Skin cancer is the most commonly diagnosed cancer each year in the US.1 It is estimated that one in every five Americans will develop skin cancer during their lifetime.2 This includes more than 5.4 million cases of nonmelanoma skin cancer (NMSC) and about 161,790 new cases of melanoma (87,110) and melanoma in situ (74,680) diagnosed in 2017.1,3,4 On average, 9,730 deaths in 2017 were caused by melanoma.1,4
The three major types of skin cancer are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. Both BCC and SCC can be grouped into the NMSC category and are the two most common types of skin cancer. Both of these NMSCs have an excellent prognosis and, in fact, a high cure rate, when detected early and removed following treatment guidelines.5-7 It is rare for BCC to metastasize, although if left untreated, it can invade important structures such as the eye or invade the bone or underlying tissue.6 Unfortunately, BCC has the possibility of returning if not removed completely, and individuals who have developed BCC have an increased chance of recurrence of BCC in other areas of the body.
Early detection and treatment of SCC is crucial because, if left untreated, SCC can penetrate the underlying tissue, which sometimes leads to treatment-related disfigurement such as the loss of an ear, nose, or eye. Rarely, SCC can metastasize to other organs and distant tissues, which can then become life-threatening.4
Melanoma accounts for less than 1% of skin cancer cases but results in most deaths from skin cancer.6 Melanoma most commonly occurs in adults, but it is becoming more prevalent in teens and young adults from 15 to 29 years old. According to a comprehensive meta-analysis, a contributing factor in many cases of melanoma is repeated and intense ultraviolet exposure resulting in sunburn and blisters.8 However, per the American Academy of Dermatology, melanoma, when caught early and treated properly, has a cure rate of nearly 100%.5
Patient outcomes are directly linked to early detection and treatment, which are essential for all types of skin cancer, especially melanoma. According to the American Cancer Society, skin cancer screenings providing early detection and treatment could potentially be the foremost way to combat the increasing prevalence of skin cancer.9 Twenty percent of primary care visits are because patients have something on their skin that they want checked.10 NPs in primary care can play an important role in early detection of all types of skin cancer. Currently, there are over 270,000 NPs in the US, and 87.1% are certified in an area of primary care.11 These NPs are in a key position to identify skin cancers early and offer treatment. However, very little is known about NPs' knowledge of skin assessment and cancer, and even less is known about how well NP students are being prepared to perform skin cancer assessments. The few studies that have been done on this topic have shown that NPs have a low level of knowledge related to skin cancer assessments. A systematic review of advanced practice registered nurses (APRNs), including NPs, shows that APRNs' ability to identify suspicious and benign lesions and make the correct referral or treatment decision was inconsistent, although it improved after training.12 Another study by Hartnett and O'Keefe assessed only NPs in practice and showed that they had a significant increase in knowledge of skin cancer and lesion identification after a brief online educational program.13 NPs as well as other APRNs must be able to identify which skin lesions do and do not need further treatment, such as biopsies of dermatologic referral.
No studies could be found focusing on NP student knowledge of skin assessments or cancer. Without this research, it is difficult to know the baseline knowledge of NP students and how well they are being prepared to perform skin cancer assessments as independent practitioners. Information about NP students will inform educators on where improvement in skin cancer education is needed. If this is accomplished, NPs will have a larger impact on patients' outcomes if they are educated with a strong foundation and knowledge base on skin cancer and lesion identification. Therefore, the purpose of this study was to examine NP students' knowledge and attitudes toward skin cancer and skin cancer assessments.
Design. This study used an exploratory, descriptive design and was approved as an exempt study by the University of Central Florida's Institutional Review Board. Participation in this study was completely voluntary and confidential.
Sample. Thirty-four NP students enrolled in a gerontology course during Fall 2016 were asked to participate. Students were informed about the study during a live class. After the introduction, a link to the online survey was sent to potential participants through the university's online course delivery system. The link took potential participants to the survey, which included an informed consent document. Participants were eligible for the study if they were at least age 18, a graduate nursing student, and currently enrolled in the gerontology course as an NP student at the University of Central Florida. The survey was open for 2 weeks, and a reminder email was sent to the class at 1 week.
Instruments. Participants were asked to complete a 12-item demographic survey and the 79-item Knowledge, Attitudes and Practice of Skin Cancer Assessments (KAP-SCA) instrument. Originally developed and intended for use by NPs, this survey included subscales about lesion identification, knowledge about general skin facts, education received in an NP program, and knowledge, attitudes, and confidence levels during skin care assessments.10
Skin cancer knowledge is assessed in two different subscales of the KAP-SCA survey. Subscale 1 includes 20 photos for lesion identification and choices for treatment options. Level of knowledge is indicated by number of correct answers for the photo identification items as follows: deficient knowledge (0-7 points), average knowledge (8-14 points), and proficient knowledge (15-20 points).
