trauma, hematoma and delayed onset nodule. While the latter was considered unlikely, it became Ms Tzimas' 'working diagnosis' because the patient developed a 2x2cm lump without signs of inflammation. Dr Nguyen then saw the patient herself, confirmed the diagnosis and proceeded to administer hyaluronidase to resolve the nodule.

• A 35-year-old male ('Patient L') who 'lives over an hour away [from Ms Tzimas' clinic and] presented for dermal filler injection', where a 'visible lump behind the ear was observed' ('Case Study 12).

In her report, Dr Nguyen indicates that the lump had been present for 10 years and had started to 'weep' a few months earlier, which raised concerns. The plan developed was for Patient L to attend his GP for a referral to an ear, nose, throat ('ENT') specialist, noting that the treatment could only take place if the patient's treating doctor provided the clinic with a 'clearance letter'.

The report notes that Patient L became 'defensive and belligerent when refused treatment ... and intimidated the staff'. When the patient returned with a clearance letter from his general practitioner, Ms Tzimas discussed her concerns as to whether the doctor was 'aware of the potential complications related to dermal fillers'. Dr Nguyen then spoke to the general practitioner to suggest an ultrasound and follow up with an ENT specialist.

highlights the importance of proper patient assessment, clear communication with healthcare professionals involved, and ensuring the safety of staff in challenging situations. Collaboration and a patient-centered approach are crucial in navigating the complex issues that arise in such cases. All these skills seen in advanced practice.

1. Each of Ms Tzimas, Dr Nguyen and Ms Boase commented on certain case studies and gave evidence about their views as to whether the case studies did (or did not) reflect advanced clinical practice at the hearing before us (which is discussed further below). Dr Weiss did not provide a report or give evidence before us. Ms Tzimas said that this was because he had retired from practice and she no longer had contact with him, while the relationship with Dr Nguyen was ongoing.[32]

1. In a statutory declaration dated 13 September 2021, accompanying her application for endorsement,[33] Ms Tzimas declared that she:

Undertake[s] 35-42 hours of Advanced clinical care hours per week.

[She is] self-employed & complete[s her] clinical hours between regenerer medical cosmetics, Island glow aesthetics (regional clinic) and [the] CPD Institute of Australia.

1. For context:
   • Regenerer Medical Cosmetics (also referred to as Better Health Training) ('Regenerer') is Ms Tzimas' main cosmetic and aesthetic skin clinic based in Moorabbin.
   • Island Glow Aesthetics ('Island Glow') is a cosmetic and aesthetic skin clinic she has in Cowes on Phillip Island.
   • The CPD Institute of Australia ('CPD Institute') is a business that Ms Tzimas established to provide training to nurses and others in cosmetic injectables.
2. In a cover letter accompanying her application for endorsement,[34] Ms Tzimas provided some further detail regarding these businesses and her role within them as follows:
   1. I am the founder of [the] CPD Institute. I have a team of staff that manage the day to day operations of the business. [The] CPD [Institute] has 10 trainers that facilitate all training. I facilitate 3 hours of training a month and 2 hours of admin time per week for this business that usually occurs sporadically throughout the day or at the beginning and end of day ...
   2. Better Health Training is an aesthetic practice. I am a self employed and Dr Rob Weiss is my supervising doctor that supports me in a clinical context via prescribing support and with my advanced clinical practice requirements. My clinical hours with Regenerer are across the following sites, Moorabbin, Keilor, Phillip Island and Geelong are 35-42 hours per week. I have a manager that overseas all sites and day to day operations such as rostering, product ordering and operation/accounts.

I have had this business for over 9 years and have completed above 5,000 hours of advanced clinical hours in this role ...

Direct patient care - Regenerer 35-42 hours per week

Administrative duties- for both regenerer and [the] CPD [Institute] 5-10 hours per week

1. This application was accompanied by a '1 week snapshot of direct patient care at regenerer',[35] which took the form of a screenshot of her calendar of clinical appointments for the week commencing 9 November 2020 and showing the names of the patients seen over the course of that week and the treatment provided (e.g. dermal filler treatment).[36] That calendar supports Ms Tzimas's evidence as to the number of practice hours she worked as it records back to back appointments from 9 or 9.30am in the morning to between 5 and 7.30pm at night from Tuesday to Friday of the relevant week.
2. In May 2022, the Board wrote to Ms Tzimas to notify her of its intention to refuse her application for endorsement on the basis that she had not met the second requirement under the Registration Standards.[37] That is, she had not demonstrated 'the equivalent of three years' full-time practice (5,000 hours) at the clinical advanced nursing practice level, within the past six years'.
3. In response, Ms Tzimas provided a further statutory declaration dated 30 May 2022, in which she included a 'table of evidence of advanced clinical practice greater than 5000 hours within past 6 years, for 2016-2022.[38] In that table, she claims 8893 hours of 'total direct clinical practice' and a further 248 hours of 'non clinical' work.
4. The direct practice hours are based on 35 practice hours per week at Regenerer and Island Glow for 48 weeks between 2016 and 2019 and a shorter number of weeks in 2020 (23) and 2021 (36) due to 'lockdown periods' during the pandemic. The description of the work performed is:

Aesthetic and psychological assessment of patients seeking treatments for cosmetic enhancement including social and medical history taking, examination, and development and provision of treatment plans under supervision of physician or nurse practitioner.

1. The non-practice hours claimed are 4 hours per week at the CPD Institute for 12 weeks between 2016 and 2019 and a shorter number of weeks in 2020 (5) and 2021 (9). The description of her work is:

Face to face training of doctors, nurses, nurse practitioners in the theoretical and technical aspects of cosmetic injecting (demonstrating [nurse practitioner] standard 4, support health systems)

1. In her evidence in chief, Ms Tzimas confirmed her view that, in each case, the case studies reflected advanced clinical practice as defined in the Registration Standard.
2. Ms Tzima provided the following explanations for asserting that her practice was advanced:
   • Case Study 1 was advanced nursing practice in terms of 'the ability to collect information, identify risks, complications ... look at the differentials and look at ... treatment plan managing, and preventing further harm to the patient'.[39]
   • Case Study 2 was 'very advanced' because Patient B showed signs of body dysmorphic behaviour (in terms of her dissatisfaction with all previous treatments and her desire to look like Kylie Jenner).[40] At the time, this was difficult to identify 'because there was nothing we could measure it against'[41] and patients of this nature are 'the most vulnerable patients' and, in the wrong hands, will be over-treated or move from one person to another.[42]
   • Case Study 3 was advanced because she has dealt with many patients who have come from other clinics with vascular occlusions which have been 'missed by other practitioners' and as part of her duty of care, she had to 'go in and dissolve [the filler] immediately'.[43]
   • Case Study 4 where Patient D presented with a comorbidity (an autoimmune condition, rather than cancer which had been erroneously included in the case note) was advanced because 'if the consultation and assessment isn't at an advanced level and these things get missed, the complications are serious'.[44]
   • Case Study 5 was advanced in terms of her being 'able to identify [the nodule] and ... deliver the appropriate treatment and prevent further complications'.[45]
   • Case Study 6 was advanced in that the adverse allergic reaction 'all happens in a very fast [pace]' and that she had to 'make a decision as to what to do next without the guidance of a doctor'.[46]
   • Case Study 7 was advanced because she does not know anyone else that uses 'all the different aids that we use and products to ensure that we cover all aspects of effective communication [and] attain informed consent', which is 'not basic'.[47]
   • Case Study 8 was advanced as she has 'many patients coming in with chronic health issues [and issues with] their self-esteem, [such that] the psychological aspect of their well-being is very compromised' and although Patient H was stable, 'the risks ... if she wants to be treated with dermal filler ... would be ... quite high'.[48]
   • Case Study 9 was advanced because she was able to 'identify and recognise and assess [and] refer [the patient] for intervention' and 'actually reporting to the doctor and the plastic surgeon what I find', rather than 'calling the doctor to say I don't know what's wrong, can I send her to you, can you fix it'.[49]
3. Insofar as her clinical supervision by Dr Weiss was concerned, Ms Tzimas explained that the supervision occurred both face to face (at his clinic in Frankston) and over the phone and that, in assessing her level of proficiency against the nursing practitioner standards as 'independent',[50] Dr Weiss was indicating that she was working 'with no cues'.[51] Ms Tzimas explained that this involved her presenting her own case and differentials and being challenged by Dr Weiss to explain these matters which helped her to learn and gain confidence in her own decision-making.[52]

(While not specifically mentioned in her evidence, we observe the Tribunal Book also includes clinical assessments from Dr Theva Thevakumar and Dr Nguyen dated 20 May 2017 and 22 October 2018 (respectively), also assessing Ms Tzimas' proficiency as independent.[53])

