FEATURE ARTICLE. 2.5 Contact Hours. Maxine A. Lucas, Lois J. Loescher, Christy L. Pacheco

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1 FEATURE ARTICLE Nurse Practitioners Knowledge of Prevention Guidelines and Counseling Practices Related to Primary Prevention of Skin Cancer Among Adolescents in Arizona Maxine A. Lucas, Lois J. Loescher, Christy L. Pacheco 2.5 Contact Hours ABSTRACT: Skin cancer is the most common cancer worldwide and one of the most preventable. Skin cancer incidence continues to rise among adolescents. The inconsistent practice guidelines for skin cancer prevention create challenges for counseling. The purposes of this study were to investigate skin cancer knowledge, attitudes, and primary prevention counseling practices by Arizona nurse practitioners caring for adolescents on an outpatient basis and to determine congruency of counseling with evidence-based guidelines. Participants completed a quantitative, descriptive, cross-sectional study using an online survey. The main variables were knowledge of skin cancer, skin cancer prevention, attitudes regarding counseling, current practice guideline use, and recommendations. Of the 67 participants who responded to the survey, 51 were eligible, and 44 completed the survey. Maxine A. Lucas, DNP, FNP-C., University of Arizona College of Nursing, Tucson, AZ. Lois J. Loescher, PhD, RN, University of Arizona College of Nursing, Tucson, AZ. Christy L. Pacheco, DNP, FNP-BC, CON Rural Health Professions Program, University of Arizona College of Nursing, Tucson, AZ. No funding was received for this work from any organizations including the National Institutes of Health, Wellcome Trust, Howard Hughes Medical Institute, or others. The authors declare no conflicts of interest. Correspondence concerning this article should be addressed to Maxine A. Lucas, DNP, FNP-C, 6917 Kingwood Rd., Little Rock, AR maxinel@ .arizona.edu Copyright B 2016 by the Dermatology Nurses Association. DOI: /JDN Participant knowledge regarding skin cancer was moderate to low, and less was known about skin cancer in adolescents. Despite positive attitudes toward skin cancer prevention, participants reported low rates of counseling in practice, similar to previous interdisciplinary research. Reported recommendations used in practice were not reflective of any one particular guideline. Future research should explore barriers to incorporating primary prevention counseling practices and aim to educate nurse practitioners on skin cancer prevention. Key words: Nurse Practitioner, Prevention, Primary Care, Skin Cancer BACKGROUND Skin cancer is the most common cancer worldwide, affecting all races, ethnicities, and ages. It is also one of the most preventable cancers, but the incidence is on the rise. More than 3 million Americans are diagnosed with nonmelanoma skin cancer (NMSC) each year (Centers for Disease Control and Prevention [CDC], 2013; U.S. Preventive Services Task Force [USPSTF], 2012; World Health Organization, 2015). The American Cancer Society estimated in 2014 that, of the 5,330 new cases of cancer diagnosed in adolescents 15Y19 years old, 6% were melanomavthe most serious skin cancer. Melanoma ranks in the top three cancers affecting persons younger than 20 years old (National Cancer Institute [NCI], 2014). Mounting evidence implicates exposure to ultraviolet radiation (UVR), a carcinogen that causes DNA damage, gene mutations, immunosuppression, oxidative stress, and inflammatory responses, increases skin cancer risk 368 Journal of the Dermatology Nurses Association

2 (Armstrong & Kricker, 2001; CDC, 2014; Gilchrest, Eller, Geller, & Yaar, 1999; Gordon, 2013). UVR exposure during childhood comprises approximately 25% of lifetime UVR exposure and has been established as a major risk factor for skin cancer in adulthood (Balk, Council on Environmental Health, & Section on Dermatology, 2011; Wehner et al., 2014). Intentional exposure to UVR, including tanning bed use, among adolescents continues to be prevalent (CDC, 2015a; Davis, Cokkinides, Weinstock, O Connell, & Wingo, 2002; Wehner et al., 2014). Thus, healthcare providers have a responsibility to begin skin cancer prevention counseling during youth to establish healthy behavioral patterns and lifestyle choices (CDC, 2011; Maguire-Eisen, 2013; Wehner et al., 2014). Preventive Behaviors for Adolescents Adolescence is a dynamic period of psychosocial, physical, and cognitive transition from childhood to adulthood, during which time decision making and behaviors are influenced by peers, family members, communities, and institutions, resulting in either risk taking or preventive health behaviors and established