The demand for dermatology services within the UK has seen a steady increase. There are around 16 700 new melanoma skin cancer cases diagnosed every year in the UK. Combined incidence rates have more than doubled (140%) since the early 1990s with a 9% increase predicted between 2023–2025 and 2038–2040 (Cancer Research UK, 2023). In addition to escalating rates of skin cancer, patients present with an assortment of complex skin conditions (British Dermatological Nursing Group, 2022). Eedy (2015) asserted that the scarcity of specialist doctors has necessitated the development of a more suitably trained, skilled and adaptable workforce. One strategy to realise this is to enhance the role of dermatology nursing staff to ensure their knowledge, skills and experience are fully exploited (Scottish Government, 2016). Ireland's Department of Health (2020) has posited that nurses can be bolstered to offer advanced services to decrease waiting times and enhance integration of specialties. Nevertheless, they must be educated and supported to deliver the requisite dermatology care for now and the future. This article delves into the findings of an educational needs assessment conducted across Scotland, Northern Ireland, and the adjacent counties of the Republic of Ireland, which have been used to foster the development of education for dermatology nursing staff, ensuring relevance, appropriateness and accessibility.
Dermatology education
The deficit of appropriate and accessible education, particularly formal courses for highly specialist nurses, has been widely reported, including in dermatology (Gould et al, 2007; Price and Reichert, 2017; British Dermatological Nursing Group, 2022). Education is essential for the enforcement of evidence-based practice and, thus, aims to augment the care received by patients (Caramanica and Spiva, 2018). However, such provision is not consistent across all areas, often lacks a cohesive structure and can be inaccessible (Gould et al, 2007). The British Dermatological Nursing Group (2022) highlights the need for suitably trained staff who can demonstrate the necessary level of competence to deliver dermatology services. Nevertheless, there is a dearth of provision for training that is satisfactory in both breadth and duration (Beroukhim et al, 2015). The British Dermatological Nursing Group (2012) issued clinical competencies for qualified nurses, divided into three levels, from novice to expert. However, these were not extensively promoted nor available across dermatology departments, and their completion was not obligatory. Currently, there is neither a nationally recognised level of competence nor an accepted educational standard for nurses working in a specialist dermatology role. However, the publication of Clinical Dermatology Nursing Role Descriptors in 2023 aims to support the progression and development of the dermatology nursing workforce (British Dermatological Nursing Group and British Association of Dermatologists, 2023). Post-registration education in dermatology, where available, lacks standardisation and is not obligatory.
Educational needs assessment: objective and population covered
This educational needs assessment was executed as a component of the National Dermatology Improvement Project, which ran from 2018 to 2022 (data collection and analysis were finalised in 2019). The objective of this project was to scope the educational needs of nursing staff in dermatology secondary care departments across Scotland, Northern Ireland, and the neighbouring counties of the Republic of Ireland. This project was financially supported as part of the Modern Outpatient Programme, which underpins the delivery of high-quality, efficacious and sustainable dermatology services (Scottish Government, 2016).
Twenty health boards (or trusts) with a dedicated dermatology service were identified, with 12 (60%) in Scotland, 5 (25%) in Northern Ireland and 3 (15%) in the Republic of Ireland. A hub-and-spoke model of service delivery was commonplace, with clinical services being offered at multiple sites. Over 400 nursing staff working in dermatology departments within secondary care were recognised. This was further categorised into department leads (senior charge nurses/ward managers), staff nurses, clinical nurse specialists and healthcare support workers (Table 1). Nursing staff employed in substantive posts in dermatology departments within secondary care were included in the study. Staff who were involved in delivering a dermatology service but employed by another specialty, such as general outpatients, were excluded. Band 5 staff nurses made up the largest group of staff (Table 1).
Table 1. Secondary care dermatology staffing numbers covered by the project
| Pay banding | Number |
|---|---|
| Band 2 (healthcare support workers) | 93 |
| Band 3 (healthcare support workers) | 19 |
| Band 5 (staff nurses) | 200 |
| Band 6 (clinical nurse specialists and charge nurses) | 74 |
| Band 7 (clinical nurse specialists and senior charge nurses) | 46 |
| Band 8 (clinical lead nurse) | 3 |
The project team identified the department leads and initially contacted them via their health board email to invite participation in the study. They were also asked to identify members of their team, who were then offered an opportunity to participate in a focus group.
Educational needs assessment: methods
A comprehensive mixed-methods approach was used for this study, incorporating questionnaires, interviews and focus group discussions. The research was conducted in Scotland, Northern Ireland and the bordering counties of the Republic of Ireland, aiming to explore the educational needs and the factors influencing the pursuit of educational opportunities among dermatology nurses.
