Margaret Bobonich, DNP (Dermatology Nurse Practitioner) & Mary Nolen, MS (Dermatology Nurse Practitioner)
Journal of the American Association of Nurse Practitioners
The number of nurse practitioners (NPs) specializing in dermatology has been rapidly rising. Most dermatology NPs acquire their knowledge and skills through post-master's continuing education, select NP fellowship programs, and on-the-job training. However, the professional competencies for dermatology NPs have not been defined or standardized. Competencies require unique knowledge, skills, and judgment for the care of dermatology patients. A national task force and validation panel was convened to define the entry-level competencies for dermatology NP practice.
The increasing complexity of health care coupled with a shortage of health care providers in the United States has given rise to a growing number of specialty areas for both nursing and medicine. The financial burden of skin disease in the United States is estimated to be $75 billion a year in treatments (ACS, 2017). The cost is expected to increase, given new advances in dermatologic therapies and an aging U.S. population (Lim et al, 2017). Because individuals aged 65 years and older have a higher burden of skin disease, it will mean an increased demand for dermatologic care providers. Yet, trends in the dermatology workforce challenge our ability to meet the rising demand and are attributed to geographic variations, advances in technology, subspecialization within dermatology, dermatology residency training capacity, and evolving trends in practice settings (Ehrlich, Kostecki, & Olkaba, 2017). Variables that also constrain the quality and cost-efficiency of dermatologic care include the Patient Protection and Affordable Care Act (2010), the Medicare Access and CHIP Reauthorization Act of 2015, implementation of electronic health records, and accountable care organizations.
The demand for dermatologic care and shortage of dermatologists has given way to the rising trend of nurse practitioners (NPs) in dermatology. There are approximately 3,700 NPs in the United States who specialize in dermatology according to the 2013–2014 National Nurse Practitioner Practice Site Census (AANP, 2015). A report from the 2014 American Academy of Dermatology Practice Profile Survey showed the employment of NPs and physician assistants (PAs) had increased to 46%, up from 28% in the 2005 survey (Ehrlich et al., 2017). In addition, it suggested that the increased utilization of NPs and PAs corresponded to the decreased waiting times for new patients from 34.4 days in 2005 down to 29.1 days in 2014.
Despite the increasing number of NPs in dermatology, there are limited opportunities for formal graduate and post-master's specialty education and training. Furthermore, dermatology NP competencies that require unique knowledge, skills, and judgment have not been defined. Competencies guide public (health care consumers, employers, colleagues, students, and insurers) expectations, allowing for comparison and judgment of quality of care.
The goal of this project was to use a task force (TF) of NPs with advanced education and training in dermatology to achieve a consensus for entry-level competencies, followed by validation from an external panel. The competenciesdescribed within this document represent those entry-level knowledge, skills, and abilities, which are essential attributes for all dermatology NPs.
How to use this document
Utilization of this work may differ depending on the individual but in all cases should be viewed as a guideline. Dermatology NP competencies delineate the unique knowledge, skills, and abilities of those practicing in the specialty. Although detailed, implementation of these competencies will vary depending on the particular clinical circumstances. Professional competencies should be reviewed and updated periodically to reflect new scientific knowledge, advances in technology, and changes in health care.
This document will provide the foundation for curriculum development and educational preparation for NPs practicing dermatology. All dermatology NPs can use professional competencies as a tool for ongoing self-assessment and lifelong learning. As dermatology NPs obtain experience, training, and expertise, their practice will include more advanced dermatology knowledge and skills beyond those identified in this document. Demonstration and evaluation of more advanced competencies can be performed through various methods including portfolio, direct observation, and certification.
The unique attributes of dermatology NP practice supplement the already established population-foci roles and core competencies for all NPs (NCSBN, 2008; NONPF, 2017). This document provides a brief overview of NP practice, roles, regulation, and education; however, the list of professional competencies is not intended to provide a complete description. Key resources that should be referenced include:
The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, Education (NCSBN, 2008).
