Our Dermatology Online
Original Article
Task shifting in dermatology: Are nurses prepared and
willing?
Kavita Kavita1, Hitaishi Mehta2, Sandhya Ghai1, Aarti Garg1, Tarun Narang2
National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
1
2
Corresponding author: Tarun Narang, MD, MNAMS. E-mail: narangtarun@yahoo.co.in
ABSTRACT
Background: The high burden of skin diseases and the shortage of dermatologists are significant challenges in providing
care to millions of people with skin diseases. Task shifting to nurses is a viable option for the delivery of dermatologic
care in resource-poor settings. Satisfactory knowledge and a positive attitude are crucial for nurses to undertake the
task of managing common skin diseases. This study aimed to investigate the knowledge of registered nurses and their
attitude toward common skin conditions. Methods: In this descriptive, cross-sectional study, a total of 187 nurses
were included from a nurses training institute by total enumeration sampling. A knowledge questionnaire and fivepoint Likert type-attitude scale were developed, validated, and employed to collect data. Written informed consent
was obtained from the participants after approval from the institute ethics committee. Results: The mean of the
knowledge scores were 10.7 ± 2.2. Nearly two thirds (62%) of the subjects demonstrated a low level of knowledge,
while the remaining 38% showed a moderate level. There was no participant in the high-knowledge category. A majority
of the nurses demonstrated a favorable attitude toward learning and undertaking the task of managing common skin
conditions. Conclusion: We observed a low level of knowledge on diagnosing and managing common skin conditions.
We recommend incorporating the relevant concepts of common skin conditions in the nursing curriculum with an
emphasis on continuing education.
Keywords: Nurses; Common skin conditions; Knowledge; Attitude; Dermatology training; Task shifting
INTRODUCTION
Skin diseases constitute a significant burden worldwide.
As per the 2017 study on the global burden of disease
(GBD), these contributed 1.76% of the total global
burden of disease measured in DALYs (disabilityadjusted life years) [1]. Skin diseases are among the
top ten causes of non-fatal disease burdens. According
to 2017 GBD data, the years lived with disability
(YLDs) from skin diseases worldwide were 41.6 million,
which is more than with cardiovascular diseases
(35.6 million) [2,3]. Skin diseases are among the top
ten causes of non-fatal disease burdens in India, and
the burden due to skin diseases has increased from 4.07
million in 1990 to 6.26 million in 2017 [4].
The high need for dermatological care in India poses a
significant challenge to the healthcare delivery system,
which already has a shortage of dermatologists. The
population ratio of dermatologists is more skewed
in low- and middle-income countries than in highincome countries. There are 3.2 dermatologists per
100,000 individuals in many states of the U.S. [5],
compared to less than one dermatologist per 100,000
individuals in India [6]. Task shifting may be one of
the solutions to increase access to dermatological care.
Task shifting means transferring clinical tasks from
physicians to trained non-physician health workers.
Although task shifting is being done to a limited extent
in dermatology, its need and effectiveness are evident
from the literature [7-10].
How to cite this article: Kavita, Mehta H, Ghai S, Garg A, Narang T. Task shifting in dermatology: Are nurses prepared and willing?. Our Dermatol Online.
2022;13(1):22-27.
Submission: 22.06.2021;
Acceptance: 30.11.2021
DOI: 10.7241/ourd.20221.4
© Our Dermatol Online 1.2022
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Task shifting may involve various categories of nonphysician health workers, but nurses are the ideal
choice. In the developed world, nurses work successfully
as dermatological nurses in both independent and
dependent roles [11,12]. India’s national leprosy
elimination program is an excellent example of task
shifting [13]. Mid-level health care providers (MLHP)
under the Ayushman Bharat scheme are also nurses who
are being trained to work independently in health and
wellness centers [14].
However, nurses’ educational level, competence, and
willingness are crucial prerequisites for successful task
shifting. To the best of our knowledge, there have
been no studies assessing nurses from India for their
knowledge and attitude regarding skin conditions.
For this reason, the present study was undertaken
to evaluate the knowledge and attitude of registered
nurses regarding the diagnosis and management of
common skin diseases. The findings of this study
will help to make recommendations for effective task
shifting and curriculum changes.
METHODOLOGY
A descriptive, cross-sectional design was adopted
for this study. Nurses were recruited from a nurses’
training institute in Northern India. All registered
nurses (n = 187) pursuing higher education (B.Sc.
nursing (post-basic)/M.Sc. nursing) were recruited
in the study.