lifestyle choices (CDC, 2011; Garzon & Dunn, 2013). Each professional organization defines adolescence differently, without a standard age range, but typically, adolescence occurs between 10 and 19 years old (World Health Organization, 2014). The successful development of healthy lifestyle choices and behaviors in adolescence provides a foundation for a healthy adult life (Garzon & Dunn, 2013). Because of the developmental milestones and impact interventions may have on this population, education and encouragement of preventive behaviors are essential for this age group. Prevention Recommendations Most skin cancer prevention recommendations target reducing UVR exposure (see Table 1; Armstrong & Kricker, 2001; CDC, 2014; Gilchrest et al., 1999). Evidence supporting behavioral interventions to change sun protective practices is limited with no randomized controlled studies supporting counseling linked to skin cancer reduction (National Cancer Institute, 2015). However, there is substantial evidence associating UVR exposure as a risk factor for the development of NMSC and melanoma. The consensus is that practicing these behavioral recommendations outweighs their potential harms (NCI, 2015). Therefore, several professional organizations, including AAD, AAP, and American Academy of Family Physicians (AAFP), encourage sun protection strategies for primary prevention (see Table 2), despite there being no consensus on who should be counseled, when they should be counseled, and what information should be emphasized. Primary prevention counseling practices by nurse practitioners and other primary healthcare providers are unknown (Federman, Kirsner, & Concato, 2014). Knowledge of nurse practitioners use of skin cancer prevention guidelines is important for understanding the current TABLE 1. Recommendations for the Prevention of Skin Cancer in Adolescents Regular broad-spectrum, water-resistant sunscreen use of SPF 30 or greater - Use on all exposed areas of the body - Apply generously and uniformly - Use enough to fill a shot glass (1 oz) - Apply 15Y30 minutes before going outdoors - Reapply every 2 hours Seek shade Avoid sun exposure between 10 AM and 4 PM Wear protective clothing - Long-sleeved shirt - Pants - Wide-brimmed hat - Sunglasses Avoid tanning beds Adapted from the American Academy of Dermatology (AAD, 2015); the American Academy of Pediatrics (AAP, 2011); and Quantrano, N. A., & Dinulos, J. G. (2013). Current principles of sunscreen use in children. Current Opinion in Pediatrics, 25(1), 122Y129. state of practice, identifying areas for improvement, and providing a foundation for further research to develop effective skin cancer prevention interventions for adolescents (Moyer, 2012). PURPOSE The purpose of this study was to describe current primary prevention counseling practices directed at adolescents by primary care nurse practitioners practicing within the state of Arizona, specifically, their (a) knowledge of skin cancer prevention and skin cancer clinical guidelines for counseling adolescents; (b) attitudes about skin cancer prevention, skin cancer risk, and skin cancer prevention counseling for adolescents; (c) recommendations for patients at average and increased risks of skin cancer; and (d) skin cancer prevention recommendations pertaining to adolescent patients. An exploratory aim was to determine if nurse practitioner recommendations and practices were congruent with any existing practice guidelines. METHODS AND FRAMEWORK The institutional review board at the University of Arizona approved all human subject procedures for this online quantitative cross-sectional survey. The study framework was collectively developed using the organizational guidelines pertaining to adolescents including the AAD (2012), AAFP (2014), AAP (2011), NCI (2015), and USPSTF (2012). The data collected were used to summarize characteristics, VOLUME 8 NUMBER 6 NOVEMBER/DECEMBER

3 TABLE 2. Current Practice Recommendations for Counseling Professional Organization AAD (2012) AAFP (2014) AAP (2011) NCI (2015) USPSTF (2012) Practice Recommendation Provide behavioral counseling regarding avoidance of ultraviolet radiation and consistent sun protection practices for all populations. Counsel children, adolescents, and young adults with fair skin between the ages of 10 and 24 years about minimizing ultraviolet radiation exposure. Incorporate advice about ultraviolet radiation exposure into health supervision practices; incorporate ultraviolet radiation exposure advice into at least one health maintenance visit per year beginning in infancy. Educate patients on risks and protective strategies (but evidence is lacking