Skin surgery

4 Skin surgery

Carrie Wingfield RN MSc

The incidence of skin cancer in the UK is increasing (see page 38). In response to this trend, many UK dermatology services have proactively transformed their workforces by training first-level registered nurses to become competent in skin surgery at different skill levels. Here, we outline the role of nurses performing skin surgery and the clinical governance that provides training opportunities for a large portfolio of evidence-based competencies within a range of clinical settings and responsibilities.

The GIRFT national dermatology report, published in 2021, acknowledges the world-leading status of British dermatology nursing. The report confirms that nurses now perform dermatological surgery, a role previously reserved for doctors, and that dermatology capacity is improving in settings where nurses are being trained and utilised in this field. The report stresses that nurses performing these roles must be supported by a consultant dermatologist-led team.1

Nursing role

Roles in dermatological surgery vary from diagnostic minor surgery to advanced-level excisions (Table 4.1). Although there are differences in nurse training, background and service delivery for skin surgery across the UK, for most nurses it is an extended role that requires background experience in skin lesion recognition, both benign and malignant.

The patient care setting. Minor dermatological surgery can be performed in various settings provided the clinical governance for patient safety has been met. These include community- and hospitalbased dermatology services, dermatology nurse-led services in primary and secondary care, and private-care clinics.

Core knowledge domains. The rationale is to develop nurses with competence in technical procedures that is underpinned by knowledge. For example, nurses undertaking surgical roles must understand why a particular procedure is appropriate for the diagnosis. Therefore, surgical competence is best supported by general dermatology education and skills (Table 4.2). Particular benefit is gained from having an assessed knowledge and clinical experience of skin lesion recognition and the use of dermoscopy. These are

TABLE 4.1

Minor and advanced surgical procedures

Minor procedures • Punch biopsy/excision • Shave biopsy/excision • Curretage and cautery • Snip excision Advanced procedures • Elliptical excision • Incisional biopsy • Excision and full-/split-thickness skin graft repair • Simple flap* • Wedge excision (ears)* • Excision with secondary intention healing*

*Competency framework not included in this chapter. Local policy and competency training advised, following core aspects.

important skills that complement dermatological surgery and improve patient experience and outcomes.

Given that surgical lists are often populated by other clinicians and lesions can evolve in terms of size and symptoms, the nurse must be able to question the procedure before starting it and seek advice to ensure the patient receives the most appropriate procedure for their skin presentation on the day of surgery. A differential diagnosis may need to be considered, leading to an alternative procedure.

Scope of practice. The BDNG role descriptors for dermatology nurses (see page 12) clearly define the suggested scope of practice and align with AfC banding (see page 38).2 The BDNG document includes recommendations for banding associated with a particular level of practice. For example, band 5 nurses would not perform surgical procedures independently, while advanced surgery may be undertaken by nurses with higher banding as part of an advanced practice role and could include further expertise in the management of patients

TABLE 4.2

Knowledge domains underpinning surgical skills

• Skin assessment • Anatomy of skin and nerves, in particular recognising danger zones for surgery • Consent process and mental capacity assessment • Clinical risk assessment, including assessment of correct site of lesion/ area before surgery commences (to avoid wrong-site surgery) • Margin control (for more advanced surgery) • Infection control and sterile technique • Dermoscopy examination • Use of photographic images • Non-surgical interventions (e.g. topical options, cryotherapy; see Table 3.2) and when these may be more appropriate than surgery • Head and neck anatomy for identification of danger zones

with skin cancer. Banding at a local level will be determined by a combination of factors, including the level of independent clinical decision-making and responsibilities in other domains (for example, leadership) against the backdrop of specific service need. For most nurses, a skin surgery role is likely to form part of a wider job description. However, it is recommended that all levels of skin surgery nurses should spend at least 50% of their clinical time using these skills in order to maintain competence.

Trust protocols for skin surgery

As skin surgery is considered an extension to a nursing role, a ratified Trust protocol approved by the relevant governance structures must be in place. Such a protocol should include: • identification of the patient groups that nurses can care for, with clear inclusion and exclusion criteria • well-defined referral criteria • a clear patient pathway, including how the patient will be followed up and what happens if they do not attend follow up

• lines of accountability and responsibility, with detail of clinical supervision • how competence is recorded, including the importance of reflecting new skills and roles within job descriptions.