Study Instruments
A knowledge questionnaire and a five-point Likert
scale were employed to assess the nurses’ knowledge
about and attitudes to common skin conditions.
Tools were developed by reviewing the literature and
consulting experts in the field of dermatology and
nursing. The validation of the tools was performed
by experts in the field of dermatology and nursing.
Their suggestions were incorporated in the final
version of the tool. The knowledge questionnaire
consisted of two sections. Section I included the
socio-demographic and professional profiles of the
participants. Section II consisted of multiple-choice
questions related to the diagnosis and management
of common skin diseases. The total score ranged from
0 to 20. A higher score represented a higher level
of knowledge. Knowledge scores were graded into
three levels. Scores between 16 and 20 (> 80%) were
© Our Dermatol Online 1.2022
classified as a high level of knowledge, while scores
between 10 and 15 (79–50%) and <10 (<50%) were
graded as a moderate and low level of knowledge,
respectively.
A five-point Likert scale (strongly disagree, disagree,
neutral, agree, strongly agree) was constructed to assess
the attitude of nurses regarding the diagnosis and
management of common skin disorders. There were a total
of twelve statements with scores ranging from 12 to 60.
A higher score indicated a more favorable attitude. A score
above the median was considered a positive attitude and
below the median a negative attitude.
Data entry and analysis were performed using the
software SPSS, version 20. Descriptive statistics were
employed to analyze the data, and the results were
presented as frequencies, percentages, means, and
standard deviations. The Chi-square test was employed
for the analysis of categorical variables. The relationship
between knowledge and attitude was established by
bivariate correlational analysis.
RESULTS
A total of 187 nurses completed the questionnaire
and attitude scale. The mean age of the participants
was 25.6 ± 4.89 years, and the majority (84.5%)
were females. As per the professional qualification,
40 (21.4%) participants had done B.Sc. nursing, and the
rest had completed their diplomas in general nursing
and midwifery. Regarding work experience, 84 (44.9%)
participants had no work experience, and 19 (10.2%)
had an experience of more than ten years (Table 1).
Only three participants (1.6%) had attended training
related to the prevention and management of skin
conditions.
Respondents’ Knowledge on Common Skin
Diseases
Most of the participants (n = 142; 75.9%) knew that
leprosy is a communicable disease. However, only
60 (32.1%) were aware that leprosy classification is
based on the number of skin lesions. Nearly one fourth
of the participants (28.3%) knew about the cardinal
features for the diagnosis of leprosy. Table 2 summarizes
details regarding knowledge on the etiology of common
skin disorders.
A per the questions about the basic understanding
of dermatology, 88 (47.1%) and 128 (68.4%) of the
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Table 1: Sociodemographic profile, professional qualification,
and work experience of the participating nurses (n = 187).
S.No
Variable
f
%
1.
2.
3.
4.
5.
6.
Age (in yrs.)
21–30
31–40
>40
Sex
Male
Female
Marital status
Never married
Currently married
Divorced
Per capita income (BG Prasad scale)
7008 and above (upper class)
3504–7007 (upper-middle class)
2102–3503 (middle class)
1051–2101 (lower-middle class)
Below 1050 (lower class)
Professional education
GNM
B.Sc. nursing
Work experience
No experience
<5 yrs.
5–10 yrs.
> 10 yrs.
158
26
3
(84.5)
(13.9)
(1.6)
29
158
(15.5)
(84.5)
149
37
1
1
Leprosy is a communicable disease.
142 (75.9)
2
Psoriasis is a chronic inflammatory skin
disorder in which epidermal cells proliferate
abnormally fast.
90 (48.1)
3.
41 (21.9)
(79.7)
(19.8)
(0.5)
Clotrimazole cream is the treatment of choice
for treating fungal infections of the skin.
4.
A papule is an elevated spot; a palpable, firm,
and circumscribed lesion generally <5 mm in
diameter.
88 (47.1)
104
57
15
9
2
(55.6)
(30.5)
(8)
(4.8)
(1.1)
5.
An elevated, circumscribed, superficial, and
fluid-filled blister <5 mm in diameter is called
a vesicle.
128 (68.4)
6
33 (17.6)
147
40
(78.6)
(21.4)
Rough and thickened epidermis and
accentuated skin markings caused by rubbing
or scratching are called lichenification.
7.
Molluscum contagiosum is a viral disease.
8.