to support routine counseling). Counsel children, adolescents, and young adults with fair skin between the ages of 10 and 24 years about minimizing ultraviolet radiation exposure. circumstances, and frequency of primary prevention counseling practices for skin cancer in outpatient care. Survey and Sample The online survey was developed using Qualtrics software and was designed to be completed in 15 minutes or less. In an effort to capture the most data, participants were required to respond to each question before moving on to the next. Fifty-nine items addressed nurse practitioner knowledge, attitudes, and practices regarding skin cancer prevention in adolescents. The online survey, along with a descriptive letter of intent, was distributed via listservs of Arizona nurse practitioners from several organizations between November 1, 2014, and November 23, To be considered for the study, nurse practitioners had to meet the following eligibility criteria: currently be practicing in the state of Arizona in an outpatient setting, working a minimum average of 200 hours per year or 17 hours per month (average minimum requirement to maintain board certification through the American Academy of Nurse Practitioners or American Nurses Credentialing Center), and must have reported caring for numbers of adolescents at any frequency greater than zero. Nurse practitioners who practiced exclusively within the inpatient setting were excluded. ANALYSIS The collected study data were exported from Qualtrics into SPSS v (2013). The data were analyzed using descriptive statistics for each of the survey items and scales. Internal consistency of the questions in the attitudes and behaviors subscales was assessed using Cronbach s alpha. RESULTS Participant Accrual Of the 67 participants who started the survey, 51 were eligible to complete the survey. Six participants dropped out of the study, and the data collected were not used in the analysis. One participant did not provide demographic information. Table 3 describes the demographic characteristics of the participants. Skin Cancer Knowledge The overall mean of correct responses regarding participants knowledge of skin cancer and skin cancer prevention was 78% (see Table 4). Forty-two (96%) participants correctly identified the main cause of skin cancer, and 24 (55%) correctly identified the current trend in the incidence of skin cancer in the adolescent population. The overall mean of correct responses regarding participants knowledge of skin cancer clinical guidelines for counseling adolescents was 39% (see Table 4). All participants correctly identified the AAD clinical guideline; one (2%) correctly identified the USPSTF clinical guideline. Attitudes Participants responded strongly that skin cancer is serious and agreed that preventive measures such as using sunscreen and wearing protective clothing could reduce chances of skin cancer (see Table 5). The participants agreed that melanoma is potentially a fatal illness, but they were neutral regarding adolescents being at risk for developing melanoma and NMSC. Participants responded strongly that preventive counseling was within their scope of practice and that the advice from a nurse practitioner could help adolescents decrease their skin cancer risk (see Table 6). They did not respond as positively about skin cancer prevention counseling being a priority in their practice. Recommendations to Adolescent Patients Participants reported that they provided skin cancer prevention recommendations to adolescent patients at an increased risk for skin cancer (e.g., genetic factors, phenotypic factors) more often than to adolescent patients in the general population (see Table 7). The most commonly chosen skin cancer prevention recommendation for both populations was the use of sunscreen. Participants Self-Reported Practices Participants reported infrequent performance of primary prevention counseling practices for their adolescent patients. Despite wide variability, the sample chose advise and counsel adolescents about skin cancer primary prevention as their most commonly used practice (see Table 8). 370 Journal of the Dermatology Nurses Association