The protocol should be supported by a specific scope of practice and competency framework to ensure the nurse possesses the knowledge, skills and abilities required for lawful, safe and effective professional practice. The scope of practice, detailing the functions that can be carried out at each band, should be cross-referenced to the overarching protocol. Core competencies should form the basis of competent dermatological surgery, but to make a competency framework that is fit for purpose in each environment, consideration will need to be given to specific local service and patient needs.

Nurses deliver skin surgery via a number of different patient pathways depending on how individual services are set up. When establishing a nurse-led skin surgery service it is critical to be clear about these pathways as they will require different levels of competence. The initial part of any patient assessment prior to a nurse-led surgical intervention should ask the following questions. • Has the lesion resolved or increased in size? • Does a change in the lesion take the procedure outside the scope of practice of the nurse?

These questions are particularly important if there is a significant time lag between the patient being added to the nurse’s list and the scheduled surgery. If the answer to either of these questions is ‘yes’, then the nurse should consult with a senior clinician or the person who originally referred the patient to determine next steps. Once it has been confirmed that it is still appropriate for the nurse to remove the lesion, the following checklist should form part of the nursing assessment. • Is the patient still happy for the procedure to go ahead? • Has documented informed consent been obtained, considering: – the mental capacity of the patient – whether the patient’s general health poses an unacceptable clinical risk? • Is there any change in the lesion that may require a different management plan?

• Has postoperative care been discussed with the patient, including: – how to look after the wound – what to do if there are signs of bleeding or infection – what sort of follow up will be required – what to do in case of an emergency?

Competence levels

Comprehensive and robust clinical governance must be established for all nurses performing skin surgery, with a clear scope of practice that is competence-based and covers all elements of the surgical service that the nurse provides. This includes SOP, with clear provision of clinical supervision and exclusion and inclusion criteria. Clinical supervision must cover all areas of skin surgery, including: • obtaining consent • documentation • performing biopsies and/or excisions to a good standard • monitoring surgical margins/keeping an accurate surgical log • lidocaine infiltration.

Competence levels, as recommended in Table 1.2 (see page 16), should reflect the contents of the service protocol and scope of practice. Competence levels can be set for each function of skin surgery (Table 4.3) and should be monitored using work-based assessment tools, including DOPS, case-based discussions, mini clinical evaluation exercises (direct observation of an interaction with a patient), feedback from multiple sources (including colleagues and patients) and patient experience surveys.

Ensuring patient safety and best outcomes

Performing minor and advanced dermatological surgery carries considerable clinical responsibility and accountability. Potential complications, such as infection at the surgical site and postoperative scarring, together with the risk of wrong-site surgery must be considered and managed appropriately. Robust protocols that align with a competency-driven scope of practice must be in place. Clearly outlined exclusion and inclusion criteria for procedures are needed, along with a named clinical supervisor (for example, consultant

TABLE 4.3

Competency framework for each function of nurse-led skin surgery Theoretical measures

Understands rationale for informed consent • Demonstrates knowledge of the principles of obtaining informed consent

Competency Practical measures

Gives patient appropriate information • Provides patient information in clear and r elevant language

Informed consent Identifies circumstances wher e specialist advice may be needed

Ensures patient has full understanding and awar eness of the procedure Performs mental capacity assessment where appr opriate, according to Trust policy and mandatory training requirements Understands the legal requir ements of lasting power of attorney Understands the concept of a ‘best interest’ decision and how it is carried out in line with local policies

Can answer routine questions asked by patients befor e skin surgery Fully explains any alternative tr eatments or the implications of no treatment Discusses the expected and potential cosmetic outcome Accurately recor ds information on relevant consent form

CONTINUED

TABLE 4.3 CONTINUED

Competency framework for each function of nurse-led skin surgery Theoretical measures

Understands indications, cautions and • contraindications of procedur e* Describes potential complications † • Describes how complications/untoward r eactions would be managed* Identifies situations where specialist advice may be r equired*

Competency Practical measures

Effectively pr epares patient physically and psychologically for the procedure*

All procedures • Checks anaesthesia is adequate before starting pr ocedure* Uses correct surgical instruments/equipment