1. More generally, Ms Tzimas' evidence as to her practice was that:
   • She deals with patients with 'complex health care needs', such as patients presenting with autoimmune conditions which is 'quite a big contraindication and risk for non-surgical procedures' and, if not disclosed, can 'lead, very quickly, to a combination of granuloma [(a small inflamed lump) and] infections'.[54]
   • While history taking can be basic, she conducts it at an 'advanced level', using a tool she developed (referred to as the CANSAT tool) to address psychological risks associated with treatment and which may not otherwise be identified 'because of patient disclosure [and] their understanding of what ... non-surgical procedures are [and] the way media and society has portrayed these treatments'.[55] She suggested the latter had 'dumbed things down'.[56]
   • The level of complexity of cases she deals with is 'more complex nowadays', especially as things like autoimmune conditions are 'quite ... prominent and prevalent' and they had seen more complications as a result in the last two years.[57]
   • While the complexity of patient presentations with issues like body dysmorphic disorder remained to the present day, 'the difference now is that we use the CANSAT tool as the baseline'.[58]
2. Ms Tzimas was cross-examined in relation to a number of the cases studies as follows:
   • Case Study 1: She was asked about the circumstances in which Case Study 1 arose, with the explanation being that she attended Dr Weiss's general practice as part of her clinical supervision. However, when it was put that this kind of situation was not likely to arise in her own cosmetics practice, she explained she does get patients at her clinic presenting with a hardened lump on their face (as opposed to such patients going to their general practitioner).[59]

She also denied that, because the clinical research task had been undertaken in 2016, early on in her degree (and, as such, when she was still learning), it did not establish advanced practice. She confirmed her evidence in chief that it 'certainly is advanced practice' and explained that there was 'a whole process involved of ... having to ... put forward to the university to show it was an advanced practice and [counted towards her] 5,000 hours prior to [her] being accepted by the university'.[60]

Further, she disagreed with the suggestion that the case study 'doesn't show anything that wouldn't be expected of a registered nurse practising at the level of a registered nurse'.[61] She explained the difference between her approach, and that of any other registered nurse, was 'taking it to the next level of doing the differentials, doing the entire assessments and coming up with a plan of action' and that this was what made it advanced practice.[62]

• Case Study 2: She did not agree with the suggestions that the case study lacked 'the reasoning and diagnostic approach that would be expected of a nurse practitioner' because it lacked diagnostic reasoning and rather just involved 'discussing options with a doctor'.[63] In this regard, she explained that the case studies were 'dot point(s)' she 'put together in preparation for the discussion with the doctor' and they would 'go through all of that stuff' with the doctor.[64]

Further, she disagreed that identifying a patient's autoimmune conditions was something that you could just ask them and that a registered nurse or enrolled nurse 'could carry out that function'.[65]

She did not accept that the case study failed to show advanced nursing practice.[66]

• Case Study 3: Ms Tzimas confirmed that vascular occlusions are something that she has 'seen a lot of', in many cases as a referral from another practitioner and which she has had to manage.[67] She also accepted that the nurses that work in her clinics were likely to see it on a regular basis and had been trained how to deal with such situations.[68] However, because she sees a lot of cases coming through where such matters have been misdiagnosed, she did not accept the suggestion that it was not advanced nursing practice (but rather what any registered nurse could be expected to address).[69]
• Case Study 4: She was cross-examined at length on her evidence that the references to cancer in the case study were erroneous and that Patient D in fact had an autoimmune condition. Despite being taken to matters such as references to blood tests to review where the patient was at (put as being consistent with the patient having cancer), she 'strongly believe[d]' the reference to cancer was a mistake.[70] However, she did agree that, in simply discussing an autoimmune condition, without explaining what condition the patient had, the case study did not 'show the level of investigation that would be expected of a nurse at the advanced level'.[71]
• Case Study 5: Ms Tzimas disagreed with the suggestion that nothing in the case study, involving the prescribing of amoxicillin for Patient E in relation to an inflamed nodule, was 'beyond what one would expect of a registered nurse in the same situation'.[72]
• Case Study 6: In answer to a question whether 'any registered nurse who is competent would take [the same] actions' of administering an Epi Pen and calling an ambulance for Patient F in light of a significant allergic reaction, she suggested that this was 'not necessarily' the case.[73] Her evidence was that she has seen cases where a nurse just calls an ambulance and makes the patient comfortable without administering an Epi Pen. While she accepted that a nurse who did that, despite the availability of an Epi Pen would be negligent, she maintained that her ability to 'make the call' was advanced practice.[74]
• Case Study 7: While Ms Tzimas accepted that other comparable practices would ask questions 'directed to body dysmorphia', she maintained that her approach reflected advanced practice because 'it is validated and evidence-based and actually produces a result' and 'gives guidance to the clinician'.[75] By contrast, 'everyone [else] asks different questions but it's not validated' or 'consistent' and could lead to different responses depending on how the questions were framed.[76]
• Case Study 8: She did not accept that any registered nurse would be expected not to proceed with a cosmetic intervention in the case of a patient who has acute current symptoms of pain, like Patient G.[77] She mentioned that she had seen cases where a patient presents with pain, but says they can tolerate it and would like to have treatment.[78]

1. In cross-examination, Ms Tzimas was also asked about:
   • The amount of time she spent on work associated with the CPD Institute in the last year.[79] She explained that it was 'not much at all, not as [much as] it did in its infancy'.[80]
   • The amount of time she spent at her clinics at the moment.[81] Ms Tzimas explained that she was 'there four days a week but they're 10 hour days'.[82]
   • Whether the identification of complications, such as any psychological condition a patient might have, involved a 'pretty straightforward process' of asking them 'what procedures have you had in the past and how do you feel about them'.[83] Ms Tzimas accepted that this was a 'standard question', that any of her nurses could ask and as such, this process was not advanced practice: rather, she accepted it was 'what you'd expect from any nurse who is practising in your particular area'.[84]

1. In her examination in chief, Dr Nguyen explained that she has been a radiologist for around 15 years and practised in the area of cosmetic medicine for around the past 10 years.[85] She explained that, as a radiologist, she had 'trained at the Western Health [looking] after both fellow and registrars and train[ing] them up to become consultants'.[86]
2. In terms of her relationship with Ms Tzimas, Dr Nguyen explained that she is the 'prescription doctor', i.e. she writes scripts for Ms Tzimas' entities.[87] On a day to day basis, Ms Tzimas would take the history of patients and call Dr Nguyen to present the case, where they go through past medical history, complications, allergies and the like and 'how [Ms Tzimas] would like to proceed'.[88] Dr Nguyen would then 'follow up with more questions if I need to ... and ask the patients before I sign off'.[89]
3. Dr Nguyen confirmed her view that, in each case, the case studies included in her report reflected advanced clinical practice by Ms Tzimas.
4. Dr Nguyen explained that Ms Tzimas would assess the patient first and then present the case to her.[90] This included Ms Tzimas coming up with the differentials, determining which differential diagnosis was correct and a management plan for its treatment.[91] She said that this process was how 'any other doctor would actually present [a case]'.[92] Dr Nguyen's role was to 'guide her or to agree or disagree with her, or to give other suggestions'.[93]
5. When asked to explain that how Ms Tzimas presented to her in the manner a doctor would, Dr Nguyen explained:[94]

there's a lot of differences between what a registered nurse would perform and how a nurse practitioner/a registrar, who is a doctor in training for a particular speciality ... my expectation of a registered nurse would be if they implement my plans and escalate if there's something that has gone wrong. And that is, I think, what a registered nurse role is. But when you move beyond that, when you're actually actively managing patients, when you're actually diagnosing things, when you are actually looking up diagnostic tests, and to confirm your suspicions, you are actually managing the patient and actually doing a role of what a doctor should be doing, essentially. And for me to work with [Ms Tzimas], and to guide her through that, I needed her to step up ... in the, like, clinical, sort of, ... way of thinking of things, because she will be held accountable for this patient's - ... but, of course, work within your boundaries and also escalate if needed. And that's what ... learning to be a nurse practitioner or advance[d] practice would be.

1. Dr Nguyen provided the following explanations for asserting that Ms Tzimas' practice was advanced:
   • Case Study 10: Dr Nguyen indicated that this was a 'very interesting case' where Ms Tzimas quickly identified that the patient had body dysmorphic disorder and had over-treated themselves, which was a 'red flag', and that there was a need to 'escalate that, because that means that we have to treat [the case] with a lot of caution'.[95] She said that, at the time (2021), 'no-one has ever really spoken about that' and, observed that Ms Tzimas was 'practising ahead ... ahead of time'.[96] Ultimately, the patient had to be referred to a plastic surgeon because the patient had an abscess on her face, which Dr Nguyen had not seen before and could not address.[97] She agreed that Patient J was a patient with 'an extremely complex healthcare need'.[98]
   • Case Study 11: She indicated that the complexity in this case, is that they did not know what the patient's lump was and whether it was a nodule or could be cancer or 'something as simple as an infection or ... a blood clot or haematoma'.[99] She noted that they had to look at papers from the UK and America and other anecdotal evidence, before seeking a plastic surgeon's opinion.[100] She considered that this demonstrated 'advanced learning in the space, to be able to diagnose'.[101] That they were able to treat the nodule successfully was 'only because of [their] ongoing active learning'.[102] She confirmed that Ms Tzimas made the diagnosis of delayed onset nodule, based on the fact that the patient presented two weeks after an injection, and Dr Nguyen agreed with that diagnosis.[103]
   • Case Study 12: This showed advanced practice because Patient L had travelled over an hour away to see Ms Tzimas and he 'looked as though he had some body dysmorphia as well ... He was extremely gaunt, but very adamant that he wanted more procedures to be performed'.[104] Also, he did not disclose all his medical history and 'that was only revealed on examination' and 'so there was multiple issues happening at the same time, and that was only revealed because of the careful history taking'.[105] Dr Nguyen went on to recount further complications after she consulted the patient's general practitioner.
2. In response to a question as to how Dr Nguyen had seen Ms Tzimas' practice change between July 2016 when they first started working together, Dr Nguyen indicated she had seen Ms Tzimas:[106]

grow, and she's got a lot more confident from when we first started. I - as a consultant, I am very strict in the way that people present to me, because, you know, I need things to be succinct. And so we've gone through how I would like her to present to me, as well as all the nursing staff under our care to present to me. So - so that means that, you know, we would help change that. We also - in terms of forming protocols, I've been involved with [Ms Tzimas] to form protocols, particularly when it comes to complications and radiology. This is something that is actually not practised by AHPRA. It has not been rolled out, but it's something that we do, that we've done in discussion where all complications, if need be, would actually have an ultrasound, or an MRI, or a CT. So - and because I'm a radiologist, I have access to that. Then I will actually look at the images. I would actually give a working diagnosis. Then we would actually formulate a plan, speak to the GPs or the specialist, then follow up in three to six months' time, and - and then we tie everything together. And this is a practice that - it's myself, Nicky, other surgeons, have all collaborated with, and it's something that is not done anywhere else, and we are, to me, extremely safe.