APRN specialties emerged in response to the health needs of a population and should be developed, recognized, and monitored by the profession (APRN Consensus Model, 2008). Dermatology NP practice requires a very distinct set of professional competencies. Acquisition of this knowledge, skill, and experience can be challenging for NPs who desire a career in dermatology. Currently, there is no standardized educational preparation, curriculum, or set of competencies that define specialization in dermatology.
In 2005, the Dermatology Nurses' Association (DNA) formed the Nurse Practitioner Society (NPS) to provide education, resources, networking, and leadership opportunities for dermatology NPs (Table 1). The NPS established the Scope of Practice and Standards of Care for the Nurse Practitioner in Dermatology (NPS, 2006). Subsequently, the Dermatology Nursing Certification Board (DNCB), in collaboration with the Center for Nursing Education and Testing, developed and administered the initial dermatology NP certification examination in 2008, which presently serves as the primary method of demonstrating competency. In 2018, the DNCB underwent restructuring to create a dedicated Dermatology Nurse Practitioner Certification Board and pursuit of accreditation through the Accreditation Board for Specialty Nursing Certification.
The National Organization of Nurse Practitioner Faculties defined and detailed professional role competencies that are deemed essential for all NPs (NONP, 2017). Dermatology NPs serve as role models to their peers and an inspiration to a new generation of clinicians considering a career in this specialty. The dermatology NP role combines clinician, educator, patient advocate, scholar, consultant, mentor, and leader, and integrates these roles for individuals, families, and communities. Dermatology NPs are committed to the implementation and preservation of this role. Dermatology NPs participate in various educational venues to strengthen their specialty knowledge and are well prepared to educate and offer consultation to other providers.
Practice and education
“A dermatology nurse practitioner is an advanced practice registered nurse licensed as a nurse practitioner who specializes in the assessment, diagnosis, management, and advocacy of individuals and communities with health and illness of the hair, skin, and nails” (Dermatology NP Coalition, 2017). Nurse practitioners in dermatology provide health care in an ethical framework and in accordance with their licensure, to persons across the life span who seek dermatologic care. In addition to diagnosing and managing acute and chronic skin disease, NPs provide a holistic approach to health promotion and disease prevention for patients and families while serving as advocates, consultants, and researchers engaged in effective interdisciplinary care. As an integral part of the dermatologyhealth care team, dermatology NPs recognize and value collaboration, when appropriate, with interdisciplinary professionals including board-certified dermatologists for optimal patient outcomes.
Licensing and credentialing
As APRNs, NPs are licensed practitioners who practice under the rules and regulations of each state’s licensing board. The Nurse Practice Act in each state delineates scope of practice through regulations that determine a wide array of variables influencing the health care delivery system in that state. It defines the responsibilities and qualifications for nursing practice. Nurse practitioners have full practice authority in many states, whereas other states require them to establish collaborative or supervisory practice agreements with a physician in the same clinical specialty (AANP, 2018).
Dermatology NPs are registered nurses who successfully complete a master's degree, post-master's certificate, or Doctor of Nursing Practice with an accredited NP program. Nurse practitioner education, certification, and licensure are attained in one of six patient population foci identified in the APRN Consensus Model (NCSBN, 2008), which includes: family/individual across the life span, adult gerontology, neonatal, pediatrics, women's health/gender-related, and psychiatric/mental health. Further specialization provides a greater depth of knowledge within that population (Supplemental Digital Content 1, available at http://links.lww.com/JAANP/A10).
Nurse practitioners who specialize in dermatology require additional knowledge and expertise guided by the Scope of Practice and Standards of Care for Nurse Practitioners in Dermatology (NPS, 2006). Dermatology NPs obtain further specialty education through various pathways including: 1) post-master's dermatology NP training programs; 2) continuing education; and 3) on-the-job training with board-certified dermatologists and expert dermatology NPs. These specialty competencies in dermatology must be attained and assessed separately from core competencies in one of the six population-foci areas.
