Skin cancer is the most common cancer in the United States with rates increasing 
for all types of skin cancers.  Ultraviolet radiation (UVR) exposure, as well as genetics, 
contribute to skin carcinogenesis.  Veterans and persons living in sun-rich areas such as 
desert communities are at increased risk due to UVR exposure. The annual cost of skin 
cancer care is predicted to be near $5 billion for treating nonmelanoma skin cancer and 
approximately $3.3 billion for melanoma.  In addition to skin carcinogenesis, UVR is the 
primary cause of premature photoaging which has a $300 billion dollar antiaging industry 
worldwide.  

Studies conducted among medical and nurse practitioner students show lack of 
skin protection knowledge and inadequate practices.  This DNP project developed, 
implemented, and evaluated a 2-hour training module for advanced practice nurses 
(APNs) at the VAMC in Las Vegas, Nevada, using Health Belief Model constructs and 
Knowles’ Adult Learning Theory.  The module was presented summer 2018 with 31 
participants.  A pre and immediate post-test assessing knowledge, practices and beliefs 
was administered, and a second  post-test was administered 12 weeks later.   

Post-training, participants increased their knowledge (mean score 59% pre-test to 
76% post test). The highest score increase was related to the cause of premature 
photoaging, p < .001.  Sunscreen was the primary method of skin protection reported by 
78% of the participants.  Actual skin protection practices increased: from 3.3 times per week at pre-test, an intention of 6.4 times at immediate post-test, to 4.9 times per week at 
12 weeks.  This indicates an overall effect of time, F(2) = 8.489, p = .001, partial eta 
squared = .207, with a significant increase in actual use at 12 weeks.  Also, Chi-squared 
analysis showed  significant increases in patient education attempts at 12 weeks, 
X2(4) = 24.2, p < .0001.  Moreover, there was a significant decrease in the number of 
nurses who “rarely” recommend skin protection of from 17% pre-test to 1% at 12 weeks.  
Significant increases were found in items indexing HBM constructs of perceived 
susceptibility, perceived severity, and the likelihood of practicing skin protection from 
pre- to immediate post-test.  The threat of skin cancer and photoaging prevention 
moderately influenced nurses’ practice (perceived benefits). 

These results support prior studies showing that skin cancer and premature 
photoaging prevention knowledge is lacking among APNs.  This implies that the 
USPSTF recommendation of providing patient education for skin prevention is not being 
implemented. Short training such as that done in this project can enhance APN 
knowledge and skin protection practices, as well as change nurse behaviors with patients 
related to skin protection, skin cancer causes, protection methods, and routine skin 
examination recommendations should be added to the curriculum in APN/MSN 
programs, and should be one of the required training for the nurses at the VAMC for their 
own benefits and to educate the Veterans.