1. In cross-examination, Dr Nguyen rejected the suggestion that she 'worked for' Ms Tzimas, but accepted that she receives a fee 'every time a script for a patient' is written.[107] She confirmed she did not charge in cases where Ms Tzimas came to her with a patient's issue, but the decision is not to go ahead with treatment.[108] However, if 'there's any complication, whether the patient is [hers] or not, [she] tend[s] to take them over, because that is the best patient care'.[109] However, this would not necessarily involve the patient physically going to her office as that depends on the circumstances. She explained:[110]

[i]f it is something that is - can be treated by [Ms Tzimas] and then she says, 'I'm happy to treat. This is my recommendation. This is how I would proceed. This is ... the dosage that I would give them. What do you think?' I'd be like, 'Absolutely', and if I think that that is safe and then ... that would proceed under [Ms Tzimas'] care, and then that would be followed up and then I would be kept in the loop until the whole issue is resolved. The only time a patient does come to me is when it's a little bit ... overly complicated when you need to actually refer on to another doctor, and that doctor is always going to be me as the first point of call if the patient comes down to see me.

1. While Dr Nguyen accepted that she was not familiar with the requirements set out in VCAT Practice Note PNVCAT2 concerning expert reports,[111] she did not agree with the suggestion that because of her 'long working relationship with Ms Tzimas and the financial arrangements ... [she was] not in a position to give impartial expert evidence about issues in this proceeding'.[112] This was because she did not have any interest in Ms Tzimas' businesses and regards her interest as being to:[113]

support nurses in general ... because ... it's an industry that needs to be, well, better managed, and I think that ... my interest is this is going - our nurses are all females, and so - and they're all mothers, and they need support, and they want to find a different way to actually have a better work life balance. That is how I see my role for them. If you ask me to - how much money I make, it doesn't - it's - it's not the money, because I don't I actually make that much. I'm a consultant radiologist. I own my own company. I don't need the money. I'm doing it purely supporting our ... women and - and nurses. So that's why I disagree.

1. Dr Nguyen also rejected the suggestion that her report was 'really an expansion' of what she had previously stated in a letter of support for Ms Tzimas' application for endorsement.[114] She reiterated that:[115]

the growth that I saw [in Ms Tzimas] was from that RN - for the registered nurse - that would only implement and would only escalate, to someone who is able to actually think by themselves, form their own differentials, work up their own diagnosis, just like any other doctor would, and then I discuss and come up with a management plan. So that - I mean, like, if it's an extension, that it's a - an exponential extension, and the, you know, in the [nurses] practise of - and in their scope ...

1. Dr Nguyen was also asked about her opinion, in her report, that Ms Tzimas had 'completed over 7,000 hours of "Advanced nursing practice" as defined in the Registration Standard' (over the period between 2016 and 2023).[116] She explained:

So for me it's ... 'cause I know ... she works ... several days a week as ... [a cosmetic] nurse. She also owns the business that we spoke about, the CPD [Institute] ... but even - so by putting in all those policies, doing all the screening hours and also practicing as a nurse combined, I - I think 1 when you - even if you do - and as a business owner they always ... you know, less than two hours a week because forming policies isn't easy, but even if you go forty hours a week or fifty hours a week, you multiply that out, you - she's - it's a substantial amount of hours.

1. When it was put to her that the 'the relevant question here [is] about advanced level of practice [and] is really focussed on clinical practice' or activity, Dr Nguyen indicated:[117]

Then, if it's just as a clinical, then even if she does three - three days a week, she - it's quite extensive. I - I speak to her, let's say, for me - there are - that is there are weeks I speak to her daily, and I'm with her for a day then there's - I also give her cases ... and every patient throughout the whole - whole week or over the years is always ... discussed with myself.

1. In responding to a question about quoting the same 7,000 hour figure in her letter of support for the period between 2016 and 2021, Dr Nguyen explained:[118]

So advanced practice like, is basically you're managing the patients. Right. Like, you're making the diagnosis, you're managing a patient. So from the get go, and as soon as I've come on board, the way that she presents to me is the fact that she's managing her patients. Whether that be a simple case or whether it be a complex case, [where there is a] need [for] further discussion. Every - everything that we - we do together or have done together, is all about learning and improving. So to me that's all about advanced practice because that is not what a typical ... nurse would do. I know that, I say that, because I used to have my own nurses that I oversee, and all they would do is tell [me] - 'Can I do this? Or, 'This is what happened, what would you do in this instance?' I don't have that collegial, you know, discussions with them. Whereas in developing someone in advanced, or to become a nurse practitioner, they become my colleagues. Therefore I mentor them very differently.

1. In re-examination, Dr Nguyen agreed with the proposition that she had a 'financial disincentive' in Ms Tzimas being endorsed as a nurse practitioner because once endorsed, Ms Tzimas would be able to write her own scripts and Dr Nguyen would no longer be required to write scripts for which she is paid.[119]

1. The Tribunal Book includes a short report from Dr Callan, a specialist plastic surgeon, dated 24 November 2024.[120]
2. In his report, Dr Callan candidly observes that he has 'minimal direct experience with nurse practitioners, and do[es] not claim to be an expert in the area'.[121] His report also discloses that he has 'run anatomical workshops for Ms Tzimas and her company [the] CPD Institute over the last five years' as a 'paid contractor'.[122]
3. In relation to the requirement, under the Registration Standard, for a nurse practitioner candidate to demonstrate 5,000 hours of advanced practice in the six year period leading up to an application for endorsement, he expresses the following view:[123]

All clinical practice, full-time or part-time, involves both routine and advanced practice. No practitioner working full time for three years or part time for six years with over 5000 hours experience would demonstrate "advanced practice" the entire time. It is insincere to suggest otherwise. This includes specialists such as me. ... What is true however is that advanced practice integrates seamlessly with the routine practice. If we accept this as a fundamental principle, Ms Tzimas has easily fulfilled the requirement of 5000 hours because she has been practicing as an advanced practitioner under supervision for this entire time.

1. In response to a question as to how Ms Tzimas demonstrated her practice at an advanced level, Dr Callan states:[124]

It is hard to imagine any nurse working at a more advanced level in practice than Ms Tzimas.

She has developed her professional knowledge, clinical reasoning and judgement, skills, and behaviours to the highest standards possible. She demonstrates professional leadership, running a company which has educated other professionals at a credentialled level for at least the past six years, and for seven years before that. She is an educator, running courses and workshops for nurses, nurse practitioners and medical practitioners, and has research credentials including publications in her specific area of expertise. She works within a specialist context and is responsible for managing people with complex issues relating to cosmetic medicine, in the consent and assessment process, in conducting her practice, and in post treatment care. This is apart from her educational role.

1. In his report, Dr Callan goes on to criticise Ms Boase's opinion concerning Ms Tzimas' case studies on the basis, among other things, that it 'conflates general and specialist practice', 'lacks detail' and 'does not demonstrate any knowledge of aesthetic practice'.[125]
2. In cross-examination, Dr Callan agreed that:
   • his professional interactions with Ms Tzimas 'haven't extended to actually working with her in a clinical setting';[126] and
   • in relation to Case Study 6, the administration of an EpiPen dose and the calling of an ambulance to address Patient F's allergic reaction to the topical numbing cream was what he would expect 'from any capable registered nurse'.[127]

1. Ms Boase prepared an expert report for the proceeding dated 24 December 2022.[128] In that report, Ms Boase provides her opinion as to what advanced nursing practice involves and how it is demonstrated in the following terms:[129]

Advanced nursing practice includes knowledge, clinical reasoning, judgement, skills, and behaviours at a higher level of capability than that of a registered nurse. This includes leadership, education and research into clinical practice ... it encompasses a higher level of clinical reasoning, decision making, and accountability in the management of patients with complex health care requirements.

...

Advanced nursing practice is demonstrated in practice through the provision of full episodes of care, including managing complex healthcare problems, and providing preventative care. The advanced practice nurse would demonstrate advanced clinical assessment skills across a range of systems, and would apply advanced clinical reasoning skills throughout the assessment to inform differential diagnosis development, to enable further assessment, diagnostic tests and treatment ...

In practice, advanced nursing practice would therefore be most clearly demonstrated through the ability to perform complex and comprehensive assessments across a variety of acute and chronic healthcare presentations, and apply high level clinical reasoning skills to inform differential diagnosis, diagnostic assessment, and treatment. It would incorporate each step of the clinical reasoning cycle ...