Subscale 2 includes 13 general skin cancer knowledge questions that measure comprehensive knowledge relating to NMSC and melanoma skin cancer. The interpretation of scores for the general knowledge items includes deficient knowledge (0-4 points), average knowledge (5-9 points), and proficient knowledge (10-13 points). The original KAP-SCA survey had 14 questions; however, one item was removed because of our belief that one of the answers was inaccurate.
The attitudes and practice subscale consists of 40 questions. Twenty questions examined NP attitudes and confidence in performing skin cancer examinations and the dermatology education the participants received at their program. Twenty additional questions solicited NP students' practice regarding skin cancer examinations, prevention, education, and procedures. These questions use a Likert scale format: 0 = none, 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. The total possible scores of the attitudes section ranged from 0 to 80.
Data analysis. The study used descriptive statistics (frequencies and percentages) to analyze the demographics and the total and subscale scores for the KAP-SCA instrument. Spearman's rho was used to examine relationships between knowledge, attitudes, and practice.
Twenty students accessed and completed the survey. Most participants were female (85%), family track NP students (85%), and White (90%). The age of the participants ranged from 25 to 54. Most of the sample reported no personal history (95%) or family history (55%) of skin cancer. Only 30% of the participants receive an annual professional skin examination. Most participants perform self-skin examinations (70%) and perform skin examinations in clinical practice (70%). For all the participants who perform skin examinations in clinical practice, 20% perform skin examinations during every clinical, 25% perform skin examinations every other clinical, 25% perform skin examinations only once, and 30% have never performed skin examinations in clinical practice.
The total mean score for the lesion identification knowledge subscale was 9.65 (range = 6 to 14) of 20 possible points. This was within the average knowledge range. Most of the participants could not correctly identify the lesion in about half of the photos. The participants correctly identified noncancerous lesions 52% of the time and correctly identified melanoma lesions 51.6% of the time. The participants correctly identified precancerous lesions 40% of the time and nonmelanoma cancerous lesions 42.9% of the time. When asked about the appropriate action to take for each lesion overall, most of the time (52.3%), the participants indicated that they would “refer to a specialist.” This option was the most popular choice regardless of the type of lesion.
The mean general knowledge score of the NP students was 6.4 (range = 3 to 9) of a possible 13 points. This also indicated average knowledge. The participants seemed most knowledgeable about risk factors for melanoma. Most (90%) of the participants were able to differentiate between risk factors for melanoma and benign factors. Most (75%) of the participants identified the most common skin cancer, proper biopsy techniques for a pigmented lesion, and proper indications for a sentinel lymph node biopsy. The participants were least knowledgeable about different types of melanoma. Only 15% of the participants correctly determined treatment for melanoma. Ten percent of the participants were knowledgeable on risk factors for SCC.
The total scores for the attitude subscale were 48.5 of 80 points, with a range of 32 to 66 points. The NP students' attitudes about performing skin cancer assessments showed that most participants agree that it is vital to look for skin cancers when examining any patient (95%) and that NPs are responsible for knowing how to provide a full-body skin cancer examination (95%). All participants (100%) agreed that lack of time is a barrier to performing full-body skin examinations. Most (70%) of the NP students did not agree that the dermatology training they received in their NP program prepared them for practice. Only 50% of the NP students stated that they received training or education on skin biopsies, and 45% reported receiving training on cryotherapy. Most (90%) of the participants agreed that they are afraid that they might miss a skin cancer so they chose to refer out a dermatology specialist. Only two of the participants (10%) felt confident performing skin assessments. None of the participants felt confident performing biopsies and cryotherapy with the education they received in their NP program.
The total scores for the practice subscale was 28.3 of 80, and the range was 8 to 51. The results for the practice subscale indicated that most (80%) would refer patients to a dermatology specialist for skin cancer examinations if they are unable to perform a skin assessment. Most NP students (90%) typically educated patients about sun protection. The lowest scores were seen in performing dermatologic procedures. None of the NP students performed excisional biopsies for lesions suspicious for melanoma. They also did not perform excisions, cryotherapy, or electrodessication/curettage to treat NMSC in the practice setting.
