How to address a knowledge and skill gap
- The purpose of this study was to explore nurses’ understanding of skin cancer, sun protective behaviors, and their ability and comfort level in teaching and screening patients.
- The study revealed large gaps in basic knowledge of skin cancer.
- A small percentage of nurses were knowledgeable and felt comfortable in teaching and examining patients for skin cancer.
Skin cancer has reached epidemic proportions. According to Stern, one in five Americans will develop some form of skin cancer by age 70. In 2014, the U.S. Surgeon General put out a call for action against skin cancer. (See Skin cancer stats.)
Nurses have the opportunity to make a significant contribution to skin cancer education and screening. They can teach patients at the bedside while conducting a skin exam, including the signs and symptoms of skin cancer. Siegel developed skin cancer education guidelines based on the Centers for Disease Control and Prevention (CDC) sun-protective guidelines. Eleven hospitals in New York have adopted these guidelines, which nurses use to educate patients. (See Follow the guidelines.)
Recognizing oncologic emergencies
We conducted a study to evaluate nurses’ understanding of skin cancer and sun-protective behaviors as well as their skill and comfort with patient screening and education.
Follow the guidelines
Siegel developed the following skin cancer education guidelines, which have been adopted by 11 New York hospitals.
Skin cancer prevention
Centers for Disease Control and Prevention guidelines to reduce the risk of skin cancer
- Seek shade.
- Avoid sun between 10:00 am and 4:00 pm.
- Use sunscreen daily and re-apply after swimming or sweating.
- Avoid tanning salons.
- Wear sunglasses, a wide brim hat (4 inches), and a long-sleeve shirt when out in the sun.
- Conduct a monthly skin self-assessment, and see a dermatologist annually for a complete body check.
You must follow-up with your provider if
- You have any moles that have recently changed in color and size.
- You have concerns about your skin, unhealed wounds, and/or recently changed areas.
Literature review
Our literature review focused on the importance of educating nursing students about skin cancer. A study by Erkin and colleagues reported on the effectiveness of educational intervention with nursing students related to their knowledge and attitudes regarding skin cancer self-examination and skin cancer risks. The study, conducted in Turkey with 900 female nursing students between the ages of 18 and 23, used a quasi-experimental single-group, pre-and post-test design. Study goals included teaching nursing students about the risks of skin cancer and the steps involved in skin self-examination and encouraging positive attitudes toward early detection of skin cancer and sun-protective behaviors. The researchers found a significant improvement in post-test scores after students learned about the ABCDE (asymmetry, border, color, diameter, evolving) rule of melanoma detection.
While teaching nursing students and nurses, Mitchell-Worsfold found that many lacked basic knowledge of skin cancer. She noted that healthcare staff require awareness of skin cancer and its prevention. She advocated for improved education for nurses so they can assist in identifying skin cancer in its initial stages.
A recent study by Siegel and colleagues examined how to improve nursing students’ knowledge and assessment skills regarding skin cancer using online resources. The quasi-experimental study, consisting of 146 nursing students, compared the intervention group (which received online education) with the control group. Study results indicated that increasing the students’ knowledge of skin cancer improved their confidence and enabled them to become more proficient in educating patients.
Siegel and Eckardt examined how to improve skin cancer education of nursing students using human simulation and moulage. This quasi-experimental study divided 156 nursing students into six classes. Two of the classes served as control groups (55 participants); four, as intervention groups (97 participants). Human simulation and moulage proved highly effective teaching approaches. The intervention groups also learned how to identify skin cancer lesions and conduct patient education using CDC guidelines.
Although melanoma accounts for only 1% of skin cancers, it’s the deadliest form.
According to the Skin Cancer Foundation, nurses should teach patients that unprotected skin exposure to ultraviolet light accounts for 95% of skin cancers. Nurses can have a positive health impact on the community if we educate them about sun-protective behaviors outlined in the CDC guidelines, including the use of sunscreen, clothing, wide-brim hats, and sunglasses as well as the avoidance of peak sun hours and the carcinogenic effects of tanning beds.
Skin cancer stats
The three main types of skin cancer include basal cell, squamous cell, and melanoma.
- Basal cell carcinoma, frequently found in sun-exposed areas of the skin, rarely metastasizes. Typically, it presents as a sore that doesn’t heal within 2 weeks. If left untreated, basal cell carcinoma can cause disfiguration. According to the Skin Cancer Foundation, approximately 3.6 million cases of basal cell are diagnosed each year.