1. In terms of explaining the requirement under the Registration Standards to be responsible and accountable in managing patients with complex health care requirements, Ms Boase expresses the view that:[130]

Responsibility and accountability in managing patients with complex health care requirements relates directly to the level of practice. The nurse practitioner role is independent and autonomous, so as part of the continuum of development of the advanced practice nurse, to practice independently and autonomously, the advanced practice nurse must be fully responsible and accountable for their practice.

This is essential, as an advanced practice nurse may be the only health care provider involved in the care of a person with complex or acute health care needs. The advanced practice nurse must be able to effectively use and apply their generalist and specialist education and experience as a nurse to the entire episode of care, including follow up care. They are fully responsible for making decisions around when further consultation or referral is required ...

1. In her report, Ms Boase goes on to undertake a comparison between the definition of advanced practice in the Registration Standards and Case Studies 1 to 4. For example, in relation to Case Study 1, while Ms Boase indicates it includes 'some elements of advanced nursing practice', it 'does not consistently demonstrate [such practice]' and '[o]verall, this case lacks specific evidence of advanced evidence-based clinical decision making, and potentially highlights some knowledge gaps, particularly outside cosmetics'.[131] Further, she suggests the case study provides 'no evidence [Ms Tzimas] would be able to provide this care autonomously'.[132] Similar observations are made about each of the other case studies.
2. Overall, Ms Boase expresses the opinion that the practice undertaken by Ms Tzimas as demonstrated by her CV and Case Studies 1 to 4 is not equivalent to the requirements of advanced nursing practice in the Registration Standard.[133] In explaining why she has formed that opinion, Ms Boase explains:[134]

It is possible that Ms Tzimas does practice at the advanced nursing practice level at times during her practice, however there is insufficient evidence within the cases provided as examples to determine this.

It is not reasonable to assume that Ms Tzimas practices at an advanced level at all times, or for complete episodes of care based on any of the information provided.

There is no evidence within the CV provided of any clinical education or professional development outside of the cosmetic or aesthetic specialty since prior to 2009. There appears to be a somewhat broader context to practice prior to 2009, however no evidence has been provided to demonstrate this is still at a level applicable to current practice. I also note there is no undergraduate nursing degree to form a basis on which to build advanced practice skills for complex healthcare management.

I also note ... the recent statement by the NMBA in relation to cosmetic injecting and advanced practice, however my report has been entirely prepared based on pre-existing definitions of advanced practice and registration standards.

1. In cross-examination, Ms Boase accepted that cosmetic medicine was not one of her specialities and that she did not have any education, training or practical experience as a practitioner in relation to cosmetic medicine.[135]
2. Ms Boase was also asked about her response to Dr Callan's critique of her report. She observed:[136]

So his disagreement seems to be that I'm confusing generalist and specialist practice. However, the nurse practitioner role is not a specialist role. A nurse practitioner is a nurse practitioner. We do not endorse nurse practitioners in specialties ...

1. While Ms Boase accepted that advancing nursing practice can occur in a specialist context, she suggested 'it can't be confined to a speciality'. Similarly, while she accepted the reference in the Registration Standards to nurses who 'work within a generalist of specialist context' means it is possible to work solely within a specialist context, she qualified this by saying that it 'doesn't mean they only practise with a narrow focus on a speciality'. She suggested that a nurse practitioner needs 'to have generalist knowledge, diagnostic capacity', despite conceding that this was not mentioned in the Registration Standards.
2. Ms Boase did concede that not every task in clinical practice is performed at an advanced level and, even with a particular consultation, there may be both routine and advanced tasks.[137] In response to a question of whether the entirety of a consultation with a patient with complex needs is part of advanced practice, despite having some elements of basic practice, Ms Boase explained:[138]

As a nurse practitioner, I do go through clinical reasoning pathway where I develop from the very basic history taking, start to perform assessment, refine that history taking, form differential diagnoses, apply investigation results, determine the need for further investigations, refine those differential diagnoses, start to form a treatment plan, discuss it with the patient, consult more widely if need be, and then formulate a treatment plan. Then I evaluate the outcomes of that treatment plan, or I evaluate the patient's ability to understand it, and so as the consultation progresses, I would say it becomes progressively more advanced the further I proceed. However, that's not to say that that initial history taking and the early stages of that consultation don't directly inform my advanced practice. It all comes into part of it. Yeah.

1. However, when it was put to Ms Boase that this was 'exactly what Ms Tzimas has done in these case studies', she disagreed, observing:[139]

I haven't seen the diagnostic reasoning presented. I can only comment on what was presented to me in those cases. And the diagnostic reasoning, the judicious decision-making around ordering of diagnostics, the interpretation of results, the formulation of treatment plans. Prescribing decision-making processes are not outlined ...

1. While Ms Boase accepted that 'leadership' was referenced in the Registration Standards and could be 'an element' of advanced practice, she suggested that '[w]e can't verify advanced practice based solely on leadership.[140]
2. Similarly, Ms Boase accepted that 'it's not possible ... to practice at an advanced level without advanced knowledge' but suggested that such knowledge 'doesn't relate to practice unless you apply it'.[141]
3. Lastly, Ms Boase accepted that she had not met or worked with Ms Tzimas in a clinical context and had not assessed her in any exam setting.[142]

1. In her written submissions, Ms Tzimas seeks that the Tribunal exercise its power under section 51 of the Victorian Civil and Administrative Tribunal Act 1998 (Vic) ('VCAT Act') to set aside the Board's Decision and 'substitute it with a decision endorsing Ms Tzimas' registration as being qualified to practise as a nurse practitioner'.[143]
2. Ms Tzimas contends the Tribunal should do so for three reasons as follows:[144]

First, the Board itself concluded that Ms Tzimas had completed three years' full-time experience (5,000 hours) at the clinical advanced nursing practice level, upon the same evidence now relied upon to reject her application. Contrary to the Board's dispositive conclusion in the decision under review, the evidence amply establishes that Ms Tzimas' practice did include the management of patients with complex health care requirements. Indeed, the only differentiating factor between the Board's previous conclusion and the decision under review is the intervention of the Position Statement of January 2022.

Second, the Position Statement has no statutory force or effect. It is not an approved "registration standard", "code" or "guideline" within the meaning of Div 3, Pt 5 of the National Law (in respect of which the Board must first "ensure there is wide-ranging consultation about its content"). The Tribunal is entirely free to disregard the "Position Statement" and, in this case, there is every reason for the Tribunal to do so, given that:

25.1 The material before the Board establishes that Ms Tzimas' practice in the course of her employment satisfies the definition of "Advanced nursing practice" in the Registration Standard. She has incorporated professional leadership, education and research into her clinically based practice. She has proven that her practice is effective and safe. She works "within a generalist or specialist context and they are responsible and accountable in managing people who have complex health care requirements." Ms Tzimas is available and willing to give further, detailed evidence at hearing about her practice to assist the Tribunal in making its determination; and trusts that the applying the description of "Advanced nursing practice" to the facts is a matter well within the expertise and knowledge of the Tribunal (here, constituted by at least two members who are health practitioners with professional qualifications in the nursing profession) to determine.

25.2 Nothing in the report of the Board's expert, Ms Leanne Boase, addresses why nursing practice "in the area of cosmetic medical procedures" is arbitrarily to be excluded from the definition "Advanced nursing practice". Indeed, Ms Boase specifically prepared her report entirely upon "pre-existing definitions of advanced practice and registration standards"; that is, by disregarding the Position Statement. If the Board's own expert sees fit to disregard the Position Statement, there is no good reason for the Tribunal to give it any weight.

25.3 Ms Boase's opinion that Ms Tzimas' practice undertaken in the course of her employment did not meet the requirements of "advanced nursing practice" is based entirely on "insufficient evidence". Although, as noted at [25.2] above; the Tribunal is well equipped to determine the ultimate issue for itself; should the Tribunal be assisted by experts then it should accord far greater weight to Dr Chau Nguyen's report and evidence as a person whose opinion is formed on the basis of first-hand observation of Ms Tzimas in the conduct of her practice.

