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T his article aims to explore how nursing practice has evolved within a secondary care dermatology outpatient setting in recent years to meet a staffing crisis faced by many dermatology departments, which resulted in some having to close. The article’s focus is on skin cancer and dermatological surgery and will describe the pivotal role nurses play in not only ensuring care needs are met, but in reshaping the service into a superior care model. The author describes the demands that forced a change in care delivery, the influence this has had on nursing practice, and how service delivery has improved.

The problem The NHS is facing an uncertain future, crippled by increasing financial constraints and population demands (The King’s Fund, 2015). An ageing population is of particular concern for dermatology services and skin cancer care because the incidence in this patient group is high and often difficult to treat. It is estimated that 54% of the population is affected by skin disease and over half of all referred activity to dermatology services relates to skin cancer management (Eedy, 2015).

It is well known that early diagnosis in cancer is the key to cure, and all skin cancers, both melanoma and non-melanoma, can be cured if detected early. However, the only detection method available is direct skin examination performed by a trained professional (Harris et al, 2001). Examination by a consultant dermatologist is considered to be the gold standard, but, quite simply, there are severe workforce issues in dermatology services and a national shortfall of consultant dermatologists (Eedy, 2015). Dermatology services have been forced to close their doors, leading to other services becoming overwhelmed with the tsunami of skin cancer that is sweeping its way across the UK. In essence, dermatology services

have been struggling to meet population demand and therefore new ways of working needed to be found.

An extended scope of clinical practice for nurses Nurses working in skin cancer services have welcomed the opportunity to develop their skills. Nurse-led care in the field of skin cancer predominantly involves the screening and detection of skin lesions and the surgical sampling and removal of skin malignancies (Lawrence, 2002).

Surgical skills The earliest description of nurses performing skin surgery was by Godsell (2004). The concept of a nurse-led skin biopsy service resulted in reduced waiting times for simple biopsies (and complex skin cancer removal), which essentially gave dermatologists the time to manage the more complex cases. Nurses’ surgical skills quickly evolved from simple biopsies to complex skin cancer removal, and now incorporates advanced dermatological surgery. Some advanced skills are not always possessed by all consultant dermatologists.

To demonstrate their competency, nurses must complete a portfolio for each clinical skill. Skills need to be practised until absolute proficiency is demonstrated, and then verified by a consultant dermatologist and underpinned by a university-recognised skin surgery accreditation or trust-agreed minor surgery course. In addition, clinical governance is maintained further with an agreed timetable of regular direct observation of procedural skills (DOPS) and mini-clinical evaluation exercise (mini-CEX) assessments, a process that mirrors the training package of a dermatology specialty registrar.

Skin cancer screening Nurses working in skin cancer screening clinics have developed skills that are fast

evolving, but little is understood about this area of nursing development. Many nurse-led clinics are protocol driven and there is no standard of practice for nurses independently managing skin cancer in the UK. This element of extended nursing practice is deemed controversial and is largely driven by medical clinicians and management teams in individual trusts (Loescher et al, 2011). Essentially, if demand dictates and the nursing team demonstrates competence and a will to progress, then nursing practice will develop. However, without a known training programme or competency package, it is difficult to provide evidence of safe practice. Three key studies in the literature attempted to demonstrate a nurse’s skin cancer diagnostic ability (Katris et al, 1998; Olveria et al, 2001; Jones and Colver, 2011). All had study design flaws, but also demonstrated that nurses were safe practitioners and recommended the development of nursing practice to be explored further.

Within the author’s department, clinical competence was demonstrated by performing a clinical audit comparing a nurse’s diagnostic and management ability with that of a consultant dermatologist (the gold standard) (Machin, 2017). One hundred patients were seen in a rapid access (2-week-wait) skin cancer screening clinic over a 1-month period. The audit findings demonstrated 97% diagnostic accuracy and 87% care management accuracy when compared to a consultant dermatologist. However, the most significant finding was that no negative consequences for patient care were detected and clinical decisions remained in adherence with the British Association of Dermatologist’s (BAD) skin cancer guidelines (https://tinyurl.com/qpykmgw). The nurse in this audit is now managing patients with a suspected skin cancer independently and a subsequent review of clinical practice has demonstrated safe diagnoses and management

The evolution of advanced practice for nurses working in skin cancer care Claire Machin, Clinical Specialist Practitioner, Dermatology Outpatients, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust ([email protected])

 

 

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for all cases evaluated, although a tendency by the nurse to be over-cautious was a key finding of the review.