† pr oficiently Safely and effectively performs pr ocedure according to local guidelines/protocol* Achieves haemostasis using an appropriate technique (e.g. subcutaneous suture[s] for punch biopsy) † Assesses patient discomfort and uses effective methods of r elief † Collects specimens appropriately and corr ectly completes histology form ‡ Accurately recor ds procedure in patient’s records* • Effectively communicates advice and after care to patient † Correctly disposes of, disinfects and maintains • equipment*

As for all procedures,* plus: Demonstrates knowledge of structure, function and anatomical hazar ds of the skin Describes action of local anaesthetic on the skin •

As for all procedures,* plus: Accurately calculates safe dosage levels • Draws up and checks local anaesthetic correctly • Checks effectiveness of local anaesthetic during the pr ocedure Gives appropriate advice to patient about duration and side ef fects of anaesthetic

Lidocaine anaesthetic infiltration † plus: As for all procedures,* Identifies appropriate sutur e material for procedure and anatomy Provides appr opriate aftercare advice for suture removal Understands and works to local policy for needle stick injuries; takes responsibility for safe disposal of sharps after pr ocedure

† plus: As for all procedures,* Selects appropriate sutur e material • Demonstrates appropriate suturing technique: placement, knot tying, appearance of final incision

Interrupted sutures/deep dermal sutur es (advanced) Selects appropriate dr essing •

† As for all procedures*

Punch biopsy As for all procedures* †‡ As for all procedures* †

†‡ plus: As for all procedures,* Ensures cur ettage is most appropriate procedure to analyse the lesion histologically

Curettage and electrocautery

CONTINUED

TABLE 4.3 CONTINUED

Competency framework for each function of nurse-led skin surgery Theoretical measures

Competency Practical measures

As for all procedures* †

†‡ plus: As for all procedures,* Ensures shave biopsy is most appr opriate procedure to analyse the lesion histologically

Shave biopsy/ excision/snip As for all pr ocedures* †

†‡ plus: As for all procedures,* Performs adequate and complete excision of lesion with appropriate choice of pr ocedure Has comprehensive knowledge of surgical margins depending on clinical diagnosis

Ellipse excision/ incisional biopsy (advanced) Understands the importance of scar orientation and use of orientation marker sutures

Note: each of the competencies described here can be attained at levels 0–5 (see Table 1.2). *All procedures.

‡ All procedures except lidocaine anaesthetic infiltration and suturing. † All procedures except lidocaine anaesthetic infiltration.

dermatologist, plastic surgeon or consultant nurse) who can collate competency work-based evidence assessments.

It is a firm recommendation that skin surgery should not be carried out in an isolated situation where no backup or supervision is available to support patient and nurse safety. Even in minor surgery, adverse events can occur such as fainting/collapse, cardiac episodes, allergic reactions and panic attacks.

The combination of technical ability and diagnostic skills is supported by a well-structured training programme that promotes patient safety together with appropriate professional development. This is important as, in the event of litigation, root cause analysis or significant/never events (Box 4.1), it can be demonstrated that the individual practitioner has not only worked within their scope of

BOX 4.1

Definitions

Root cause analysis3

• A quality governance procedure used to investigate adverse events • Raised as part of a critical incident/significant event where there is the potential for harm • Looks at clinical governance and protocols, including competencies where appropriate • Aims to discover the root cause of the problem and identify appropriate solutions

Never events4

• Identified by NHS England as serious incidents that are preventable • Wrong-site surgery is considered a never event. Protocols for nurse-led procedures to avoid wrong-site surgery should include: – Patient photographs to identify the area – Patient to agree to surgical site at consent – Use of a mirror to assist patient’s identification of the area – Use of previous consultation notes to assist in identifying the area – Seeking a second clinical opinion if there is any clinical doubt about the surgical site

practice/protocols but also has overarching accredited training and qualifications.

Courses and training. The competency framework outlined in Table 4.3 demonstrates that training and education are paramount in this field. For both minor and advanced skin surgery, training and education should encompass both work-based learning and academic study to ensure the best learning outcomes and most effective patient care.

Work-based learning should be undertaken with appropriate clinical supervision using work-based assessment tools. Used in combination with protocols and scope of practice the nurse can collate assessment evidence to be signed off as competent at levels 0–5 (see Table 1.2, page 16). Competencies should be reassessed on an annual basis and form part of the nurse’s appraisal process.