Original Cronbach's alpha scores indicated overall acceptable reliability in the practice (.89) and attitudes (range = .54 to .77) subscales. The knowledge subscale was lower with an alpha of .50. Shelby believed that a low score was due to participants' multiple levels of knowledge related to different skin lesions. The Cronbach's alpha in this study for the whole scale was .868; however, the knowledge subscale showed a Cronbach's alpha of .364 for photo identification and .174 for general skin cancer knowledge. The reason for this is unclear but could support Shelby's idea of different levels of knowledge.10
Overall, this study showed that NP student knowledge was average as measured by the KAP-SCA scale. The results for the lesion identification knowledge questions showed that it was challenging for the NP students to identify different types of skin lesions, with each type of lesion being identified correctly about 50% of the time. These results are different from those of other studies with practicing NPs in which practitioners had a more difficult time identifying benign lesions compared with melanoma lesions.10 Both primary care NPs in practice and NP students have difficulty recognizing and differentiating between skin cancer abnormalities and benign lesions; this may be because students do not have enough exposure to skin problems in clinical practice during patient assessments. In addition, if students are not comfortable identifying skin lesions under practice supervision, they are unlikely to be comfortable identifying lesions after graduation when working as independent practitioners.
In this study, participants indicated that “refer to a specialist” was their preferred treatment choice. This was consistent with prior studies of NPs.10 This could be related to participants' inability or lack of confidence in correctly identifying a lesion, as previously discussed. Diagnosing skin issues takes practice and skill, as well as time to become competent in identifying different skin lesions correctly. If NPs did not learn to identify lesions as students, referring to a specialist may be considered the safest option to prevent a missed diagnosis or a misdiagnosis. On a positive note, referring to a skin specialist indicates safe care.14 However, if NPs and NP students were more confident in their ability to recognize benign versus malignant lesions, unnecessary and expensive dermatology referrals may be reduced.
This study's finding that students lacked confidence when performing skin cancer assessments is consistent with other studies with NPs. Shelby also found that practitioners felt that their NP program was lacking comprehensive education and training in dermatology.10 Outside a formal NP program, Hartnett and O'Keefe showed that lesion identification and skin cancer knowledge could improve with intervention and additional education.13 The need for further education and training related to skin care and treatment is not uncommon. A study conducted at Radboud University Medical Center assessed the knowledge, attitudes, and skills of 268 general practitioners.15 The results showed that over 50% of general practitioners felt that they needed additional training in skin cancer. Another study was completed with 223 fourth-year medical students at Boston University. Among the students, 52% considered themselves unskilled in performing skin cancer assessments, 28% had never observed a skin cancer assessment, 40% had received no training, and 35% had never practiced skin cancer assessments.16 From these data, it can be inferred that all practitioners may benefit from more knowledge and education in skin assessment, lesion detection, and development of treatment plans.
Average knowledge and lack of confidence can have a direct impact on practice related to skin cancer assessments. The results suggest that most of the NP students are comfortable educating patients on basic preventive measures such as sun protection; this finding is consistent with the parent study on NPs in practice.10 Although these health promotion and preventative aspects are necessary and important, these skills are expected at the basic registered nurse level and are not consistent with skills expected within the scope of practice of an NP. These findings uncover the need for further education for NPs to perform within their intended scope of practice to perform skin assessments, detect skin lesions, develop and implement treatment plans, and refer to a specialist for further care, when appropriate.
This study has multiple implications for nursing education. There are multiple opportunities to improve NP students' knowledge about skin cancer. Given that skin cancer is the most common cancer in the US, programs focused on NP primary care should emphasize dermatology education and supplement it with hands-on experiences such as a dermatology clinical rotation, simulations, or workshops. These workshops could include training in basic dermatology procedures such as biopsies and cryotherapy. This will help facilitate learning and increase confidence in performing skin cancer assessments and procedures. In addition, NP conferences should also consider practical hands-on workshops or preconference workshops on this specialized topic. This would give practitioners the opportunity to gain specialized knowledge or even increase their comfort level with diagnosis in practice. Given that skin cancer rates are rising and younger adults are being diagnosed with skin cancer earlier, another implication could be to focus on primary prevention. This could include emphasizing the importance of sun protective behaviors for all patients, especially the younger population.
This study had several limitations. First, the sample in this study was small. Future studies should focus on larger and more diverse populations of NPs and NP students. Knowledge of skin issues could also be investigated in different NP programs focusing on different populations. Second, the KAP-SCA tool was originally designed for NPs and not NP students. Some questions may not have been applicable to students, which led to negative responses. More research needs to be conducted on NPs' knowledge and attitudes toward skin cancer assessments, and the KAP-SCA tool can be used as a model for future studies and tools.
This study shows the need to put more emphasis on skin cancer assessment in NP curricula. NPs are in an ideal position in primary care to distinguish between benign and malignant lesions and to treat them or refer to a specialist, when appropriate. Nursing educators should reexamine how dermatology education is presented within primary care NP programs and should consider placing more importance on basic dermatology education and procedures and skin cancer recognition. This training is especially important in settings where skin cancers are more prevalent, for example, within geographic locations with increased sun exposure and in populations like geriatrics. Better skin cancer assessment training would increase NP students' knowledge and confidence level, which may have a direct impact on patient outcomes and healthcare costs.