There are few formal post-master's dermatology NP training programs in the United States. Both the Lahey Clinic in Burlington, Massachusetts, (http://www.lahey.org/Departments_and_Locations/Departments/Dermatology/Nurse_Practitioner_Fellowship_in_Dermatology.aspx), and University Hospitals Cleveland Medical Centers in Cleveland, OH (http://www.uhhospitals.org/cleveland/services/dermatology/clinical-education/dermatology-nurse-practitioners-post-masters-training-program), provide interprofessional dermatology education and training. These programs were created through strong partnerships and collaboration with board-certified dermatologists and leaders in academic centers committed to high-quality dermatology education for both physicians and APRNs. A well-organized curriculum, including didactic, grand rounds, portfolio, and clinical experiences, advances as the trainee progresses through learning milestones. The University of South Florida College of Nursing Doctorate of Nursing Practice program offers NPs an option to complete additional course work and clinical practicum experiences in a specialty area such as dermatology (http://health.usf.edu/nursing/academics/dnp/ms-to-dnp).
Nurse practitioners dedicated to dermatology who practice a minimum of 3,000 hours may be eligible for the Dermatology Certified Nurse Practitioner (DCNP) examination offered by the DCNB. Certification through written examination provides validation of knowledge competencies that are consistent with the scope and standards of dermatology NP practice. The APRN Consensus Model (NCSBN, 2008) strongly recommended professional certification in a specialty area of practice. It demonstrates to our colleagues, employers, and the public, a level of expertise in quality dermatology nursing care. Recertification of the DCNP is earned through continuing education or examination every 3 years.
In the Fall of 2015, there was a national call for volunteers to participate in a TF to establish dermatology NP competencies. Fourteen NPs were selected who were board-certified in one of the population-foci areas and with a minimum of 5 years of experience practicing in the specialty of dermatology (Supplemental Digital Content 2, available at http://links.lww.com/JAANP/A13). They represented a variety of practice settings, geographic areas, and dermatology subspecialties. Characteristics of TF members included scholarly contributors to education, research, and publications as well as national leadership in dermatology NP organizations. The TF convened monthly through conference calls from February through May of 2016. Participants were charged with reviewing current scientific evidence in dermatology practice as well as key documents regarding specialty practice and core competencies for NPs including the APRN Consensus Model (NCSBN, 2008) and Nurse Practitioner Core Competencies Content (NONPF, 2014).
The original standards document, the Scope of Practice and Standards of Care for the Nurse Practitioner in Dermatology (NPS, 2006), provided a foundation of work for the TF. Because competencies provide evidence of professional standards, maintaining consistency between the documents was fundamental. However, it became evident that the scope and standards required an update and revision. This was not an intended goal of the TF but vital to the aim of creating a document that is current, consistent, and valid. As such, the TF was engaged in dialog and coordination with a DNA work group and The Dermatology NP Coalition with the mutual goal of advancing the scope and standards of practice. Our work was also conjoined with the DCNB as they updated content and worked toward accreditation of the DCNP certification examination through the American Board for Specialty Nursing Certification.
The first TF meeting focused on published data on dermatology NP education, “A Core Curriculum for DermatologyNPs: Using Delphi technique” (Bobonich & Cooper, 2012). The study included one pilot and two Delphi rounds that scored the level of importance of curricular content. Understanding that competencies (knowledge, skills, and abilities) guide curriculum development, the TF used the data and completed another Delphi round on the content in an effort to update the findings to current-day practice. The TF members reviewed and assessed 91 Delphi items for:
Relevance: Is the knowledge, skill, or ability necessary for entry-level practice? Measure: Relevant or not relevant.
Specificity: Is the item clearly stated and specific? Measure: Yes, no, or write in suggested revision.
Comprehensiveness: Are there any knowledge, skills, or professional attributes omitted? Are there any additions necessary to reflect current practice? Measure: Accept as stated, remove, or revise.