Third, and further and in any event, the further evidence filed by the applicant (Ms Tzimas' statements and the Nguyen and Callan reports) establishes that her practice satisfies the definition of "Advanced nursing practice" in the Registration Standard. It is true that the Nguyen and Callan reports are not reports by experts without any connection to Ms Tzimas. But the authors of those statements have a significant advantage over Ms Boase: each has known Ms Tzimas and her practice over many years. Dr Nguyen has worked closely alongside Ms Tzimas. Each is perfectly placed to provide an opinion on her level of practice

1. In closing, Mr Stoller (counsel for Ms Tzimas) submitted that Ms Tzimas had done everything that she had been asked to do by the Board and the Australian Health Practitioner Regulation Agency ('Ahpra') for endorsement as a nurse practitioner. In this regard, she had:
   • Applied to Deakin University to undertake the Nurse Practitioner Masters course, which required her to establish 5,000 hours of advanced nursing practice.
   • Proceeded to undertake the course and obtained the degree, satisfying the university that she was operating at that level.
   • Applied for endorsement as a nurse practitioner and had been initially successful. This is said to be 'relevant because an expert panel looked at the material and determined that Ms Tzimas did meet the Registration Standard'.
2. Mr Stoller contended that the Tribunal 'ought to reach the same conclusion' as the South Australian branch of the Board. This is because what the Registration Standards require, and what is established by the evidence, is that Ms Tzimas had the 'ability' from day one to operate at the advanced level. In this regard, when the Tribunal looks carefully at the transcript of Ms Tzima's evidence as to what she says she does and compares that to the evidence of Dr Nguyen, it will 'see a match'.
3. Mr Stoller submitted that, in making its decision, the Tribunal ought not take the Position Statement into account. This is because:
   • it was not in place when Ms Tzimas' application for endorsement was made; and
   • while the Tribunal is 'entitled' to take account of government policy, it does not have to where it would not be fair to do so, as in this case.
4. Further, even if the Tribunal takes the Position Statement into account, it does not preclude nurse practitioner endorsement for cosmetics. Rather, it just sets out that 'ordinarily' such endorsement will not be granted.
5. As to the evidence of Ms Tzimas engaging in advanced nursing practice, Mr Stoller observed that three registered health practitioners (other than Ms Tzimas) had given evidence directly (i.e. Dr Nguyen, Dr Callan and Ms Boase) and the Tribunal Book also included Dr Weiss' assessments of Ms Tzimas' proficiency. He submitted that Dr Weiss and Dr Nguyen were 'best placed' to assess the standard at which Ms Tzimas practises given they 'actually observed her undertaking clinical practice for years'. He observed that Ms Boase had accepted that 'direct observation day to day is best'.
6. Further, because Dr Weiss and Dr Nguyen work in the same area of specialisation, this 'enables them to understand the complexity of the work that Ms Tzimas undertakes'. By contrast, Ms Boase's opinion is 'based on written documents'. Mr Stoller observed the Board had put to Dr Callan that he could not give an opinion as to Ms Tzimas' practice without directly observing it. He submitted that the same applied to Ms Boase.
7. Mr Stoller contended that Ms Boase's evidence was 'of limited use'. Although she has the skill and expertise to assess proficiency, her report was of 'limited scope' because it was confined to assessment of Ms Tzimas' CV and case studies 1, 2 and those referred to in the Mapping Document[145] which 'focuses on a narrow subset' of the information relied upon by Ms Tzimas in support of her application.
8. Further, while the Tribunal could accept Ms Boase's opinion, it would 'find a wealth of other evidence' (i.e. Ms Tzimas' own evidence and that of Dr Nguyen and Dr Callan).
9. On a 'related point', while the Board had asked Ms Boase about Ms Tzimas' evidence, they had not asked her about Ms Tzimas' evidence that 'as well as seeing people for cosmetics, many people see her when procedures by others have gone wrong'. By contrast, Ms Tzimas had been cross-examined on this evidence and indicated that such people had attended her clinic by way of referral and word of mouth. Mr Stoller submitted that this evidence was 'absolutely plausible' given her position in the industry and her role in training people in the industry.
10. Mr Stoller also pointed to the Clinical Competency Assessment Tool and Dr Weiss' assessment of the level of Ms Tzimas' proficiency as being 'independent', observing that under the university rubric, to achieve that proficiency, a student has to be providing care with 'no cues' from the supervising doctor. He submitted that this is also what Ms Tzimas needs in order to establish advanced practice, noting Ms Boase' opinion as to the 'capability to practice autonomously'.
11. Mr Stoller submitted that Dr Weiss' assessment was 'similar' to Dr Nguyen's evidence as to how Ms Tzimas presents her patient's cases and highlighted Dr Nguyen's observation that Ms Tzimas' presentations were 'like a registrar'.
12. Mr Stoller contended that the Board's attack on Dr Nguyen's independence 'goes nowhere'. While he accepted that she is 'not completely independent', she has the 'advantage' of seeing Ms Tzimas in practice. Further, the only financial interest of Dr Nguyen is in Ms Tzimas 'losing [the proceeding] because if she succeeds, then she can prescribe herself, which is the way Dr Nguyen makes money'.
13. As to Ms Tzimas' own evidence, Mr Stoller submitted that she shows passion, expertise and that she practises at a 'high level' and deals with patients with complex issues, including mental health concerns. While there was a lot of focus on her case studies in cross-examination, he observed that the application for endorsement does not require the provision of case studies and the criticisms of those case studies 'may or may not be fair' in circumstances where they were prepared as notes for discussion with her clinical supervisor.
14. Mr Stoller noted that Ms Tzimas' CV shows she has a 'broad history' in nursing, starting out in mental health, moving to a hospital setting at the Cabrini hospital, then aged care and now cosmetic procedures. That history 'informs' her development of the CANSAT tool and her response to complex cases. Further, the Registration Standard itself contemplates that nurse practitioners can be 'generalists or specialists'.
15. In terms of leadership, education and research, Mr Stoller observed that Ms Tzimas:
    • Leads a team of 7 to 8 nurses.
    • Contributes to education of the profession through the CPD Institute.
    • Participates in research and the publication of articles that 'advocate for issues that the Board raises in its new guidance'.
16. In summary, Mr Stoller submitted that the evidence establishes that Ms Tzimas engages in responsible and accountable practice and does so in a manner that is 'safe' and has demonstrated her ability to practice autonomously.

1. In its written submissions, the Board observes that:[146]

Endorsing a registered nurse as a nurse practitioner is a significant step. It signals to patients, the public and other health practitioners that the nurse is capable of operating at the highest level of the nursing profession. It also confers broad powers to prescribe medications, which are not conferred on other nurses.

1. In making its decision to refuse endorsement, the Board observed that:[147]

While the applicant's submission and application states advanced practice in excess of 5,000 hours have been achieved between 2016-2021, the described clinical practice demonstrates that these hours have been achieved by providing direct client care for aesthetic procedures such as facial treatments, dermal fillers and cosmetic enhancements. The applicant has been unable to demonstrate that these hours included the management of patients who have complex health care requirements.

1. Although the Board accepts that Ms Tzimas holds an 'approved qualification', namely the Nurse Practitioner Masters,[148] the Board submits that the Tribunal should affirm its decision because:[149]

(a) Ms Tzimas has not demonstrated that she has completed 5,000 hours of practice at the clinical advanced nursing practice level within the relevant period (22 September 2015 to 22 September 2021) [i.e. in accordance with the second requirement of the Registration Standard]; and

(a) nor has she demonstrated compliance with the Board's Nurse Practitioner Standards for Practice [('Practice Standard')][150] or that she is competent to practise as a nurse practitioner [i.e. in accordance with the fourth requirement of the Registration Standard].

1. The Board's submissions highlight that the Practice Standard 'establish[es] a framework for practising as a nurse at the highest level',[151] including that a nurse practitioner:

46.1 "demonstrates extensive knowledge of human sciences and health assessment";

46.2 "assesses the complex and/or unstable healthcare needs of the person receiving care through synthesis and prioritisation of historical and available data";

46.3 "assesses the impact of comorbidities, including the effects of co-existing, multiple pathologies and prior treatments in the assessment of the person receiving care";

46.4 "demonstrates comprehensive skill in clinical examination including physical, mental health, social, ethnic and cultural dimensions";

46.5 "requests and/or performs selected screening and diagnostic investigations";

46.6 "is responsible and accountable for the interpretation of results and for following-up the appropriate course of action";

46.7 "synthesises knowledge of developmental and life stages, epidemiology, pathophysiology, behavioural sciences, psychopathology, environmental risks, demographics and societal processes when making a diagnosis";

46.8 "acts to prevent and/or diagnose urgent, emergent and life-threatening situations";

46.9 "determines clinical significance in the formulation of an accurate diagnosis from an informed set of differential diagnoses through the integration of the person's history and best available evidence";

46.10 "safely prescribes therapeutic interventions based on accurate knowledge of the characteristics and concurrent therapies of the person receiving care"; and

46.11 "demonstrates clinical leadership in the design and evaluation of services for individuals and communities in health promotion, health protection or the prevention of injury and/or illness".

1. While the Board accepts that the Position Statement is 'not an "approved registration standard", nor is it part of the [Practice Standard]', it submits that the statement 'is within the scope of the Board's statutory functions to provide guidance ... including the Board's view of what is likely, or unlikely, to constitute "advanced nursing practice" in particular contexts'.[152] The Board submits that the Tribunal should give its views 'considerable weight because of the Board's specialist expertise and unique experience as the administrator of the legislative scheme in relation to nurses'.[153] The Board highlights that the Position Statement does not say that a nurse practising in cosmetic medical procedures 'can never demonstrate "advanced nursing practice" and compliance with the ... Practice Standards - only that it is unlikely'.[154]
2. In submitting that the evidence relied on by Ms Tzimas 'does not demonstrate that she performed 5,000 hours of "advanced nursing practice" in the six years prior to 22 September 2021', the Board relies on Ms Boase's opinion.[155] The Board submits that as a nurse practitioner (since 2009) and a teacher of advanced clinical practice subjects at La Trobe University (since 2015), 'Ms Boase is well placed to assist the Tribunal with assessing Ms Tzimas' application for endorsement'.[156]
3. The Board highlights Ms Boase's analysis of the case studies put forward by Ms Tzimas and her view that these 'fall well short of demonstrating "advance[d] nursing practice".'[157] Ms Boase's conclusion that Ms Tzimas has not met the requirements for advanced nursing practice is suggested to be 'balanced, but firm'.[158] The Board submits the Tribunal should accept her conclusions that:[159]

It is possible that Ms Tzimas does practice at the advanced nursing practice level at times during her practice, however there is insufficient evidence within the cases provided as examples to determine this.