First, 31 dermatology department leads were invited to complete an electronic questionnaire. This structured questionnaire allowed the project team to gather data on the types of clinical services offered, the availability and format of specialist education, and plans for extending services. They also sought information on currently available education and perceived gaps in education. There was a 100% response rate to the questionnaire.
Second, semi-structured face-to-face interviews were conducted with the department leads. These interviews lasted 30 minutes and focused on identifying and understanding the barriers to releasing staff for education. They also facilitated an exploration of perceived barriers to staff participating in education within their teams. All the department leads participated in the face-to-face interviews.
Finally, focus group discussions were arranged with dermatology nursing staff. Thirty-one focus groups were proposed with 146 dermatology nursing staff in bands 2-7. Each focus group lasted 1 hour and was arranged at least one week in advance, at a suitable time to enable staff to attend. The project team facilitated these focus groups, and notes were taken.
The aim of the focus groups was to stimulate discussion and share experiences in a secure space. They centred on the participants' own educational needs, gaps in education, preferred method of delivery and barriers to education. They also allowed for the exploration of motivational factors affecting the uptake of educational opportunities.
Three health board areas could not accommodate a focus group, with reasons for this being given as lack of staffing and time constraints. One health board declined to participate.
The data collected from the interviews and focus groups were thematically analysed to identify key patterns and themes.
Educational needs assessment: findings
Questionnaires
The information gathered from questionnaire responses, supplied by department leads, indicated a diverse array of clinical activities, with the majority encompassing outpatient clinics and treatment, phototherapy, minor surgery and patch testing. Nurse-led clinics were primarily concerned with the management of chronic diseases, systemic therapy monitoring and minor surgical procedures. A broader spectrum of specialist services was accessible within larger teaching hospitals. Interestingly, none of the respondents indicated plans to expand their clinical services.
All department leads reported access to specialist education, with a considerable amount delivered through informal work-based learning by colleagues. Pharmaceutical companies frequently conducted short educational sessions; however, these were often product or condition specific. A national phototherapy education programme was available, but solely in Scotland. Specialist education, including skin surgery and dermoscopy sessions, were also offered. Nevertheless, opportunities for staff attendance were limited due to the location and scheduling of these sessions. The majority of department leads (n=27, 87%) identified an overall deficiency in education and could highlight specific areas of educational voids. The most frequently identified educational gap, referred to as ‘basic knowledge’, encompassed skin anatomy, common skin conditions, and their treatments (n=30, 97%). All department leads in Ireland identified phototherapy as a high-priority area for educational development. They also highlighted the lack of a formal dermatology education pathway culminating in a specialist qualification (Figure 1).
Interviews
Face-to-face interviews facilitated an understanding of the barriers preventing the release of staff for educational purposes. The primary hindrances included workload, time, staffing and funding (Figure 2). A notable issue in certain areas was the lack of staff with adequate experience to supervise and train others. The department leads also discussed the barriers preventing nursing staff in their teams from participating in education. These included lack of time, funding and study leave. Strikingly, more than one quarter of department leads thought there was a lack of interest in education among staff, evidenced by a reluctance to actively seek educational opportunities.
Focus groups
Most focus group participants concurred that there was an overall scarcity of dermatology education. The most identified gap, mirroring the findings with the department leads, was with regard to basic dermatology education (83%), followed by systemic therapies, paediatrics and surgery (Figure 1). Informal peer-delivered work-based education and face-to-face learning were the preferred learning modes. E-learning was favoured among focus group participants, particularly when optional, relevant to their roles, and integrated into a structured educational programme. However, staff often linked e-learning to mandatory training and considered it time consuming, irrelevant to their roles, and not conducive to learning.
Several barriers to education participation emerged during the focus group discussions, including lack of time, funding, staffing, study leave, accessibility and limited role progression opportunities Figure 2). These findings echoed those of the department lead interviews. However, the most frequently cited barrier to education within focus groups was a lack of awareness and poor promotion of educational opportunities. Confusion arose regarding the application and approval processes for study leave and funding. Moreover, participants questioned the relevance and appropriateness of some educational offerings. In discussing methods of advertising education nationally, many participants agreed on the effectiveness of social media. Sentiments regarding the shortage of support for education and unequal opportunity availability permeated some focus groups. Participants thought that nursing staff of higher banding had more opportunities to attend educational events and observed a lack of transparency in the decision-making process for educational opportunity allocation.
Educational needs assessment: discussion
Overall, the data collected across the different staff groups revealed a number of similar areas for development. The next steps were for the project team to collate these findings and consider how they could improve access and uptake of dermatology education.
