ANATOMY AND PHYSIOLOGY 1 (2125)

This discussion is due 2/10/21

Please read the article attached. 

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140 British Journal of Nursing, 2020, Vol 29, No 3

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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 (claire.machin2@nhs.net)

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British Journal of Nursing, 2020, Vol 29, No 3 141

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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

Eedy D. The crisis in dermatology. BMJ. 2015;350:h2765.
https://doi.org/10.1136/bmj.h2765

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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