4 TABLE 3. Sociodemographic and Practice Characteristics of Participants (N = 43) Sociodemographic Characteristics Age Mean (SD) 47.9 (11.1) years Range 28Y72 years Frequency % Gender Female Male 2 5 Education Bachelor s 0 0 Master s DNP 2 5 PhD 3 7 DNP and PhD 1 2 Other 1 2 Ethnicity Not Hispanic or Latino Hispanic or Latino 3 7 Unknown 1 2 Other 3 7 Race White Asian 3 7 American Indian/Alaskan Native 2 5 Unknown 1 2 Native Hawaiian/ Other Pacific 0 0 Islander Black or African American 0 0 Practice characteristics Certification specialty a Family Pediatrics 5 12 Adult 4 9 Women s health 3 7 Adult-gerontology 2 5 Acute care 1 2 Psych mental health 1 2 Other 3 7 Work setting a Family practice Acute care/urgent care 4 9 Community health 4 9 Dermatology 2 5 Public health 2 5 (continues) TABLE 3. Sociodemographic and Practice Characteristics of Participants (N = 43), Continued Sociodemographic Characteristics University/college student health 2 5 Academic faculty/adjunct faculty 1 2 Cardiovascular 1 2 Complementary 1 2 HIV/AIDS 1 2 Oncology 1 2 Pediatrics 1 2 Other 5 12 Years practicing as a nurse practitioner G Y Y Y Y Average hours per month in practice Range 20Y350 hours/month Mean (SD) (60.7) hours/month Percentage of working hours spent caring for adolescents G Y Y Y Y Y Y Y Y Y Percentage of patient visits related to health promotion, wellness, etc. G Y Y Y Y Y Y Y Y Y (continues) VOLUME 8 NUMBER 6 NOVEMBER/DECEMBER

5 TABLE 3. Sociodemographic and Practice Characteristics of Participants (N = 43), Continued Percentage of patient visits related to episodic occurrences G Y Y Y Y Y Y Y Y Y a Participants able to choose more than one certification specialty and work setting. No participants listed the work settings of allergy/ immunology, emergency, endocrinology, gastroenterology, infectious disease, nephrology, neonatal, neurology, occupational health, orthopedics/sports medicine, pain management, palliative, pulmonology/respiratory, retail health, rheumatology, school based clinic (K-HS), surgical, or wound care. TABLE 5. Attitudes About Skin Cancer and Skin Cancer Risk (N = 44) Item Mean Score (TSD) a Melanoma is potentially a fatal illness (0.79) Skin cancer is serious (0.96) Using sunscreen as recommended 6.25 (0.75) reduces the chances of getting skin cancer. Wearing clothing that protects the skin from the sun reduces the chances of getting skin cancer (0.82) Adolescents, in general, are at risk for 5.48 (1.46) developing melanoma. Spending little time in the sun reduces 5.25 (1.86) the chances of getting skin cancer. Nonmelanoma skin cancer is 4.89 (1.35) potentially a fatal illness. Adolescents, in general, are at risk for 4.77 (1.48) developing nonmelanoma skin cancer. Overall mean score 5.71 (0.73) Cronbach s alpha (!).728 a Response options range from 1 = never to 7 = all of the time. The least commonly reported primary prevention counseling practice was providing adolescents with skin cancer primary prevention resource materials. TABLE 4. Overall Knowledge of Skin Cancer, Skin Cancer Primary Prevention, and Guidelines for Counseling (N = 44) Mean Score Correct Item Frequency (%) Main cause of skin cancer Most protective clothing Most protective hat Sunscreen application timing Incidence of skin cancer in the adolescent population Overall score 78 Guideline American Academy of Dermatology American Academy of Pediatrics American Academy of 2 5 Family Physicians U.S. Preventive Services Task Force 1 2 Overall score 39 Congruency With Existing Practice Guidelines Fourteen (32%) participants stated that they did not use an established guideline (see Table 9), and overall, the participants recommendations and primary prevention counseling practices were not congruent with existing practice guidelines. Of the participants who reported using a clinical practice guideline (n = 29),12 stated that they followed the AAD practice guideline, which recommends counseling all populations about avoidance of UVR and consistent sun protection practices. This guideline was not reflected in the mean scores of selfreported counseling practices. Additional incongruences were evident in the small increase in mean scores of reported counseling practices for adolescents in the general population versus those at risk. DISCUSSION Knowledge Participant skin cancer knowledge findings were similar to comparable studies. Maguire-Eisen and Frost (1994) reported a 69% overall knowledge score regarding nurse practitioner knowledge of risks, prevention, and recognition of malignant melanoma. However, Furfaro, Bernaix, Schmidt, and Clement (2008) used the same scale as that of Maguire-Eisen and Frost and found an overall average knowledge score of 80% for nurse practitioners knowledge of malignant melanoma. Shelby (2014) reported a 372 Journal of the Dermatology Nurses Association