Academic study comprises a formal accredited university-led module with a clinical portfolio of evidence and OSCE.

Identifying training needs. Some nurses may already be practising dermatological surgery through work-based assessment with no external verification or learning.5 It is therefore critical that clinical skills remain up to date and that the competencies of all staff are continuously assessed. External qualifications are recommended to support in-house training. A validated surgical course will complement and enhance technical ability while underpinning the important background knowledge required to perform procedures and promote sustainable clinical governance. In addition, job descriptions should reflect the enhanced skills required to perform dermatological surgery.

At annual review, training or educational needs should be identified and plans made to achieve them. These may include accessing the BDNG’s online resources, study days and conferences, such as the 2-day taster course ‘Introduction to Skin Surgery for Nurses’. Higher education options include an MSc in skin lesion management at the University of Hertfordshire, which has a skin surgery skills module.6

Minimum standards for staffing and facilities.7 All staff should be appropriately supported during surgical interventions, with at least one support nurse (two for more advanced surgery), as well as

access to secretarial and administrative support. All staff must keep up to date with mandatory training, in particular cardiopulmonary resuscitation, and know the location of their nearest resuscitation trolley, in line with the Trust’s resuscitation policy.

Skin surgery nurses should have access to senior clinical advice and support within their departments in case of adverse incidents or if they run into difficulties. Working as a sole practitioner with no onsite backup is not advocated.

All surgical procedures must be undertaken in an appropriate clinical space used solely for surgery (Table 4.4).

TABLE 4.4

Minimum standards for skin surgery facilities7

• Reception and waiting area/recovery area for day-case procedures • Dedicated operating facility (used solely for surgery) – Adequate size – Clean room with wipe-clean surfaces – Clear of clutter – Wheelchair access • Operating couch • Suction/smoke extraction • Ideally, hands-free theatre-style sink with wall-mounted antiseptic/scrub materials • Good lighting • Good quality instruments/sharps box • Electrosurgical generator (e.g. unipolar/bipolar Hyfrecator®) • Telephone and emergency call buttons • Computer access • Patient changing area with curtains or screen • Nearby resuscitation equipment • Access to relevant histology equipment (e.g. pots) • Postoperative information for patient

Ongoing monitoring. An annual audit should be carried out, measuring the following against agreed organisational standards. • Patient experience. • Infection control, ensuring correct aseptic non-touch technique and adherence to infection control policies. • Use of Local Safety Standards for Invasive Procedures (LocSSIP) or

World Health Organization surgical check lists as part of clinical risk assessments. • Margin control for advanced surgery (this forms part of an individual’s annual competency assessment). • Documentation, including consent forms, ensuring they adhere to

Trust/local policies. • Surgical site infection, monitoring infection trends, patient aftercare information and appropriate antibiotic use. • Attendance at skin cancer MDT meetings (80% attendance is required for those practising advanced surgery).

Performance review. The skin surgery nurse’s annual performance review should run alongside a portfolio of competency evidence that includes work-based assessment, training and education. The annual review should identify any professional development needs and/or knowledge deficits so that appropriate training can be planned. It is also the ideal time to ascertain that appropriate clinical supervision is still in place and is adequately supporting nursing staff.

Trust-based protocols and scopes of practice should also be reviewed annually to ensure they remain fit for purpose.

Meeting service needs. An annual assessment should also be made to determine whether service needs continue to be met. This may include: • assessing the need for succession planning and training of new staff • acting on feedback from patient surveys • ensuring there are adequate numbers of support staff and that they are trained appropriately • ensuring the environment meets infection control standards for dermatological surgery • ensuring equipment is always of an acceptable standard and in full working order.

Meeting nurses’ needs. Alongside the support of immediate colleagues, the development of nurses to perform surgical procedures requires good management and provision of the appropriate infrastructure to support their clinical activity. Consequently, to ensure the viability and sustainability of nurses undertaking skin surgery, capacity issues in overstretched departments, such as limited room space or shortages of support staff, must be addressed. Clinical supervision must always be in place, so daily clinic planning must take into consideration medical vacancies, staff sickness and annual leave; rosters need to reflect the governance required for clinics to go ahead.

Senior nursing and managerial staff need to be engaged to ensure they understand the clinical nurse activity involved in undertaking surgical procedures. This avoids any misunderstanding or misconceptions about the role and ensures that clinical governance is robust at an organisational level.

