Gillian Godsell, MSc Advanced Nursing Practice, RGN, OBE
Skin Cancer Nurse Specialist, Skin Surgery Unit, University Hospital, Queen's Medical Centre, NottinghamThe incidence of skin cancer has almost doubled in the UK over the past 25 years (MacKie et al, 2002) and the condition is a recognised health problem worldwide (Creagan, 1997). The increase has been blamed on people's preoccupation with getting a tan (Cancer Research UK, 2003) - along with the increased use of tanning appliances such as sunbeds (ICNIRP, 2003) and the rising level of international travel (Buchanan, 2003).
The incidence of skin cancer has almost doubled in the UK over the past 25 years (MacKie et al, 2002) and the condition is a recognised health problem worldwide (Creagan, 1997). The increase has been blamed on people's preoccupation with getting a tan (Cancer Research UK, 2003) - along with the increased use of tanning appliances such as sunbeds (ICNIRP, 2003) and the rising level of international travel (Buchanan, 2003).
Government initiatives and new technologies have resulted in many changes to the way nurses deliver care. The NHS Plan (DoH, 2000) urges employers to empower appropriately qualified nurses to undertake a wider range of clinical tasks, including performing minor surgery.
The cancer target clinic at the University Hospital NHS Trust, Nottingham, sees about 100 referrals of suspected skin cancer a week, and many of these patients require a biopsy to confirm a diagnosis.
To limit morbidity and mortality from the condition, it is essential to diagnose and remove the lesion at the earliest opportunity (Osborne, 2002).
An internal audit of our service revealed that dermatology patients requiring a biopsy had to wait about eight weeks for an appointment to have the biopsy carried out by a doctor after being referred from the clinic. The long waiting list prompted the decision to develop the nurse biopsy role to be developed in our unit.
Feedback from patients indicated that the wait caused intense anxiety, not only for those who received a positive diagnosis but also for those who were not found to have cancer.
I initiated a consultation across the trust - at the time I was working as dermatology nurse. It involved the key stakeholders - patients, doctors, nurses and pharmacists. It was decided to train a nurse to perform biopsies for suspected skin cancers and undiagnosed inflammatory skin conditions.
The post went to the dermatology nurse because the skin clinic workload allowed it. A training package was developed in accordance with The Scope of Professional Practice Guidelines (UKCC, 1992).
This initiative followed the principles outlined in The NHS Cancer Plan (DoH, 2000), which states: 'Radical changes are needed in the way staff work to reduce waiting times and deliver modern, patient-centred services.'
Nurse-surgical posts strengthen continuity of care (Humphris and Masterson, 2000) and allow collaboration with other health professionals to ensure the patient receives appropriate and timely care.
Smith and Daughtrey (2000) show that, with a more consistent and integrated approach to the continuing needs of the patient, as provided by a specialist nurse, gaps in provision and duplication of services can be avoided. The interactive relationship that develops between the nurse and the patient has also been shown to have a therapeutic value (Peplau, 1994).
Aims and objectives of the nurse biopsy service
The Greenhalgh report (1994) showed that sharing responsibility for managing the care of a patient is in the patient's best interests and also improves the quality of care (Box 1).
The aim of the nurse biopsy service was to reduce waiting time for a biopsy and to improve care delivery for patients with suspected skin cancer and undiagnosed dermatological conditions. The role involves the following:
- Obtaining consent
- Administering local anaesthetic
- Surgical removal of a section of skin
- Insertion of sutures.
Woodward (2001) suggests that reducing the waiting time between the discovery of a suspicious lesion and diagnosis reduces the anxiety experienced by the patient.
Furthermore, prognosis is maximised by early removal of fast-growing tumours such as squamous-cell carcinoma and malignant melanoma, which can be fatal if left untreated (Jerant et al, 2000).
Various frameworks can be used to formulate a structured learning programme, which must then be ratified by the trust in which the nurse is to practice. The training package used for the dermatology biopsy nurse was based on The Scope of Professional Practice Guidelines (UKCC, 1992).
This document emphasises the need for nursing practice to be sensitive, relevant and responsive to the needs of the patient. It highlights the importance of the practitioner's professional accountability and enables the nurse to construct a framework for learning that is developed within the context of the individual's own personal experience, education and skills (Castledine, 1998).
However, while these guidelines are ideal for teaching practical skills such as suturing, curettage and injecting local anaesthetic, they do not take account of all the knowledge requirements for a surgical role.
Therefore Burnard's (1992) model of learning was incorporated within The Scope of Professional Practice framework to identify the knowledge and skills required to perform skin biopsies. The training package took nearly 18 months to develop and was then ratified by the nursing development unit and the hospital trust.