6 TABLE 6. Attitudes About Skin Cancer Counseling for Adolescents (N = 44) Item Mean Score (TSD) a Counseling adolescents about skin cancer prevention is within my scope of practice (0.81) Advice from nurse practitioners can help adolescent patients decrease their skin cancer risk (1.18) I feel obligated to counsel my adolescent patients about skin cancer prevention (1.16) Counseling adolescents about skin cancer prevention is a good use of my time (1.14) Skin cancer prevention for adolescents is something that concerns me (1.18) Counseling from a nurse practitioner will influence an adolescent s skin cancer risk-reducing 5.18 (1.21) behaviors. An adolescent s genetic factors affect my decision to provide skin cancer prevention counseling (1.87) Skin cancer prevention counseling is a priority in my practice (1.67) Counseling adolescents about skin cancer prevention takes too much time (1.63) An adolescent patient s phenotypic factors affect my decision to provide skin cancer prevention 4.16 (1.89) counseling. Overall mean score 5.32 (0.75) Cronbach s alpha (!).718 a Response options range from 1 = strongly disagree to 7 = strongly agree. mean of 59.3% (26%Y80%) correct responses to general skin cancer knowledge questions and a mean of 50% (22%Y76%) correct identification of skin lesions, both cancerous and benign. In another study, 43% of nurse practitioners self-reported their knowledge levels as basic to minimal (Blake & Malone, 2014). These comparisons are limited, as none of the previous studies specifically addressed the adolescent population. Although these studies may be reflective of overall nurse practitioner knowledge, they may not be accurate concerning the adolescent population. All participants were able to correctly identify the AAD recommendation for skin cancer counseling. They may have correctly chosen this recommendation because TABLE 7. Skin Cancer Prevention Recommendations to Adolescent Patients (N = 44) General population At-risk population Recommendation Mean Score (TSD) a Use SPF 15 or higher sunscreen 4.80 (1.94) Wear sun protective clothing (hats, long sleeves, etc.) 4.59 (1.81) Seek shade when outdoors during the day 4.39 (1.93) Avoid sun exposure during the peak hours of 10 AMY4 PM 4.14 (2.09) Overall mean score 4.48 (1.76) Cronbach s alpha.927 Use SPF 15 or higher sunscreen 5.05 (1.88) Wear sun protective clothing (hats, long sleeves, etc.) 4.77 (2.00) Seek shade when outdoors during the day 4.66 (2.02) Avoid sun exposure during the peak hours of 10 AMY4 PM 4.59 (2.08) Overall mean score 4.77 (1.92) Cronbach s alpha.971 a Response options range from 1 = never to 7 = always. VOLUME 8 NUMBER 6 NOVEMBER/DECEMBER

7 TABLE 8. Participants Self-Reported Behaviors Pertaining to Adolescent Patients (N = 44) Practice Behavior Mean Score (TSD) a Advise and counsel adolescents 4.16 (1.92) about skin cancer primary prevention Assess the patient s sunscreen use 3.82 (2.03) Assess the patient s barriers to 3.41 (2.19) sunscreen use Assess the patient s use of other 3.39 (2.07) methods of sun protection (e.g., sun protective clothing, sun avoidance) Assess the patient s ultraviolet radiation exposure Follow an established practice guideline for skin cancer primary prevention counseling 3.25 (2.14) 2.93 (2.01) Provide skin cancer primary prevention 2.68 (2.11) resource materials Overall mean score 3.38 (1.87) Cronbach s alpha.964 a Response options range from 1 = never to 7 = all of the time. the correct answer was the first and most encompassing option. However, the response options for this item were identical to those for the AAFP (2014) and the USPSTF (2012), which point to possible item order effects, wherein the order of responses affects the respondents answers in a more or less systematic fashion (Strack, 1992). Other reasons for the discrepancy in knowledge among the different guidelines are not known because this is the only known study to investigate congruency between nurse practitioner knowledge and use of skin cancer counseling guidelines. Attitudes Although limited by topic and sample, many studies, including the current findings, support nurse practitioners overall positive attitudes toward skin cancer prevention, belief that skin cancer prevention is within their scope of practice, and agreement that nurse practitioner interventions can be effective in the prevention of skin cancer (Blake & Malone, 2014; Maguire-Eisen & Frost, 1994; Shelby, 2014). The participants in this study reported that skin cancer is serious (6.34 T 0.96) and that melanoma is potentially fatal (6.52 T 0.79). The participants responded less strongly that adolescents were at risk for developing melanoma (5.48 T 1.46) or NMSC (4.77 T 1.48). These findings are comparable with those reported by Balk, O Connor, and Saraiya (2004), in which 95% of surveyed pediatricians agreed that cumulative sun exposure during childhood increased the patient s risk of skin cancer and 93% believed that skin cancer was a significant public