Next steps

If you are interested in a career in skin surgery, network with other nurses who are already performing this role; most will be happy to discuss the role and advise on where to find further information. Also discuss your interest with your line manager/clinical lead, and present a case for how your development in this area could impact on the department’s capacity and improve patient accessibility.

Find out more about higher education options (see Table 1.1) and funding options. Visit the BDNG website to utilise the online resources, study days and conferences; the BDNG also has a skin surgery subgroup offering contact, support and training.

The future

To meet patient needs, workforce changes in dermatology services mean that patient care will be delivered according to clinical competence rather than strict role boundaries. Nurses and other healthcare professionals, such as physician associates, will continue to develop new skills and take on extended roles such that their jobs will look very different from traditional nursing roles. We hope that the governance recommendations in this chapter help to direct the

nurse and the team they work with towards developing roles that are professionally satisfying but that also enhance patient safety and the quality of care delivered.

Personal reflection

Dermatology is a diverse specialty to work in as a consultant nurse, and the opportunities are there for professional development if you take the initiative and are well supported. It is a career move I have never regretted and know I will continue to enjoy.

Key points – skin surgery

• Skin surgery is usually an extended role for dermatology nurses with knowledge and experience in skin lesion recognition; roles vary from diagnostic minor surgery to advanced-level excisions. • All levels of skin surgery nurses should spend at least 50% of their clinical time using their surgical skills to maintain competence. • Competence in surgical procedures must be underpinned by knowledge in a wide range of areas, including skin assessment, anatomy, clinical risk assessment, infection control and non-surgical interventions. • Core competencies for all skin surgery procedures include obtaining consent, physically and psychologically preparing the patient for the procedure, ensuring the patient receives adequate anaesthesia before the procedure commences, performing the procedure safely and effectively with proficient use of instruments and equipment, achieving haemostasis, assessing and relieving patient discomfort, accurate recording, effective communication of aftercare, and correct disposal and disinfection of equipment. • Skin surgery should never be carried out in isolation without backup or supervision to support patient and nurse safety, and it should always be undertaken in an appropriate clinical space used solely for surgery with appropriate facilities. • All skin surgery nurses should receive an annual performance review to reassess competencies and identify training or educational needs. An annual audit of the skin surgery service should also be undertaken to ensure organisational standards and ongoing service needs (for example, adequate staff levels and training) are met.

References and resources

1. Levell N. Dermatology. GIRFT

Programme National Specialty

Report. NHS Publishing, 2021. www.bad.org.uk/ getting-it-right-first-time-girftdermatology-report-launches, last accessed 1 February 2022. 2. British Association of

Dermatologists Education

Board. Clinical Dermatology

Nursing Role Descriptors:

Guidance on Scope of Practice.

British Dermatological Nursing

Group, British Association of Dermatologists and Royal

College of Nursing, 2020. bdng.org.uk/wp-content/ uploads/2020/08/BAD-BDNG -RCN-NURSING-WORKSTREAM -A4-LANDSCAPE-002.pdf, last accessed 1 February 2022. 3. Haxby E, Shuldham C. How to undertake a root cause analysis investigation to improve patient safety. Nurs Stand 2018;32:41–6. 4. NHS England. Never Events

Policy and Framework. NHS

Improvement, 2018. www. england.nhs.uk/publication/ never-events, last accessed 1 February 2022.

Further reading

Price CJ, Sinclair R. Fast Facts: Minor Surgery, 2nd edn. S. Karger Publishers Ltd, 2008. 5. Eddy L, Duffy R. A study of the skills, education, and qualifications of nurses performing dermatological surgery in the United Kingdom.

Dermatol Nurs 2019;18:10–15. 6. University of Hertfordshire. MSc

Skin Lesion Management [course details]. www.herts.ac.uk/ courses/postgraduate-masters/ msc-skin-lesion-management, last accessed 2 April 2022. 7. British Association of

Dermatologists. Staffing and

Facilities Guidance for Skin

Surgery Dermatology Services.

Clinical Services Unit British

Association of Dermatologists, 2014. https://cdn.bad.org.uk/ uploads/2021/12/29200244/

Staffing-and-Facilities-for-Skin-

Surgery-Dermatology-Services-

V4-Checked.pdf, last accessed 12 July 2022.