Advanced or entry-level: Is the knowledge skill or ability an entry-level or advanced competency? Measure: Accept as stated or remove if advanced.
The Delphi round from the TF was summarized and returned to the group. Items were retained, deleted, or revised based on the consensus. Although the group achieved consensus on the majority of items, there was a great deal of discussion around content regarding interpretation of dermatopathology reports, advanced surgical and cosmetic procedures, and academic/leadership competencies. These items were reevaluated and ultimately designated as more advanced specialty competencies and not entry-level. Omission of these knowledge, skills, and abilities from the list of competencies would not restrain or restrict experienced and trained dermatology NPs from performing more advanced competencies. Delphi items that were retained and revised were developed into competency statements and organized. The TF produced a final draft of competencies and corresponding standards for review by a validation panel.
A validation panel that comprised TF members as well as NPs with leadership in NP specialty education, NP organizations, credentialing, and certification organizations were invited to a 1-day, in-person meeting on September 24, 2016, in Chicago (Supplemental Digital Content 2, available at http://links.lww.com/JAANP/A13). Karen Sue Hoyt, PhD, ENP-C, FAANP, FAAN, Chair of the ENA NP Validation Work Team for the Competencies for NPs in Emergency Care (ENA, 2008), was the appointed facilitator. Administrative and financial support was provided by the AANP. The validation panel included professionals from various organizations with expertise in one or more of the following areas: clinical dermatology, education of NPs, credentialing, and certification of NPs of graduate and post-graduate nursing programs.
The goal of the validation panel was to objectively review and refine the draft of the Competencies for DermatologyNurse Practitioners document. Items were again reviewed for their specificity (detail and clarity), relevance (necessity for specialty practice in dermatology), and comprehensiveness (inclusion of current knowledge, skills, and ability) for dermatology practice. It was critical that each item was assessed for its uniqueness to dermatology and not an already established core competency essential to all NPs. Recommendations and revision of the drafted competencies included deletion, addition, and revision competency statements and corresponding standards.
The validation panel also deliberated proposed competencies for standards of professional performance for dermatology NPs. These competencies were deemed consistent with the already established Nurse Practitioner Core Competencies Content (NONPF, 2014) and, therefore, redundant. The panel's recommendations were adopted and revisions made to the current document. The recommendations were also shared with the DNA and Dermatology NP Coalition volunteers working simultaneously on updates for dermatology nursing education, standards, and certification.
Dermatology NP Competencies (Table 2) are defined as entry-level knowledge, skills, and behaviors/abilities that are requisite for all dermatology NPs. Competencies provide evidence of the corresponding standard (ANA, 2010a). This document, and the competencies contained within, do not supplant the Scope of Practice or Standards of Care for the Nurse Practitioner in Dermatology (NPS, 2006), which provides detailed information guiding dermatology NP practice. Key concepts that should be considered in assessing this document:
“Whether a particular standard or competency applies depends on the circumstances.” (ANA, 2010a, p. 31)
Competencies provide a model of professional practice and guide curriculum development, self-assessment, and lifelong learning.
Professional competencies can influence credentialing and accrediting bodies as well as policy makers and funding programs.
Dermatology NP competencies identify specialty competencies built atop population-foci roles and core competencies for all NPs (NONPF, 2017).
This document does not provide a detailed description of the essential core competencies for NPs, which is detailed by NONPF (2017).
The emergence of dermatology as a specialty for NPs necessitates the development of competencies that herein describe the unique knowledge, skills, and abilities for professional practice. Specialty competencies are a vital tool for the evaluation of professional performance and provide a critical foundation for the development of educational preparation for practice as a dermatology NP. This document, along with the Dermatology NP Scope and Standards of Practice, identify entry-level competencies for all dermatology NPs. Dissemination of this document will provide clarity of the role and quality indicators for practice of dermatology NPs.
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