health problem. Despite nurse practitioners positive attitudes regarding skin cancer prevention, some do not agree that it is a practice priority or believe that skin cancer is a problem within their patient population. Study participants were neutral regarding skin cancer prevention counseling as a priority in their practice. Comparatively, most (73%) of the participants in Blake and Malone s (2014) study disagreed that skin cancer prevention was not a priority in their practice. A systematic review by Loescher, Harris, and Curiel-Lewandrowski (2011) reported that 13%Y38% of advanced practice nurses stated that skin cancer was not a problem in their patient population or that screening was not needed in their practice setting. In addition, only 38% of participants in Balk et al. s (2004) study described skin cancer prevention as a very important preventive care topic, ranking lower than car seat use, nutrition, smoking exposure, and exercise. Most participants (60%) disagreed that counseling adolescents about skin cancer prevention takes too much time. In comparison, Balk et al. (2004) reported time being a barrier for skin cancer prevention for 58% of the surveyed pediatricians. A systematic review by Loescher et al. (2011) found that 14%Y70% of advanced practice nurses reported time constraint as a barrier to skin cancer assessment. Similarly, Shelby (2014) reported that over 80% (97/111) of nurse practitioners described time as a barrier to practicing full-body skin examinations. This is a topic that warrants further investigation as this evidence shows that practitioners report less time constraints with skin cancer counseling versus screening. Recommendations for Patients at Average and Increased Risks of Skin Cancer Participants in this study were neutral to negative regarding genetic and phenotypic factors affecting their decision TABLE 9. Choice of Established Skin Cancer Prevention Counseling Recommendation or Practice Guideline Used in Practice (N = 44) Guideline Frequency % American Academy of Dermatology U.S. Preventive Services Task Force American Academy of Pediatrics 6 14 National Cancer Institute 1 2 Other 1 2 None Other was specified as common sense. 374 Journal of the Dermatology Nurses Association

8 to provide skin cancer counseling to their adolescent population. The participants did not show a significant increase in preventive recommendations for adolescents at an increased risk of skin cancer. In comparison, 51% of pediatricians surveyed by Balk et al. (2004) reported selectively counseling patients based on skin cancer risk with the most influential factors being white or light skin (74%), tendency to burn (67%), and family history of skin cancer (56%). Similarly, Rodriguez et al. (2007) reported overall low skin cancer screening rates by primary care physicians, but patients at a higher risk (phenotypic and genotypic factors) were screened more frequently. It is unclear from this study why the participants did not significantly increase preventive recommendations for atrisk adolescents. This may be a result of inconsistent evidence based guidelines, infrequent visits with this age group, or an educational barrier that requires investigation. Skin Cancer Prevention Practices Pertaining to Adolescents The current findings support prior studies showing that most nurse practitioners never or only sometimes provide preventive counseling or skin cancer prevention education to their patients (Blake & Malone, 2014; Mikkilineni, Weinstock, Goldstein, Dube, & Rossi, 2001; Shelby, 2014). When nurse practitioners did counsel or educate their patients, they were most likely to discuss sunscreen use and least likely to provide the patient with resources or materials regarding the prevention of skin cancer (Blake & Malone, 2014; Maguire-Eisen & Frost, 1994). Similarly, Mallett et al. (2011) assessed dermatologist communication with patients regarding skin cancer prevention and found on baseline data that 29% of studied dermatologists assessed patient s sunscreen use and 29% assessed other methods of sun protection. Given that the previously mentioned studies provided, in part, the basis for the questionnaire used in this study, the similarity of these results is not unexpected. In addition, the current study adds to the literature that primary prevention counseling practices are similar despite various training backgrounds (i.e., MD, DO, NP). Congruency of Counseling Practices With Clinical Guidelines The previous literature has shown that nurse practitioners face several barriers to providing skin cancer prevention counseling. These include provider attitudes and beliefs about