Improving service delivery It could be argued that nurses are plugging the gaps rather than being encouraged to develop their practice. However, the benefits of advanced practice in skin cancer nursing is evidenced by cost savings, waiting-list reduction, and improved overall productivity and continuity of care. Furthermore, nurses are generally easily accessible and approachable with excellent communication skills and take a holistic approach to care delivery. Quite simply, a nurse demonstrating such advanced practice skills is a practitioner who holds the same level of competence to diagnose and manage skin cancer as a consultant dermatologist, but also has the inherent compassion and care of a nurse that was instilled during their nursing training. Therefore, a nurse performing at this level can truly make a difference not only to the care provided, but to the overall experience of patients and their families.

Nurses who possess advanced knowledge and skills have the ability to save a life. Often patients do not think one particular skin lesion is anything to worry about and do not ask for it to be assessed by the screening clinician at their initial consultation. Yet the proficient nurse will spot that this lesion is in fact a melanoma during the routine skin biopsy for another lesion. An experienced nurse would also be able to perform surgery that would not be possible for a novice surgeon. Such nurses who have developed advanced surgical techniques can provide a superior cosmetic outcome to that of a junior registrar with limited experience.

Examples such as these aim to demonstrate

that a nurse who has received adequate training and experience in a highly focused aspect of dermatological care hold the knowledge and insight to make a difference and fine-tune care provision.

It is also important to mention that nurses practising at this level also undergo intense academic and clinical training within skin cancer care and dermatological surgery, which is supported by university accreditation for an advanced practice role.

What the future holds Despite what has been described in this article, and what is being demonstrated as routine practice throughout the UK, there are major gaps in practice development and care provision. The UK currently employs an array of specialist nurses in skin cancer care, but there are vast inconsistencies in the roles and responsibilities they hold. Role titles such as nurse practitioner and clinical nurse specialist are often used interchangeably but there can be differences in the care they deliver. For instance, a clinical specialist nurse may perform dermatological surgery in one settling but not in another. Penzer-Hick (2018) described inconsistencies in job titles among some NHS Agenda for Change pay bands, with no clear demarcation for the level of responsibility the band of pay brings. Furthermore, nurses at band 5 are known to be performing more advanced surgical procedures than those at band 8.

Therefore, a standardised framework for clinical progression is required to ensure clinical governance remains robust, trusts can recruit into posts and the longevity of service provision. Wingfield et al (2018) described a 3-year training programme for skin cancer nurse consultants that consists of a programme of intense role-specific training

while acquiring a master’s level qualification in advanced clinical practice. This is a process that is seen in many centres throughout the UK but has not been formalised. Little is known about advanced practice roles in skin cancer nursing and further exploration of such roles is required.

The aim for the future is to work collaboratively with other centres and produce a nationally agreed training syllabus, competency pathway and agreed scope of practice for each nursing level. BJN

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Godsell G. A nurse-surgical post cuts waiting times and extends nurses’ skills base. Professional Nurse. 2004;19(8):453-455

Harris JM, Salache SJ, Harris RB. Can internet based continuing medical education improve physicians’ skin cancer knowledge and skills? J Gen Intern Med. 2001;16(1):50-56

Jones N, Colver GB. Skin cancer nurses: a screening role. Journal of Clinical & Experimental Dermatology Research. 2011;2(6)

Katris P, Donovan RJ, Gray BN. Nurses screening for skin cancer: an observational study. Aust N Z J Public Health. 1998;22(3 Suppl):381-383

The King’s Fund. How can dermatology services meet current and future patient needs, while ensuring quality of care is not compromised and access is equitable across the UK? 2015. https://tinyurl.com/rdq5dag (accessed 30 January 2020)

Lawrence CM. An introduction to dermatological surgery. London: Churchill Livingstone; 2002

Loescher LJ, Harris JM, Curiel-Lewandrowski C. A systematic review of advanced practice nurses, skin cancer assessment barriers, skin lesion recognition skills, and skin cancer training activities. J Am Acad Nurse Pract. 2011;23(12):667-673. https://doi.org/10.1111/ j.1745-7599.2011.00659.x

Machin C. Can a nurse practitioner independently diagnose skin cancer? Dermatology Nursing. 2017;16(3):10-15

Olveria SA, Nehal KS, Christos PJ, Sharma N, Tromberg JS, Halpern AC. Using nurse practitioners for skin cancer screening: a pilot study. Am J Prev Med. 2001;21(3):214-217

Penzer-Hick R. A survey of dermatology services in the UK. Dermatology Nursing. 2018;17(2):28-32

Wingfield C, Davies K, Levell NJ, Skellett AM. Dermatology nurse consultant succession planning: an introduction to the nurse registrar role. Dermatology Nursing. 2018;17(3):31-38

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