There should be >5 lesions for the diagnosis
of multibacillary leprosy.
109 (58.3)
9.
Cardinal features for the diagnosis of leprosy.
53 (28.3)
10.
WHO criteria for the classification of leprosy
are based on the number of skin lesions.
60 (32.1)
11.
Permethrin is the treatment of choice for
scabies.
134 (71)
12.
Tinea cruris is caused by a fungus.
13.
Tinea capitis is caused by dermatophytes.
56 (29.9)
14.
Pyoderma is caused by a bacterium.
123 (65.8)
15.
Obesity, foods with a high glycemic index, and
stress are the risk factors for acne.
153 (81.8)
16.
Topical steroids are not used in the treatment
of acne.
59 (31.6)
17.
Acute urticaria is characterized by a red rash
all over the body, swelling of the lips, and
difficulty in breathing.
125 (66.8)
18.
Stopping the suspected drug is the most
crucial step in the nursing management of
drug rash.
142 (75.9)
19.
Correct diagnosis of tinea corporis from a
photograph.
110 (58.8)
20.
Correct diagnosis of psoriasis from a
photograph.
54 (28.9)
84
66
18
19
44.9
35.3
9.6
10.2
nurses knew the characteristic features of papules
and vesicles, respectively, while the question about
lichenification was answered correctly only by 17.6%.
The characteristics of urticaria were known to 66.8%,
while 58.8% and 28.9% could correctly identify
fungal infections and psoriasis, respectively, from the
photographs.
Nearly one fifth (n = 41; 21.9%) of the participating
nurses were aware that clotrimazole cream is the
treatment of choice for treating fungal infections of
the skin, whereas 59 (31.6%) knew that topical steroids
should not be used for the treatment of acne vulgaris.
Most nurses (n = 134; 71.7%) were correct about
permethrin being the treatment of choice for scabies.
Nearly three fourth (n = 142; 75.9%) correctly answered
the question about the nursing management of drug
rash (Table 2).
The mean and SD of the knowledge scores in the study
were 10.7 ± 2.2. Nearly two thirds (n = 116; 62%) of
the subjects demonstrated a low level of knowledge,
and the remaining 77 (38%) demonstrated a moderate
level of knowledge. There was no participant with a
high level of knowledge.
Respondents’ Attitudes
A five-point Likert scale was used to assess the nurses’
attitudes toward common skin conditions and their
involvement in managing these. A majority of the nurses
© Our Dermatol Online 1.2022
Table 2: The nurses’ knowledge on common skin
conditions (n = 187).
S.No Item of Knowledge
Correct
Responses (%)
11 (5.9)
145 (77.5)
(n = 152; 81.3%) agreed and strongly agreed to the
statement that they had studied dermatology during their
basic nursing education training. Still, only 58 (31%) were
satisfied with the dermatology content in the nursing
curriculum. Only 51 (27.3%) felt confident performing
skin examinations of patients, although 77 (41.2%)
agreed that they were adequately trained in the diagnosis
and management of common skin conditions during
nursing training. Regarding the nurses’ willingness to be
involved in the management of common skin diseases,
most of the nurses (n = 146; 78%) agreed and strongly
agreed with the statement. Nearly 81% agreed that nurses
should also perform skin examinations. A majority (n =
155; 82.9%) did not consider lack of time as a reason for
not performing skin examinations.
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Nearly half of the nurses (n = 93; 49.7%) disagreed
and strongly disagreed that most skin diseases are
communicable. Half (50.3%) felt confident in taking
care of patients with any skin condition, whereas
65.8% disagreed that they were afraid of taking care
of patients with skin disorders as they are contagious.
Only 51 (27.3%) agreed that they were confident in
diagnosing common skin conditions. A majority of
the subjects (85.6%) agreed and strongly agreed to the
question about their willingness to learn more about
dermatology and to attend continuing education
courses and lectures for the diagnosis and management
of common skin conditions.
The median attitude score of the participants was 43
(IQR: 40–46). Most of the nurses (76.2%) scored above
the median, demonstrating their positive attitude and
willingness to undertake the task.
The association of knowledge and attitude scores
with selected variables was assessed with a chi-square
test. The results showed no significant association
of knowledge scores with age, sex, professional
qualification, and years of experience. However, there
was a positive association between knowledge scores
and attitude.