Deficit of educational provision
These educational needs assessments validated the scarcity of dermatology education provision and access across Scotland, Northern Ireland, and the bordering counties of the Republic of Ireland. This observation aligns with the findings of Price and Reichert (2017), who highlighted the lack of suitable and accessible education, particularly formal courses for highly specialist nurses. Beroukhim et al (2015) identified the need for dermatology education that is user friendly, compatible with substantial clinical workloads, and adequate in depth and duration. The Scottish Government (2016) posited that, if specialist nurses are to deliver high-quality, evidence-based patient care, standardisation of post-registration education's content, quality, and quantity is crucial.
Furthermore, most dermatology education currently delivered is informal work-based learning provided by experienced peers, focused on sharing practical skills, often following the traditional medical and nursing training model of ‘see one, do one, teach one’.
Specialist education
Many of the department leads and clinical nurse specialists requested information about master's level dermatology modules. Some nurses had completed an MSc course in clinical dermatology, however, this was not available as distance learning and was therefore not accessible to everyone. Paediatric dermatology training was requested by a small group of nurses. A UK higher education institution decided enough demand was available to run a course and some of the dermatology specialist nurses enrolled on this. Another higher education institution was approached to provide a dermatology module as part of its MSc Advancing Practice programme. A distance learning module was developed, and several dermatology nurses completed this. However, because of a lack of student enrolments, this module was discontinued, because it was not financially viable.
Barriers
The obstacles to managers releasing staff for education included workload, staffing pressures, and the financial burden. These findings were in line with those of several similar studies (Chong et al, 2016; Govranos and Newton, 2014; Hallin, 2014; McCrow et al, 2014). Nursing staff highlighted similar barriers to education, including funding, study leave, time, staffing, and lack of support. Beroukhim et al (2015) also reported similar findings and found that even staff engaged in learning struggled to allocate sufficient time for education due to the absence of appropriate dermatology education. Penzer-Hick (2018) found that 60% of outpatient-based dermatology nurses did not have protected study time.
Access
To ensure transparency and consistency of access staff proposed that all available education should be advertised, along with the funding application process. Price and Reichert (2017) were also concerned that a lack of staff awareness of educational opportunities was a barrier. Caramanica and Spiva (2018) asserted that education regarding practical clinical skills that facilitate staff growth and service development are more likely to be accessed, and this was also reflected in this study.
Motivation
Being an effective practitioner was viewed by the participants as motivation for undertaking education. Most focus group participants cited motivation as a key factor when considering their role development, particularly when learning a new clinical skill. However, using education to stay updated with other practice aspects was not considered equally important.
Wilkinson and Hayward (2017) found that traditional teaching and learning methodologies presuppose education provision with no requirement for learners to seek it independently. Conversely, most work-based learning assumes that adults are self-directed and motivated to learn. Martyn et al (2014) also argued that nurses find the transition to becoming active learners – taking responsibility for, participating in, and generating learning opportunities – challenging.
The lack of a clear career pathway with a direct route for progression was a significant demotivating factor, particularly for clinical nurse specialists. A Royal College of Nursing (2021) workforce survey also noted an increased number of nurses feeling frustrated due to the lack of career progression and professional development opportunities.
Lack of support
Staff identified the lack of both clinical and educational support, particularly from managers, as the most significant factor impacting their career development. The findings of Price and Reichert (2017) were in line with this, identifying that only 12% of registered nurses thought that their employers supported educational opportunities. Access to education was often hampered by the perception that career opportunities are contingent on service length rather than clinical skills and competence. It was also found in this study that there was a variance in the knowledge and motivation among nurses to identify and access educational opportunities. Cleary et al (2013) reported a similar view, stating that nurses value workplace support for education because this improves both staff retention and job satisfaction.
Signposting
Signposting nursing staff and co-ordinating appropriate education was an important aspect of the project – several participants commented that they were not informed about educational opportunities. Some participants were unaware that the education they were seeking was already available. Examples include training on psychosocial assessment, dermoscopy, photodynamic therapy, leg ulcer, and skin cancer modules. The project team were able to direct participants to the education that was required.
Educational development
Following the educational needs assessment, the findings and data were used to inform the development of relevant and sustainable education, which could be accessed by all levels of nursing staff working in dermatology. E-learning modules were developed to meet the educational needs identified. These included the structure and function of the skin, eczema, psoriasis, blistering conditions, emollients, and an introduction to topical therapies. E-learning can be a powerful tool in providing education and maximising the potential audience capacity (Cameron et al, 2014). This content was made available on a national e-learning platform accessed via NHS Education for Scotland. The target audience was secondary care dermatology nursing staff, and some departments made this education mandatory for all their staff. This module (https://learn.nes.nhs.scot/48522) has been accessed and completed by a range of healthcare practitioners from a variety of settings, including primary and secondary care, nursing homes and universities.