It is not reasonable to assume that Ms Tzimas practices at an advanced level at all times, or for complete episodes of care based on any of the information provided.

There is no evidence within the CV provided of any clinical education or professional development outside of the cosmetic or aesthetic specialty since prior to 2009. There appears to be a somewhat broader context to practice prior to 2009, however no evidence has been provided to demonstrate this is still at a level applicable to current practice. I also note there is no undergraduate nursing degree to form a basis on which to build advanced practice skills for complex healthcare management.

1. The Board submits that Dr Nguyen's report 'does not provide significant support for [Ms Tzimas'] application' because:[160]

58.1 In the first place, Dr Nguyen's report is not an independent expert opinion but a letter of support from a colleague and a service provider for Ms Tzimas' businesses. This does not mean the Tribunal cannot have regard to what Dr Nguyen says, but it means her report should be given less weight than an independent expert opinion.

58.2 Further, Dr Nguyen's expertise is as a specialist radiologist. She lacks the specific expertise in relation to the assessment of nurse practitioner candidates that Ms Boase has developed over years of experience as a nurse practitioner and educator.

58.3 In any event, Dr Nguyen's report does not provide persuasive evidence that Ms Tzimas has completed the required period of "advanced nursing practice".

1. The Board contends that Ms Tzimas' application 'should be judged by reference to the case studies she has provided' (as opposed to the additional case studies raised by Dr Nguyen).[161] Further, it submits that the three further case studies identified in Dr Nguyen's report:[162]

lack detail as to how Ms Tzimas is said to have demonstrated "advanced nursing practice". For the most part, the case studies are simply descriptions of patient presentations with statements such as "Nekitaria (sic) discussed the case with myself and an ultrasound was arranged". They do not demonstrate how it is said that Ms Tzimas engaged in advanced nursing practice on each occasion.

On the material that is before the Tribunal, Ms Tzimas has not demonstrated that she has completed 5,000 hours of "advanced nursing practice". She has not demonstrated the requisite level of responsibility and accountability for "managing people who have complex health care requirements". Her practice has been in a limited field and, while it may sometimes involve elements of advanced practice, Ms Tzimas has not demonstrated that she practises consistently at that level or that she has completed the equivalent of three years of practice at that level in the relevant period. As Ms Boase observes, in evaluating Ms Tzimas' application, it is relevant to note that she does not have a foundational Bachelor of Nursing qualification. This reinforces the conclusion that, although Ms Tzimas may be experienced in the field of cosmetic injectables, she has not demonstrated that she consistently engages in "advanced nursing practice".

1. In closing submissions, Mr Ayres (counsel for the Board) submitted that, while Ms Tzimas is a 'capable and experienced registered nurse in her area of practice', the evidence is 'too narrow' and does not demonstrate her practice at an advanced level for 5,000 hours 'prior to 2021 or since'.
2. Mr Ayres submitted that Ms Tzimas' evidence was often 'unreliable and unclear' as to where and when she had engaged in clinical practice (e.g. in relation to her claim of a return to some part time work in aged care). However, he suggested it was 'clear that she spends a lot of time on the business side of her clinics and with the CPD Institute'.
3. Mr Ayres suggested that, given Ms Tzimas' concession that any of her nurses can undertake the patient screening processes, this means that this activity is 'not advanced practice'. While he accepted that Ms Tzimas may conduct her screenings with a 'different level of engagement' to the nurses that work in her business, there was 'nothing in the evidence that demonstrates Ms Tzimas has skills in this area that elevates her screening to an advanced level'.
4. Mr Ayres observed that Ms Tzimas has 'many accomplishments outside clinical practice' (i.e. in terms of her research and development of tools), but submitted that they were not clinical practice. He suggested that a problem with Dr Nguyen's evidence is that she thought that these activities did count. He submitted it was 'worse with Dr Callan' whose evidence was 'of little use because he had no relevant experience with nurse practitioners and has only seen Ms Tzimas in a training context'.
5. As to the criticism of the narrow material covered by Ms Boase in her opinion, Mr Ayres submitted that the case studies considered by her were 'at the core of the application'. He submitted that she provided a 'careful and balanced' report.
6. Despite accepting that the Tribunal is able to take account of Dr Weiss' assessments of Ms Tzimas, Mr Ayres observed that the Clinical Competency Assessment Tool was not a detailed report and 'does not show the substance of his opinion'. Further, as Dr Weiss was not called, his assessments amount to 'untested material prepared for a different purpose'. Since there is other evidence that is better, such as the case studies, this 'radically reduces the value of the material from him'.
7. In terms of the case studies put forward by Ms Tzimas, Mr Ayres submitted:
   • They do not include enough information to conclude that she was engaging in advanced practice. For example, a capable registered nurse can administer an Epi Pen (a point that Dr Callan agreed with). Conversely, that Ms Tzimas is a 'capable registered nurse' does not mean that she practises at an advanced level.
   • They do not demonstrate that she dealt with patients with complex healthcare needs or that she was managing their conditions. For example, referring a patient with mental health issues to a psychologist did not demonstrate advanced practice.
   • While Case Study 1 was the 'most detailed', it was 'straight forward' and the context was a consultation in Dr Weiss' general practice that represents 'a different context to a cosmetic clinic'.
8. While Mr Ayres accepted that Ms Tzimas evidence as to seeing patients that have problems that have arisen from treatments provided by others may be true, he contended that this does not mean it is advanced practice. In this regard, Mr Ayres pointed out that the Registration Standard requires a nurse practitioner candidate to work with patients with complex healthcare needs, but, in most cases, Ms Tzimas' engagement with such patients was 'straight forward' and she was not managing those patients. Rather, she simply referred them to a general practitioner or specialists. Contrary to the submissions on behalf of Ms Tzimas, Mr Ayres submits the Registration Standard and Practice Standard do require evidence of practising at an advanced level and not just the ability to do so.
9. As to the further case studies put forward by Dr Nguyen, Mr Ayres noted that they were only Dr Nguyen's accounts and were not addressed by Ms Tzimas in her evidence. He submitted the accounts were not reliable as they did not establish what Ms Tzimas did or her clinical reasoning. Further, because Dr Nguyen had worked with or for Ms Tzimas for a long time and got paid for it, she was not an independent expert.
10. With respect to Ms Tzimas' calculation of engaging in 8,893 hours of clinical practice between 2016 and 2021, Mr Ayres submitted:
    • The time spent at the Regenerer and Island Glow clinics would include management of the businesses and management of staff, such that the Tribunal could not be satisfied that it was all clinical practice. Nor could the Tribunal be satisfied that it was all practice at an advanced level, even if sometimes there were elements of advanced practice.
    • The work with the CPD Institute was not relevant and should be 'crossed out'.
11. Mr Ayres referred to evidence in the Tribunal Book that Ms Tzimas was found to have engaged in unsatisfactory professional practice in relation to the administration of a dermal filler as part of a live workshop facilitated by the CPD Institute in March 2020. As a consequence, conditions had been imposed on her registration requiring her to undertake education and attend mentoring. He submitted this 'seriously undermines' her claim to have been engaging in 5,000 hours of advanced practice by September 2021.
12. Further, Mr Ayres contended that 'some significance' should be placed on the evidence (again in the Tribunal Book) of Ms Tzimas' difficulties with passing the subject on diagnostic testing when she was undertaking her Nurse Practitioner Masters. He submitted that her evidence about this was 'defensive' and that there was no evidence to substantiate her claims of discrimination against cosmetic nurses.
13. Mr Ayres submitted that, 'ultimately, while Ms Tzimas is an experienced registered nurse, her practice is 'too narrow' to establish advanced practice as she is not involved regularly in managing patients with complex health needs.

1. As indicated at the outset of the decision (see [8]), the Tribunal's role in reviewing the Board's Decision is to consider the evidence before the Tribunal with a view to making the correct or preferable decision.
2. In determining whether the evidence establishes a particular fact, it is the civil standard of proof that applies, namely the balance of probabilities.
3. In considering the practical application of that standard, it is important to recognise that as 'a tribunal of fact', VCAT is free 'to accept the evidence of the [applicant] alone if it finds the [applicant] to be truthful' and, indeed, it is only necessary for Ms Tzimas to tip the scale 'ever so slightly' in her favour to succeed on the balance of probabilities. [164]

1. The Registration Standard identifies advanced practice as involving:
   • Recognisably higher levels of capability in terms of professional knowledge, clinical reasoning and judgment, skills and behaviour. Implicitly, this requires a comparison of the capability of the nurse practitioner candidate to that of an ordinary registered nurse.
   • The incorporation of professional leadership, education and research into the nurse's clinically-based practice.
   • Practice that is effective and safe.
   • The nurse is responsible and accountable in managing people who have complex health requirements.
2. We address each of these requirements below.