To aid dissemination and avoid 'reinventing the wheel', copies of the framework used at Queen's Medical Centre have been sent in the past two years to more than 80 dermatology departments in the UK, many of which have developed a nurse-surgery service of their own.
Evaluation of the role
Statistics showing how the role has developed and improved services are shown in Box 2.
In addition, the findings of a a patient satisfaction survey were collated. All patients attending in a one-month period during 2003 - 102 in total - were asked to complete a questionnaire in the department after receiving their surgery. All patients completed it.
The results showed:
- Patients were happy to have their biopsy performed by a nurse
- Given a choice, they would rather have the biopsy performed on the day of their visit by a nurse than return at a later date to have it performed by a doctor.
An audit of the histology reports from among the specimens obtained by the nurses showed that a diagnosis was obtained in 100% of cases, indicating that the nurses' surgical technique was good.
Clinical supervision is undertaken by the specialist nurse and job satisfaction among all the nurses involved is high - the nurses remain motivated and inspired, and all have taken ownership of the role. Many units throughout the UK are now developing the role, using the framework devised at Queen's Medical Centre.
Nurse biopsy in practice
There are now nine nurses within University Hospital Trust, Nottingham, who are trained to perform skin surgery. This means that the department can provide a biopsy service from Monday to Friday. There is now a one-stop service for all patients, which cuts the wait from eight weeks to none. Thus a patient who attends the dermatology outpatients' clinic with a suspected skin cancer, or other undiagnosed skin condition, can have a biopsy of the suspicious area at the initial visit to the clinic, without having to return a few weeks later to have the biopsy performed by a doctor.
Not only has waiting time been cut down, but also the travelling time and expenses incurred by patients.
Nurses undertake about 140 biopsies a month allowing consultants and the clinic's dermatology doctors to focus on the more complex types of surgery. This has achieved a reduction in waiting time for more complex dermatology surgery from eight weeks to two.
One major constraining factor in the development of this role was the lack of a course, aimed specifically at nurses, to teach the technical skills needed to perform surgery.
Initially, the skills were obtained by nurses attending the basic surgery course for doctors run by the British Society of Dermatological Surgeons. However, the course did not completely cater for nurses' needs - and a tailor-made course has now been developed by a nursing and medical team at the Queen's Medical Centre.
This is run twice a year and attended by 50 nurses from across the UK.
The course not only covers practical skills such as suturing and tissue sampling, but also incorporates lectures on setting up a nurse biopsy service in both primary and secondary care, consent and other legal issues surrounding the implementation of such a service.
Nurses from a range of specialties have attended, including practice nurses, tissue viability nurses, ophthalmic and research nurses.
The size and staffing levels of a department dictate what service, if any, the nurse can provide. The unit in Nottingham is large, with medical staff always on hand if the nurse encounters problems, such as clotting difficulties, adverse reactions to anaesthetic, or any other medical emergency. This may not always be the case in smaller units.
Another problem with staffing levels is that, if a service has only one nurse who can perform biopsies, cover will not always be available if this individual is on annual leave or is off sick.
For this reason, it is advisable to have at least two nurses trained to undertake biopsies.
The nurse who conducts the biopsies needs to be firm about the referrals made to the service. They need to be able to admit when it would not be in the best interests of either the patient or the nurse to undertake the surgery. For example, for a biopsy of skin in the temple or under the chin, where arteries and nerves are close, it may be more appropriate for a doctor to carry out the procedure. Difficulty in obtaining consent would be another appropriate reason for referring back to the dermatology doctor.
Outreach nurse biopsy
The surgery course continues to expand, and evaluation of the course is fed back into planning each successive one.
Account has been taken of the fact that some dermatology units, including the Queen's Medical Centre, have developed a more advanced surgical nurse role, which involves advanced dermatology nurse practitioners undertaking more extensive surgery than biopsy, such as complete excision of tumours and other dermatological conditions.
Links with primary care are being established, and an outreach biopsy service is being developed to enable surgery to be undertaken in primary care. This, combined with teledermatology in the future, would enable a complete service to be provided without the patient ever having to set foot in a hospital.
The development of the nurse biopsy role has enabled nurses to broaden the use of their skills and knowledge, and deliver a more patient-focused service.
It allows the nurse to follow the patient through their dermatology journey, from initial consultation to post-surgery follow-up and eventual discharge, providing greater continuity of care.
The development of the role is only one of many innovative ways that nurses have changed the way they work, and it is important for nurses and their clinical colleagues to share areas of good practice and innovation to ensure that patients throughout the country benefit.
But while the UK has an acknowledged shortage of both nurses and doctors, it is essential that nurses do not undertake purely medical roles at the expense of the nursing care that patients also require.
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