Phototherapy education was identified as a need by many of the dermatology nurses from Ireland. The National Managed Clinical Network for phototherapy in Scotland, Photonet, has a mandatory e-learning programme for all phototherapists. Photonet was approached and agreed to share this module more widely. It was hosted on the national e-learning platform accessed via NHS Education for Scotland (https://learn.nes.nhs.scot/49081/phototherapy). This module has now been shared with a further 14 health boards and there have been 227 enrolments in Ireland alone.
All the focus group participants requested face-to-face study days. Two study days were developed and delivered for healthcare support workers. Topics included basic dermatological conditions and practical sessions teaching topical cream application, sampling, patch testing, assisting in surgery and patient education. Three study days were also held for registered nurses, and these were funded by a pharmaceutical company and were free to attend. These sessions received positive feedback in evaluations from attendees, and this information was shared with individual health boards to encourage them to replicate these sessions locally to continue to provide education for their staff.
A private Facebook group called ‘Dermatology nurses in Scotland and Ireland’ was formed as a result of this project and used to inform members about courses and study days that might be of interest. Around 130 people joined the group, which was initially established to share educational opportunities, and which was then also used to help share best practice. For example, the group shared good practice with the aim of changing national guidelines on the recommended dilution and safe use of potassium permanganate (Chin et al, 2022). This networking opportunity enabled the development of relationships between different dermatology units, connecting staff in similar roles who would have otherwise worked in isolation.
Recommendations for the future
The specialty of dermatology in the NHS relies on the continuous development and advancement of the role of the dermatology nurse (Penzer-Hick, 2020); the need for education to develop a nursing workforce to sustain dermatology services has been recognised by the Scottish Government.
The short-term benefits of the project have been achieved in the successful implementation of an e-learning programme and this continues to be used as an educational tool. The opportunity for networking between different health boards has allowed more collaborative working. Ideas and knowledge have been shared, especially in developing nurse-led initiatives. However, the appointment of a permanent national education co-ordinator is required to maintain the momentum of this project. There is a need to continue to develop national dermatology education at each level of the career framework, continue to build a network, and encourage the participation of nursing staff.
This project could be replicated in other areas of the UK, with NHS or government support and funding. Dermatology is just one example of many nursing specialties that would benefit from a national approach to education and collaboration between different geographical locations.
Limitations
The project had a goal of developing education for dermatology nurses working in secondary care. Although it is recognised that most dermatology patients are cared for in primary care, because of limited time and funding, primary care nurses were not included in this study. However, several nurses from primary care have not only accessed the e-learning, but also participated in the Facebook group and educational events.
Much time was devoted to creating the content for ten e-learning modules, unfortunately, support for the software development required for the modules was withdrawn before they could go live. As an alternative, staff were signposted to the British Dermatological Nursing Group website (https://bdng.org.uk), where members can access a suite of e-learning modules.
Using video conferencing for lunchtime education was trialled during this project, but the software could not cope with large groups. Since COVID-19 and the changes prompted by social distancing measures, video conferencing software is now widely used, and this has transformed the accessibility of dermatology education.
This funded project ended in November 2022, and some of the activity, such as developing and delivering national study days and administration of the Facebook group, has temporarily ceased.
Conclusion
Changes to nursing roles within dermatology are required to ensure they are fit for purpose and responsive to increasing demands on services and patient's expectations. To ensure that dermatology nurses are competent and capable of performing such a role, a range of high-quality, flexible, accessible, and coordinated education is required. Most of the education currently available for dermatology nurses is lacking and consists mainly of informal, on-the-job training provided by more experienced colleagues. However, this project has provided an opportunity for the development of specialist education. The educational needs of dermatology nurses have been identified through discussion with dermatology department leads and nursing staff. The barriers to and facilitators of education highlighted should be considered when developing sustainable, relevant education to maximise uptake and ensure it is fit for purpose.
KEY POINTS
- Dermatology nursing education within the UK and Ireland is facing significant challenges, including a lack of formal educational opportunities, barriers to releasing staff for education, and a regional disparity of available resources
- The educational needs of dermatology nurses were identified through discussion with dermatology department managers and clinical staff
- Interviews and focus group discussions identified barriers and facilitators to be taken into account when developing education to maximise uptake and ensure it is sustainable, relevant and fit for purpose
- The introduction of digital learning modules and the creation of a networking platform have proven effective in addressing some of these challenges, providing both a versatile education platform and fostering a collaborative environment among dermatology units
- To ensure the sustainability and progression of dermatology nursing education, the appointment of a permanent national education co-ordinator and continuous support for career development are critical. The replication of this educational model in other specialties could also be beneficial
CPD reflective questions
- How can you proactively seek educational opportunities within your area of specialisation and overcome the identified barriers such as lack of time and funding?
- How can digital learning tools and social networking platforms be used more effectively in your current dermatology practice to enhance your knowledge and skills?
- Reflecting on your own career development, what role does continuous education play and how can you contribute to the enhancement of education in dermatology nursing within your department or organisation?