1. We are satisfied and find that Ms Tzimas' 'professional knowledge, clinical reasoning and judgement, skills and behaviours' have developed to a higher level of capability that is recognisable.
2. We have formed this conclusion based on a combination of:
   • her own evidence as to these matters with respect to the patients the subject of the Case Studies (see [34]), noting that (apart perhaps from Case Study 1), the case studies themselves only represented dot points for discussion with her supervisors, as opposed to a full explanation of every aspect of the relevant consultations;
   • the contemporaneous and corroborative assessments of Dr Weiss from August 2016 and June 2017 recognising that at the time of the consultations the subject of Case Studies 2 and 3 (January 2016 and July 2017), Ms Tzimas was already practising 'independently' or, in other words, without cues from him (see [35]), which is also corroborated by Dr Nguyen's evidence that Ms Tzimas had been practising in that manner 'from the get go' (see [51]) and so certainly was doing so by July 2018 in the context of Case Study 4; and
   • the further Case Studies raised in Ms Nguyen's report and her evidence that Ms Tzimas presented on, and actively managed, patients in the same way that she would expect of a registrar (see [42]-[43]), coupled with her evidence that Ms Tzimas had essentially been practising in that manner from the start of their relationship.
3. In the latter regard, while Dr Nguyen's evidence is not the evidence of an independent expert, we have given it significant weight because she is the only witness before the Tribunal who has actually observed Ms Tzimas engaging in her clinical practice. While Dr Nguyen may not be involved in the assessment of nurse practitioner candidates, she is well placed to provide observations as to the level of Ms Tzimas' capacity as compared to other registered nurses (and doctors) she has worked with. Contrary to the submissions of the Board, her largely unchallenged evidence in that regard is highly persuasive. While there is some uncertainty as to when the additional case studies identified in Dr Nguyen's report took place, even if this was after September 2021, it remains relevant to an assessment of Ms Tzimas' capability prior to that time because of Dr Nguyen's evidence that Ms Tzimas was practising in the same manner from the start of their professional relationship, which was in July 2016.[165]
4. We acknowledge that Ms Boase is a nurse practitioner herself, a lecturer in advanced clinical practice and is independent of the Board. Nevertheless, her report, and the weight to be accorded to her views, is impacted by the following matters:
   • She was only asked to comment on Case Studies 1 to 4, representing only a third of the case studies in evidence before the Tribunal.
   • She does not know Ms Tzimas and has never observed her in clinical practice or under any form of assessment and was not privy to the evidence given by Ms Tzimas or Dr Nguyen before the Tribunal.
   • She admits to having no experience with non-surgical cosmetic procedures and, as such, is not in a position to express informed views as to the particular issues and complications that arise in that respect.
   • Despite her report suggesting that it was undertaken without regard to the Position Statement (see [62]), she asserted in evidence that '[w]e do not endorse nurse practitioners in specialities' (see [64]) which rather suggests that she has a view that is impacted by that statement. Indeed, her responses to the cross-examination about the Registration Standard's references to advanced nursing practice in a specialist context (see [65]) seem to suggest that all nurse practitioners must have generalist capability, which (for the reasons discussed below in the context of the Position Statement) strays beyond the requirements of the Registration Standard itself.
   • There is a contradiction between her report and her evidence that suggests some misconception as to the test to be applied. In this regard, in her report, Ms Boase suggested that it was 'not reasonable to assume that Ms Tzimas practices at an advanced level at all times, or for complete episodes of care' (see [62]). However, in cross-examination, she conceded (consistent with the opinion of Dr Callan) that not every task in clinical practice is at an advanced level and that even within a particular consultation, there may be both routine and advanced tasks (see [66]).
5. We accept that the Position Statement is intended to provide guidance to the nursing profession and reflects the Board's specialist expertise and experience. However, unlike the Registration Standard, it is not subject to approval of the Ministerial Council (see [7] and [12]-[13]). To the extent it reflects a policy of the Board as administrator of the legislative scheme, it needs to be consistent with that scheme. As indicated at [5], section 95 establishes two pre-requisites for a nurse to qualify to practice as a nurse practitioner, being an approved qualification and compliance with the Registration Standard. The definition of advanced nursing practice in the Registration Standard recognises that a nurse can practice at an advanced level 'within a generalist or specialist context'. In our view, in recognising that a nurse can practice in a specialist context, it presupposes that the level of their capability is assessed as against other nurses practising in the same context. While it is appropriate for the Board to provide guidance to the nursing profession that the routine practice of cosmetic medical procedures is 'unlikely' to meet the requirements of advanced nursing practice, we consider it goes too far in stating that practice in that area 'is not working at the advanced practice level' (emphasis added). This emphatic statement reflects an inflexible policy position that is inconsistent with the legislative scheme because the scheme sets a standard for endorsement (through the Registration Standard) which recognises that nurses may practice in a specialist context. Whether a nurse's practice within that specialist context is advanced or not will necessarily require consideration of all the facts and circumstances. Although the Tribunal is engaging in merits review, rather than judicial review, the Tribunal could fall into error if it was to inflexibly follow the line set out in the Position Statement.

Incorporation of leadership, education and research into clinical practice

1. We are satisfied and find that Ms Tzimas incorporates professional leadership, education and research into her clinically based practice.
2. The Tribunal Book includes details of various research papers that Ms Tzimas has participated in,[166] and she has provided cogent evidence as to how that research has informed her clinical approach, particularly with respect to assessment of the psychological state of her patients and the development of the CANSAT tool which she applies in practice.
3. We also consider that Ms Tzimas has demonstrated 'thought' leadership in terms of the role she takes at the CPD Institute and sharing her experience, knowledge and tools with other practitioners in the non-surgical cosmetic field. That leadership is recognised in that other practitioners refer patients to her in the event of complications and, in that way, can be seen to be incorporated into her practice. Further, it is apparent that she employs her experience, knowledge and tools in training the nurses that work in her practice. This aspect of Ms Tzimas' practice is consistent with the recognition in the Practice Standard (at 46.11) that a nurse practitioner should demonstrate clinical leadership in the design and evaluation of services for individuals and communities in health promotion, health protection or the prevention of injury and/or illness (see [92]).
4. An impressive aspect of Ms Tzimas' evidence before the Tribunal was her positive attitude to education and continuous development. For instance, in cross-examination, not only did she accept that it was appropriate for the Board to impose education and mentoring conditions on her as a result of the finding of unsatisfactory professional performance (see [109]); she also volunteered that she 'learnt a lot from t[167]'.167
5. Similarly, in terms of her difficulties with respect to passing the diagnostic testing subject as part of her Nurse Practitioner Masters (see [110]), it is evidence that she persevered and as she said, in response to Mr Ayres' suggestion that she got 'bare passing grades' for that (and some other[168]bjects):168

I passed and I'm really proud of that, given the workload that I had and everything that I had to do. I passed.

1. Further, Ms Tzimas evidence as to the impact of her studies on her clinical practice gives life to the 'continuum' that is referred to in the Registration Standards:[169]

During our clinical supervision, that's - that's what we did. That was part of the requirements throughout university as well. It's - it's that discussing. It's that brainstorming. It's that critical thinking to ... skill me up and give me the knowledge and the confidence to be able to do that whole process on my own, which is where - you know, first year, I wasn't that great; the second year, I felt better ... and then by the third year and what - and what I do now in practice is that I'll call the prescribers and I'll say, 'This is what the presentation is. This is what's happening. These are the differentials. This is what I think we need to do. I'll do ... a telehealth ... with the doctor, and then offline I'll go, 'Yeah, I agree with you. I think that's what we should do', and they move forward (indistinct). So that - that's - but I can't - I can't execute - I can't do anything.

prior to me commencing my university degree, I was pretty strong and confident with ... what I needed to do or what I felt I needed to do, but I ... needed the education and I needed the support and ... it goes without saying - I'm not - not saying that I was good to go prior to my university degree. It's an ongoing [process].

1. Ms Tzima's evidence of incorporating education into her clinical practice is supported by the case studies themselves (particularly Case Study 1 that incorporates references to papers) and the evidence of Dr Nguyen (particularly in terms of the delayed onset nodule the subject of Case Study 11).

1. We are satisfied and find that Ms Tzimas practice is effective and safe.
2. That Ms Tzimas' practice is effective and safe is evident from the outcomes of a number of case studies, such as Case Study 5 where the treatment provided was monitored over a period of 4 weeks, with no further intervention being required in light of Patient E's significant improvement.
3. It is also corroborated by Dr Nguyen's evidence that, as a result of Ms Tzimas' collaborative approach with her and with other treaters, Ms Tzimas' practice is 'extremely safe' (see [45]).
4. It was not put to Ms Tzimas, and there is no evidence to suggest, that she would stop taking that collaborative approach if she obtained endorsement as a nurse practitioner and could commence prescribing Schedule 4 drugs herself.

Responsibility, accountability and managing people with complex health requirements

1. We accept Ms Tzimas' evidence as to the sort of patients who present in her clinics and the nature of their conditions (e.g. she is seeing an increasing number of patients with autoimmune diseases). This evidences her satisfaction of the requirement that she deals with people 'who have complex health care requirements'. Her evidence in this regard was credible[171] and is corroborated by the documented Case Studies and the evidence of Dr Ngueyn. For example:
   • Dr Nguyen gave evidence that Patient J (the subject of Case Study 10) had 'an extremely complex healthcare need' and
   • The fact that it was necessary to research journal articles regarding the presenting condition of Patient K (the subject of Case Study 11) confirms the complexity of her health requirements.
2. That Ms Tzimas is responsible and accountable for such patients is corroborated by Dr Nguyen's evidence that Ms Tzimas was the one that was 'actively managing patients' and had a clinical way of thinking about things recognising that she 'will be held accountable for this patient's [health]' (see [43]).
3. For these reasons, we are satisfied and find that Ms Tzimas has demonstrated that she is responsible and accountable in managing people who have complex health requirements.