- Squamous cell carcinoma, the second most common skin cancer, appears scaly and itchy, and it can bleed. Its appearance may vary from patient to patient. If left untreated, squamous cell carcinoma can metastasize. It accounts for 1.8 million skin cancer cases per year (205 cases per hour).
- Melanoma, according to the American Cancer Society, accounts for only 1% of all skin cancers, but causes the most skin cancer deaths. The American Cancer Society estimated the diagnosis of approximately 97,610 melanomas in the United States in 2023.
Our study
Our university’s Institutional Review Board approved our study’s protocol. We recruited a convenience sample of participants from a national data source, which included past student members of the National Student Nurses Association (NSNA) who reported graduating in 2019. We told the nurses that their participation was voluntary and confidential and that they could withdraw from the study at any time. Ultimately, 251 nurses agreed to participate.
Design and method
We sought to determine the nurses’ knowledge and role regarding skin cancer and sun-protective behaviors. We invited nurses to participate using their NSNA email. Those who agreed to participate completed a 5- to 10-minute online survey, which we adapted and modified from the survey tool used by Siegel in previous studies.
Survey questions assessed participants’ demographic characteristics, whether they had learned about skin cancer in nursing school, and whether they knew anyone with skin cancer. The survey also included two role items and seven knowledge items, each of which we measured on a five-point Likert scale. The role items measured the nurses’ understanding of their role in educating and assessing patients’ skin. The knowledge items measured the nurses’ understanding of skin cancer and sun-protective behavior.
Findings
Most of the primarily young and female participants identified as White or Caucasian. Many reported that they had learned about skin cancer in nursing school. Approximately 44% of participants reported that they knew someone with skin cancer and described the experiences of family members, friends, and patients. Some nurses reported having had skin cancer themselves. (See About the participants)
The second part of the survey consisted of seven 5-point Likert scale questions, ranging from strongly disagree to strongly agree. (See Nurse role and knowledge.)
Significant gap in knowledge
Treatment for early stage melanoma has proven successful, and diagnosing this and all forms of cancer as early as possible aids good outcomes. However, the results of this small study reveal a gap in knowledge in the sample of nurses surveyed.
For example, 32 of the 251 nurses surveyed (12.75%) reported that they didn’t learn about skin cancer in nursing school. This is troubling since one in five Americans will suffer from skin cancer by age 70. Skin cancer, its prevention, and how to recognize different lesions should be included in all nursing school curricula as part of basic assessment skills and then reinforced in practice through continuing education.
Answers to the question about the personal knowledge of someone with skin cancer highlighted the condition’s prevalence. Of the 251 participants, 110 said they knew someone with skin cancer, and a few of the nurses had skin cancer themselves.
Of those participants who said they learned about skin cancer in nursing school (219), 85.95% understood that skin cancer can metastasize and 78.22% understood that childhood sunburns can cause skin cancer. We also found that 49.80% agreed that they could teach about the CDC sun-protective guidelines. In addition, 25.80% of participants reported that they could recognize a possible basal cell carcinoma; 27.71% could distinguish between benign and cancerous moles; 14.86% stated that they could recognize a possible squamous cell carcinoma; and 24.49% felt they could recognize a lesion suspicious for melanoma and refer the patient for further treatment.
Only a few participants reported feeling comfortable teaching about and examining patients for skin cancer. With a better understanding of this condition, these nurses can better serve their communities.
Limitations and recommendations
Limitations included the small sample size and the homogeneity of the participants (female, White, and young). Future research should use a larger and more diverse national sample population. Studies also should work to determine if nursing school curricula consistently include skin cancer content. Further research also should explore the effectiveness of different types of education, including simulation, moulage, and online resources.
Nursing implications
A recent resolution by the NSNA stated that skin cancer should be taught in all nursing schools nationwide. However, this small study revealed that not all nursing schools include skin cancer in their curricula. Nurse educators working in universities, hospitals, and the community can educate students and practicing nurses about sun-protective guidelines to prevent skin cancer, the prevalence of skin cancer, and how to recognize skin cancers for appropriate referrals. These continuing education programs would improve competence so nurses feel confident and comfortable teaching patients about these topics.