DISCUSSION
Skin diseases are associated with significant morbidity
and the psychosocial and emotional issues in individuals
suffering from skin conditions are comparable to that
of arthritis, back pain, diabetes mellitus, epilepsy,
cancer, and even asthma [15,16]. Skin diseases are
highly common in rural and urban areas, yet there
is a shortage of well-trained dermatologists who
may address the needs of these problems [17]. Most
dermatologists work in urban areas, whereas almost 70%
of India’s population lives in rural areas [18]. Hence,
task shifting is the need of the hour for addressing
this supply and demand imbalance in skin disorders,
and nurses are the ideal choice as they are one of the
vital health care providers in any health setup [11].
Adequate knowledge and a favorable attitude are
prerequisites for effective and successful task shifting
in any specialty. The current study was conducted in
a nurses’ training institute in Northern India. It was
aimed to generate useful outputs that may support
future actions to improve the knowledge and attitude
of nurses involved in dermatological care. Although
there exist numerous skin disorders, we selected the
© Our Dermatol Online 1.2022
most common skin conditions prevalent in India to
assess the participants’ knowledge [2,19].
A study by Kouotou et al. assessed the knowledge,
attitudes, and practices of medical personnel
regarding atopic dermatitis. Twenty-two percent of
the participants were nurses, and 45% of them showed
a moderate level of knowledge, with none in the
good level of knowledge category [20]. Although we
attempted to study knowledge on dermatology and
not a specific disease, our study’s findings agree with
the findings of the above research, as most of our study
participants were also in the low to moderate knowledge
category and none were in the good knowledge category.
Dermatological conditions are considered difficult
to diagnose and manage, even by primary care
physicians and family physicians. In a cross-sectional
survey on the primary care physician’s ability to
recognize common dermatoses, it was observed that
the mean score on a photograph quiz was 4.1/10,
and 70.5% of the participants rated their ability to
diagnose and manage skin disorders as average, on
a five-point Likert scale. The authors believed that
primary care physicians had poor knowledge of skin
disorders, and there is a need for more training in the
diagnosis and management of common dermatological
conditions [21]. Federman et al. also concluded that
family care physicians cannot diagnose and manage
dermatological conditions [22]. Similar findings
were revealed in other studies [23,24]. Another study,
involving 400 health workers from Mali, revealed
inadequate knowledge on skin conditions. Knowledge
of health workers on the typical cases of pyoderma,
scabies, tinea capitis, and hypochromic patches
was assessed by showing pictures on a PowerPoint
presentation [25]. The authors reported that 19% of the
subjects showed correct knowledge on the treatment
of scabies. We observed that most of the nurses
(71.7%) knew that permethrin is the treatment of
choice for scabies, and 58.8% could correctly diagnose
fungal infections. However, in a study from Mali, only
6% of health workers could diagnose mycosis. The
difference might have been due to various factors,
such as different methodologies and data collection
instruments and the basic qualification and knowledge
of the healthcare workers.
Our study demonstrated a positive attitude and
willingness of the nurses to learn and be involved in the
management of skin conditions (76% of the participants).
Similar results were reported in a study from Sub-Saharan
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Africa on task shifting for the diagnosis of Kaposi’s
sarcoma. In this study, physicians, clinical officers,
nurses, and technicians were trained by a dermatologist
in doing skin punch biopsy. Although initially targeted
at physicians, the proportion of skin biopsies done by
nurses (62%) were more as compared to physicians (15%),
clinical officers (12%), and technicians (11%), which
suggests nurses’ willingness to undertake this task [26].
Although most of the participants in our study agreed
to have studied dermatology in their curriculum, only
27.3% said that they felt confident in performing skin
evaluations, and 69% of the study subjects believed that
the dermatology content of their curricula was not enough
and should be enhanced with the addition of practical
training. Earlier studies showed that training healthcare
workers and physicians in the care of skin diseases may
be the key to improving knowledge and patient care.
A study from Mali showed a marked improvement in the
management of skin diseases in primary health care after
a single day of training of the healthcare workers [24,25].
(institutional and national) and with the 2008 revision of the
Declaration of Helsinki of 1975.
Statement of Informed Consent
Informed consent for participation in this study was obtained from
all participants.
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CONCLUSION
13.
Nurses demonstrated a low level of knowledge on
the diagnosis and management of common skin
conditions, but a majority showed a positive attitude
and willingness to learn and care for patients with skin
diseases. It is recommended that relevant concepts
related to skin conditions should be integrated into
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Copyright by Kavita Kavita, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
Source of Support: Nil. Conflict of Interest: None declared.
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