1. The last matter to address is whether Ms Tzimas has established that she has 5,000 hours of experience at the clinical advanced nursing practice level, as required by the Registration Standard.
2. It is important to appreciate, as indicated by Dr Callan in his report (see [55]) and conceded by Ms Boase (see [66]), that the Registration Standard does not require a nurse to be demonstrating advanced practice for every hour of their clinical practice. That is an impossible task. Indeed, the evidence suggests that it is not even possible within a consultation or an episode of care. Rather, we accept Dr Callan's interpretation of this requirement, namely that there must be demonstration of seamless integration of routine and advanced practice.
3. For the reasons already discussed above, we consider that Ms Tzimas has demonstrated that seamless integration in her clinical practice and, as such, we accept that each hour she devotes to clinical practice, as opposed to education through the CPD Institute or management of her businesses, counts towards the practice hour requirement.
4. We do not accept Mr Ayres' submission (at [100] and [108]) that it is clear that Ms Tzimas spends a lot of time addressing the business side of her clinics and in relation to the activities of the CPD Institute. To the contrary, the evidence Ms Tzimas has given is that she had other staff to manage the business side of things (see [27]). That evidence is supported by the snapshot of her clinical appointments for the week commencing 9 November 2020 which demonstrates back-to-back clinical appointments throughout the lengthy clinical days (see [28]). She was not challenged in cross-examination on either the accuracy of that evidence or whether it was in fact representative of her clinical activity through the period in question (i.e. 2016 to 2021).
5. Ms Tzimas admits to facilitating 3 hours of training at the CPD Institute a month and spending 2 hours a week on the administration of that business (see [27]). However, the training activities are not included in the 8,893 hours claimed as clinical practice and, given her evidence that the administration 'usually occurs sporadically through the day or at the beginning and end of the day', it does not detract from the overwhelming majority of her clinic days (Tuesday to Friday) being devoted to clinical practice.
6. We also do not accept Mr Ayres' submission (see [109]) that the Tribunal cannot be satisfied that Ms Tzimas was practising at the advanced level between:
   • March 2020, when she engaged in the conduct the subject of the finding of unsatisfactory professional performance; and
   • October 2021, when the mentoring condition was lifted.
7. As already noted, Ms Tzimas' evidence is that she learnt a lot from the education and mentoring (see [125]). That is reflective of the continuum of development emphasised in the Registration Standard itself.
8. Further, a nurse practitioner candidate will necessarily have a mentoring relationship with a doctor and/or nurse practitioner in developing their own professional knowledge, clinical reasoning, judgement, skills and behaviours (see Dr Nguyen's description of this relationship at [51]). Among other things, this is because a nurse practitioner candidate is not a nurse practitioner and so cannot, for instance, prescribe Schedule 4 drugs themselves and have to be in a position to explain to the doctor or nurse practitioner why they believe such a drug should be prescribed. As such, we do not see the imposition of a mentoring condition as being inconsistent with the requirements for establishing advanced nursing practice.
9. For these reasons, we are satisfied and find that Ms Tzimas has the 5,000 hours of experience at the clinical advanced nursing practice level required by the Registration Standard.

1. Neither Ms Tzimas nor the Board focused considerable attention on this requirement in their closing submissions.
2. In the Board's written submissions, it is suggested that Ms Tzimas has not demonstrated compliance with the Practice Standard or that she is competent to practice as a nurse practitioner.
3. For essentially the same reasons that we accept that Ms Tzimas complies with the second requirement of the Registration Standard, we are satisfied and find that she complies with the Practice Standard.
4. In this regard, Ms Tzimas' evidence is that, if anything, the complexity of the conditions of the patients she deals with, and therefore the diagnosis and treatment of those conditions, has grown more complex and advanced over time (see third bullet point at [36]). That evidence is corroborated by Dr Nguyen in discussing the complexity of the patients the subject of Case Studies 10 to 12, which are likely to be more recent (see [44]).
5. As Ms Boase has not observed Ms Tzimas in practice and did not address Case Studies 10 to 12, she is not in a position to address Ms Tzimas' compliance with the Practice Standard.

1. For the above reasons, we are satisfied that Ms Tzimas has demonstrated each of the four things (see [7]) required to be demonstrated under the Registration Standard. In particular, we are satisfied that she has met the two requirements on which the parties diverge, namely that she has demonstrated:
   • the equivalent of three years' full-time experience (5,000 hours) at the clinical advanced nursing practice level within the six years preceding her application; and
   • compliance with the Practice Standard.
2. To the extent that we have a further discretion under section 95 of the National Law as to whether (or not) to endorse a nurse who otherwise meets the requirements of the Registration Standards (as suggested by Mr Ayres in opening submissions), we consider the preferable decision is to exercise that discretion favourably to Ms Tzimas.
3. Accordingly, we have ordered that the Board's Decision be set aside and substituted with a decision that she be endorsed as a nurse practitioner.

[1] The delay in having the application for review come on for hearing is largely attributable to the time taken for the parties to gather and exchange the material on which they sought to rely, particularly expert and/or lay witness evidence.

[2] Decisions and Actions of the South Australian Board of the Nursing and Midwifery Board of Australia of 7 January 2022: Tribunal Book ('TB'), 252-256.

[3] Decisions and Actions of the South Australian Board of the Nursing and Midwifery Board of Australia of 6 May 2022: TB, 281-285.

[8] Ibid, ss 52-56 (general registration) and ss 57-61 (specialist registration).

[11] There was one decision on endorsement, being Pereira v Psychology Board of Australia [2016] VCAT 1882. However, that dealt with a transitional pathway to endorsement as a clinical psychologist and, as such, involved a different scenario.

[12] See, for example, George v Dental Board of Australia [2022] QCAT 5 [1].

[13] That is, the evidence in the Tribunal Book ('TB') and of the witnesses who gave evidence before the Tribunal, which is more extensive than the material before the Board when it made the decision.

[16] Applicant's Outline of Submissions dated 2 May 2025 ('AOS') [23].

[18] Agenda Paper dated 7 January 2022: TB, 133-138.

[19] Expert Report of Dr Chau Nguyen dated 8 August 2023: TB, 379-389 ('Nguyen Report').

[20] Peter Callan Report dated 24 November 2024: TB, 449-453 ('Callan Report').

[22] The Position Statement is made by the Board in exercise of its functions under section 35 of the National Law, which include the development and approval of standards, codes and guidelines for a health profession.

[23] Respondent's Outline of Submissions dated 6 October 2023 ('ROS') [49].

[24] Expert Report of Leanne Boase dated 24 December 2022 ('Boase Report'): TB, 414-423.

[26] Statutory Declaration of Ms Tzimas dated 30 May 2022: TB, 293-294. Essentially, the figure is the sum of 35 to 38 hours per week multiplied by the number of weeks worked, with some adjustment for the COVID-19 lockdown periods.

[27] See, for example, Freckleton v Victorian Building Authority [2020] VCAT 69 where it was accepted that a condition could be imposed on the registration of a commercial builder limiting the builder to undertaking the construction, transportation and installation of transportable commercial buildings (being the more limited area in which he practised).

[28] One of the main benefits of endorsement as a nurse practitioner in Victoria is the ability of a nurse to prescribe schedule 4 and 8 medications, which must normally be prescribed by a doctor: see Drugs, Poisons and Controlled Substances Act Regulations 2017 ('DPCS Regs'), ss 16(1), 16(2) and 20. Such a condition seems to be contemplated in section 14(3) of the Drugs, Poisons and Controlled Substances Act 1981, which provides that, if conditions are 'imposed in relation to the practice of a nurse practitioner', such as 'a condition, limitation or restriction prohibiting the prescription of any drug or substance or any class of drugs or substances', then the registered nurse is 'deemed to be not authorized to obtain and have in his or her possession' the specified drug(s).

[32] T86.2-13 (this is a reference to page(s) and line(s) from the transcript of the hearing).

[50] Completed Clinical Competency Assessment Tool dated 18 August 2016, 12 June 2017, 4 April 2018, 25 August 2018 and 16 August 2019: TB, 204-224 and 238-250.

[114] T126.13-19 (referencing Letter of Support dated 13 September 2021: TB, 18).

[124] TB, 450 (line 67) to 451 (line 76).

[133] TB, 422 (response to question 4.6).

[134] TB, 422 (response to question 4.7).

[145] Letter from Minter Ellison to Ms Boase dated 30 November 2022 (TB, 407-413) [4.2]-[4.6].

[146] Respondent's Outline of Submissions dated 6 October 2023 ('ROS') [4] (footnotes omitted).

[147] ROS [10] (referencing Board's Decision [4]).

[150] Nurse practitioner standards for practice effective from 1 March 2021: TB, 308-317.

[152] ROS [49] (referencing National Law, s 35(1)(a)-(c) and (q)).

[159] Ibid [56]-[57] (citing Boase Opinion in response to question 4.7).

[164] Commissioner of Taxation v Cassaniti [2018] FCAFC 212 [88] (Steward J, citing Allied Pastoral Holdings Pty Ltd v Commissioner of Taxation [1983] 1 NSWLR 1). It is noted that those observations were made in the context of an appeal of a federal tax assessment, being a situation where the applicant bears an onus of proof (which is not the case here).

[165] Nugyen Report, response to Question 4: TB, 380.

[166] TB, 80-130. The topics of these papers include issues associated with body dysmorphic disorder and assessment of patients' unrealistic expectations.

[171] For example, she appropriately conceded that any nurse practicing in her area could ask questions of patients to ascertain if there were any complications (see third dot point at [38]).