Dr Neesha Oozageer Gunowa

ABSTRACT Aim To examine community nurses' experiences of caring for people with dark skin tones at high risk of developing a pressure injury. Design Qualitative descriptive design. Methods Focus groups and individual semi‐structured interviews were conducted among registered nurses working in the community between November 2023 and March 2024. Thematic analysis was used. Results The findings reveal the lack of nurse education on diverse skin tones, how community nurses gain knowledge on skin tone diversity in the context of pressure injuries and the topics community nurses believe are crucial to improve the management of pressure injuries in patients with dark skin tones. Conclusion The study highlights the gap in nurse education regarding diverse skin tones, revealing how community nurses acquire knowledge related to pressure injuries in patients with dark skin tones. Implications for the Profession and/or Patient Care This research could inform the development of targeted educational programmes and training initiatives, ultimately preventing patient harm and enhancing the quality of care and health outcomes for patients with dark skin tones. Impact It provides valuable insights into key topics that community nurses consider essential for improving the early recognition and management of pressure injuries in people with darker skin tones. Reporting Method The research adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Public Contribution A project steering group contributed to the concept of the study and checked the interview questions were relevant and suitable.

The education sector faces major challenges in providing learning experiences so that newly qualified nurses feel adequately prepared to work in a community setting. With this in mind, higher education institutions need to develop more innovative ways to deliver the community-nurse experience to student nurses. This paper presents and explores how simulation provides an opportunity for educators to support and evaluate student performance in an environment that models a complete patient encounter in the community. Following the simulation, evaluative data were collated and the answers analysed to identify key recommendations.

Aim To examine the personal experiences and perceptions of people with dark skin tones and their carers, in relation to pressure injury. Design Qualitative study using semi-structured interviews. Methods Twenty-two interviews with people with dark skin tone and/or their family carers, who were known to and visited by community nurses for pressure area management or who had been identified as being at high risk for developing a pressure injury were carried out. Results Thematic analysis of the interview transcripts revealed that skin discolouration towards a darker hue than usual was the commonest symptom identified by participants as a sign of altered skin integrity and potential pressure damage. Four main overarching themes were revealed through comprehensive analysis of the transcripts: (1) indicators of pressure injury; (2) experienced symptoms of pressure damage; (3) trust in healthcare workers; and (4) improving care for populations with dark skin tones. Conclusion The findings from this study clearly present how early-stage pressure damage is identified among people with dark skin tones. Implications for the Profession and/or Patient Care These findings have the potential to reduce health inequality by influencing and informing clinical policies and strategies in practice. Findings could also lead to the development of patient-informed educational strategies for nurses and health workers which will enable the early identification of pressure ulcers among people with dark skin tones. Further research is needed to better understand health disparities in relation to preventable patient safety harm. Impact The findings demonstrate the importance of engaging with and listening to the stories and experiences of people living with pressure damage to help in the early recognition of pressure injuries. Reporting Method The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative research were followed. Patient or Public Contribution A project steering group reviewed information sheets for participants and checked the interview questions were relevant and suitable.

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.

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.

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.

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.

In March 2023, Ledger et al. published a paper entitled Patient perceptions and understanding of pressure ulcer (PU) risk in the community: Empirical Research Qualitative. This study aimed to explore patient perceptions and understanding of their PU risk and how information is communicated between a nurse and patient in the home setting. The paper showcases how the patient's perception and understanding of PU risk is different from the scientific, professional view.

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.