counseling, confusion regarding scope of practice, lack of national guidelines, lack of knowledge of skin cancer, and time constraints (Christos, Oliveria, Mâsse, McCormick, & Halpern, 2004; Johnson et al., 2006; Maguire-Eisen & Frost, 1994). In this study, participants reported positive attitudes toward counseling, felt time was not a limiting factor, and believed that counseling was within their scope of practice. Lack of congruency of national guidelines and knowledge regarding prevention guidelines may be a significant factor in the low rates of self-reported behaviors in practice. In addition, most of the participants (77% and 86%, respectively) reported fewer than 40% of their patient visits related to health promotion and less than 40% of their working hours caring for adolescents. Participants may have reported low rates of primary prevention counseling practices because of seeing so few adolescents for wellness. The participants felt neutral regarding skin cancer counseling being a priority in their practice. This may be reflective of incongruent recommendations and major guideline groups, such as the USPSTF and NCI, not positively affirming the efficacy of counseling (Federman et al., 2014). As there is significant lag time between UVR exposure and skin cancer development, participants may be focusing their efforts on other preventive counseling and screening recommendations that have been well established and shown to be of stronger, immediate benefit in clinical trials. Participant Characteristics The demographic characteristics of the participants were comparable with those in similar studies and known nurse practitioner population demographics. The participants had, in general, fewer years in practice in comparison with those in other studies (Blake & Malone, 2014; Maguire- Eisen & Frost, 1994; Shelby, 2014). However, other characteristics (age, gender, educational level, race, and certification specialty) were similar to other nurse practitioner studies of skin cancer as well as national and state level data on nurse practitioners (Arizona State Board of Nursing, 2014; Blake & Malone, 2014; Furfaro et al., 2008; Health Resources and Services Administration, 2014; Maguire- Eisen & Frost, 1994; Shelby, 2014; Wilson, Harootunian, Sama, & Johnson, 2012). A lack of data regarding the geographic location of participants and practice locations (i.e., urban, rural) limited geographic comparison. Most of the participants (77%) reported that 40% or less of their patient visits were related to health promotion or wellness, and 39% reported spending 21%Y40% of their time related to episodic occurrences. The Health Resources and Services Administration (2014) found similar findings in a national survey of nurse practitioners who reported that 55% of their patient visits were related to preventive care. In addition, the CDC (2015b) found in their National Ambulatory Medical Care Survey that 19% of outpatient visits in 2011 were for preventive care and 33% were related to acute problems. Most participants (86%) reported caring for adolescents less than 40% of their working hours. Similarly in Furfaro et al. (2008), 47 (51%) of the providers reported their primary clients as a mixed population, whereas 39 (40%) reported seeing primarily adults, and only four (4%) reported pediatrics as their primary client population. Furthermore, the CDC (2015b) found that, of the percentage of outpatient visits that were considered VOLUME 8 NUMBER 6 NOVEMBER/DECEMBER

9 preventive (19%), 26% of those were for patients less than 15 years old, and 17% were for those 15Y24 years old, with most (28%) of those being seen for preventive care in the 25- to 44-year age group. These low levels of provider visits related to health promotion, and more specifically, health promotion visits with adolescents may influence the results of this study. However, the participants, with similar practice characteristics, are representative of other outpatient primary care providers and do not appear to be biased by nonresponse participants (Dykema, Jones, Pich2, & Stevenson, 2013). Strengths and Limitations This study was limited by small sample size and limited time of data collection. By relying on Webmasters to disseminate the survey link to active listserv members, the number of participants was potentially limited, thus limiting the applicability of the research findings. In addition, unsuccessful attempts were made to contact other organizations, which further limited the potential sample size. Collecting data over a longer period may the enhance sample size and thus the applicability of the results. Furthermore, the participants in this