Nurses educate patients on numerous health behaviors, including proper diet, the importance of exercise, adherence to cancer screenings, the dangers of smoking and drinking alcohol, bike safety, car seat safety, and safety in the home. Patients in the community would benefit from nurse-provided education about skin cancer and sun-protective behaviors. In addition, nurses perform skin assessments of all patients who enter the hospital, making it an ideal time to teach about sun-protective behaviors and assess for skin cancer.
Several reputable online resources can help nurses educate their patients, including the American Cancer Society, the American Dermatology Association, and the Skin Cancer Foundation.
Skills and confidence
Nurses can make a difference in the skin cancer epidemic by teaching the public about skin cancer prevention and performing skin assessments. The gaps revealed in this study require further examination, but they point to the need for more consistent teaching of skin cancer in nursing schools as well as periodic professional development opportunities in the workplace. Although rare, melanoma, if diagnosed early, has a 99% 5-year survival rate. However, if it’s allowed to metastasize, the 5-year survival rate drops to 20%.
Nurses must have the skills to recognize these lesions and refer patients for further evaluation, and they must have confidence in their ability to perform skin assessments and provide patient education. After all, anyone with skin can get skin cancer.
The authors work at Malloy University in Rockville Centre, New York. Victoria Siegel is a professor of nursing, Veronica Feeg is a professor emeritus, Lincy Philip is a PhD student, and Patricia Eckardt is a professor.
American Nurse Journal. 2025; 20(2). Doi: 10.51256/ANJ022535
References
American Cancer Society. Key statistics for melanoma skin cancer. July 17, 2024. cancer.org/cancer/types/melanoma-skin-cancer/about/key-statistics.html
American Nurses Association. Nursing Scope and Standards of Practice. 4th ed. Silver Spring, MD: American Nurses Association; 2021.
Centers for Disease Control and Prevention. Sun safety facts. July 1, 2024. cdc.gov/cancer/skin/basic_info/sun-safety.htm
Erkin Ö, Aygün Ö. Effects of an educational intervention on nursing students’ knowledge and attitudes regarding skin self-examination and skin cancer risks. J Nurs Res. 2020:28(1):e62. doi:10.1097/jnr.0000000000000326
Mitchell-Worsfold, L. Nurses can Improve their knowledge of skin cancer. Cancer Nurs Pract. 2019;18(3):16. doi:10.7748/cnp.18.3.16.s15
National Cancer Institute. Cancer stat facts: Melanoma of the skin. seer.cancer.gov/statfacts/html/melan.html
Pham L, Martin B, Nahar V, et al. Skin cancer prevention practices among nursing students: A critical need for improvement. J Dermatol Nurs Assoc. 2917;9(4):196-8. molliesfund.org/wp-content/uploads/2022/01/JDNA-D-20-00089-1.pdf
Siegel V. Student nurse knowledge of skin cancer, sun protective behaviors, perceptions of acquiring skin cancer, and the role of the nurse. [doctoral dissertation]. Oakdale, NY: Dowling College; 2009.
Siegel V, Eckardt P. A prospective observational cross-sectional study examining the effect of using human simulation and moulages to assist in skin cancer education of nursing students. J Dermatol Nurs Assoc. 2017:9(6):296-301. doi:10.1097/JDN.0000000000000353
Siegel V, Moore G, Siegel L. Improving nursing students’ knowledge and assessment skills regarding skin cancer using online teaching resources. J Dermatol Nurs Assoc. 2021;13(6):305-8. doi:10/1097/JDN.0000000000000649
Skin Cancer Foundation. Skin cancer facts & statistics. November 2024. skincancer.org/skin-cancer-information/skin-cancer-facts
Skin Cancer Foundation. Squamous cell carcinoma overview. skincancer.org/skin-cancer-information/squamous-cell-carcinoma/
Skin Cancer Foundation. UV radiation & your skin. August 2021. skincancer.org/risk-factors/uv-radiation/
Stern RS. Prevalence of a history of skin cancer in 2007: Results of an incidence-based model. Arch Dermatol. 2010;146(3):279-82. doi:10.1001/archdermatol.2010.4
U.S Department of Health and Human Services. Surgeon General call to action to prevent skin cancer. July 28, 2014. hhs.gov/surgeongeneral/reports-and-publications/skin-cancer/executive-summary/index.html
Key words: skin cancer, patient education, sun protective behaviors, skin cancer prevention
