Dr Neesha Oozageer Gunowa

Understanding the variances in visual skin changes across all skin tones is important in clinical care. However, the experiences of those teaching skin assessment to pre- and post-registrant nurses are unknown. To determine the barriers and facilitators experienced in teaching skin assessment across a range of skin tones to pre- and post-registrant nurses. A cross-sectional, mixed-methods online survey was undertaken throughout February and March 2023 based on the Theoretical Domains Framework of behaviour change. In this self-selecting sample, most participants were aware of why it was important to include all skin tones when teaching skin assessment and were professionally motivated to include this in their practice. However, resources and support are needed to overcome an unconscious bias in teaching skin tone diversity, resulting in a lack of availability of good quality photographs and educator confidence in their own skills. Educators not considering skin tone when selecting patient cases and relying on people with dark skin tones to highlight where practice is not inclusive may also lead to insufficient exposure for students. There is some awareness of the importance of including diverse skin tones in teaching, but further education and resources are needed.

Early identification of changes to the skin is one of the most important tools to protect patients who are at risk of developing pressure ulcers (Haesler, 2019). Analysis of the recording of pressure ulcers on a Trust’s Incident Management system (Datix) shows that Black and Asian patients have higher representation when reporting grade 3 and 4 pressure ulcers than White patients. Staff surveys were carried out to understand the impact of patient skin tone on staff confidence when managing early signs of pressure-related tissue damage. Analysis of these surveys show that staff progressively had less confidence in identifying early signs of tissue damage in patients with dark skin tones. This reduction in confidence is consistent across different staff ethnicities and across different levels of staff experience managing pressure ulcers. Recommendations for practice to address this issue based on responses from staff about what they think works in management and identification of early signs of skin damage in patients with dark skin tones have been made.

Dismantling structural racism challenges nurses to consider the extent to which issues of inclusion, diversity and race are operationalised in day-to-day professional practice. This includes nurse education. To be truly effective, any examination of teaching content in nurse education needs to be investigated through document analysis plus observation in the classroom. However, tools to ensure consistency between these methods of collecting data are limited. To design a structured tool for collecting data by analysing teaching materials and observing teaching on pressure injuries and people with darker skin tones. This novel approach of using a single tool provides a unique opportunity to explore teaching materials and what is actually taught in the classroom. The data collected can assist with comparative analysis, enabling an in-depth view of curriculum content. The nuanced and subtle data gathered using the complementarity of analysis between teaching materials and teaching observations in the exemplar tool presented created a unique data set for examination. This tool has broad applications for nurse researchers, particularly for examining topics that are often perceived to be sensitive, such as race and skin tone. It can be used for in-depth scrutiny of classroom teaching, to develop and influence curriculum content and team discussions, and in larger studies exploring nurse education content.

In this article, we aimed to explore the literature to ascertain what research evidence exists in relation to the identification of pressure injuries in people with dark skin tones. Pressure injuries development has been widely researched and documented; however, much of this work does not address ethnicity or race and assumes Caucasian-ness. Thus, the perceptions of people with dark skin tones and the influence of skin pigmentation on identification and management of pressure injuries is under examined. Literature review. A comprehensive electronic database search was undertaken of PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane and British Nursing Index (BNI) between 1990-July 2016. Alongside the electronic data, journals, books, papers from conferences, relevant national and international organisations and reference lists were also used to help source key studies. A search of the literature revealed 11 relevant articles. The foci of studies included the following: risk of sustaining a pressure injuries based on skin tones, identification of pressure injuries amongst people with dark skin tones, pressure injuries and place of care and socio-economic impact on pressure injuries development. Overall, findings indicate that people with darker skin tones are more likely to develop higher stage pressure injuries. Reasons for this are not fully elucidated; however, it may be associated with current skin assessment protocols being less effective for people who have darker skin tones resulting in early damage arising from pressure not being recognised. From the literature reviewed, it can be seen that there is a lack of guidance and evidence, and people with darker skin tones are more likely in comparison with people presenting as Caucasian to develop higher stage pressure injuries. The current literature suggests a need for researchers and clinicians to consider skin tone variances rather than ethnicity when exploring comprehensive skin assessment.

Objective To explore health disparity in on‐campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries. Background As a discipline, nursing espouses ideologies of inclusion, equity and valuing diversity. However, little is known about how these ideologies translate into clinical care. Pressure injury prevention is a routine aspect of nursing care; yet, there is evidence of inequity in relation to clinical care and patient assessment, as people with darker skin tones have a higher prevalence of severe pressure injuries before detection of damage occurs. Despite limited literature being available surrounding the topic of pressure injuries and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health disparity within the nursing curriculum. Design A multiple method collective case study. The STROBE checklist was followed in reporting this study. Methods Documentary and observational data of lectures regarding pressure injuries were collected during 2017 and 2018 from five Higher Education Institutes in England delivering approved nursing undergraduate programmes. Results Documentary analysis confirmed all Higher Education Institutes overwhelmingly directed teaching and learning activities about pressure injury towards people with Caucasian skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with pressure injuries and darker skin tones. There was no discursive language or awareness of colour or colour blindness. Conclusion Radical critique of all teaching and learning activities needs to occur, to help explore, improve and meaningfully and authentically include diversity and inclusivity in nurse education, and in particular, how people across the skin tone spectrum are included and represented in teaching and learning activities. Relevance to clinical practice Critical examination of current teaching practice is crucial to address disparity and ensure care for people with darker skin tones is optimised. Nurse educators have a responsibility to educate for the care needs of all, as the quality of nurse education has a direct impact on care delivery and health disparity. This paper highlights the importance of addressing skin tone diversity and offers the opportunity for reflective practice, not just in formal education, but in clinical settings by preceptors and senior staff.