study reported limited exposure to adolescent patients, which may have impacted the results and may not be reflective of average nurse practitioner patient exposure. To increase the applicability of the results, the study should be replicated with a larger, more variable sample, with an extended data collection timeframe. The study content also lends itself to limitations. Nurse practitioner knowledge, attitudes, and counseling practices regarding skin cancer prevention are largely understudied. In addition, current research in this area inconsistently uses variables, measurement scales, and inclusion and exclusion criteria. Comparable data become significantly less when specifically addressing the adolescent population, which is inconsistently defined. Despite study limitations, an online survey was created and successfully delivered without problems with the survey software, distribution, or data collection. Importantly, the study addressed a significant gap in the literature regarding nurse practitioners primary prevention counseling for the adolescent population. This study identified discrepancies between attitudes, knowledge, and primary prevention counseling practices within a select group of nurse practitioners. These findings may provide a framework for future research to identify if this is generalizable to the nurse practitioner population as a whole. Implications for Clinical Practice and Research This study adds to the body of literature supporting increasing nurse practitioner knowledge of skin cancer and skin cancer prevention for adolescents. The current study found that participants did not recognize skin cancer prevention as a prominent problem for their adolescent patients and did not increase preventive counseling for adolescents with risks for skin cancer. This may be indicative of a lack of knowledge similar to results found by Furfaro et al. (2008) and Maguire-Eisen and Frost (1994). Providers have expressed interest in obtaining more training on skin cancer prevention (Balk et al., 2004), and several studies have shown that educational interventions for providers increase preventive skin cancer services for patients with increased risk factors for skin cancer (Mikkilineni et al., 2001; Rodriguez et al., 2007). The development of educational interventions such as increasing dermatology curriculum in basic and advanced nursing programs, continuing education programs, and educational workshops may improve nurse practitioner understanding of skin cancer prevention and therefore might increase preventive practices in the clinical setting. Additional research on nurse practitioners primary prevention counseling practices regarding adolescent patients is warranted as there are limited current data. Future studies should use reliable psychometric assessments that have been developed for comparable data. This study provides a foundation for the continuing investigation of nurse practitioners skin cancer prevention counseling for adolescents. CONCLUSION Although limited by sample size and data collection time, this study adds to the literature on nurse practitioners in primary care. Despite Arizona nurse practitioners having positive attitudes toward skin cancer prevention for adolescents, this sample had an average to low knowledge score regarding skin cancer and reported inconsistent use of prevention counseling in practice. In addition, the prevention counseling used was not congruent with any specific clinical guideline. Although these findings address a significant gap in the literature regarding nurse practitioners primary prevention counseling for the adolescent population, additional research is warranted. h REFERENCES American Academy of Dermatology. (2012). AADA responds to USPSTF recommendations on sun-protection counseling. Retrieved from American Academy of Dermatology. (2015). Prevent skin cancer. Retrieved from prevent-skin-cancer American Academy of Family Physicians. (2014). Skin cancer. Retrieved from skin-cancer.html American Academy of Pediatrics. (2011). Policy statementvultraviolet radiation: A hazard to children and adolescents. 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Retrieved from the Arizona Healthcare Workforce Center website: org/member_and_media_resources/documents/azhhaworkforcedata Center-CHiRAnnualReport-June2012_000.pdf World Health Organization. (2014). Health for the world s adolescents. Retrieved from World Health Organization. (2015). Health effects of UV radiation. Retrieved from For more than 48 additional continuing education articles related to dermatologic conditions, go to NursingCenter.com\CE. VOLUME 8 NUMBER 6 NOVEMBER/DECEMBER