What influences the inclusion of skin tone diversity when teaching skin assessment? Findings from a survey

Visual signs of tissue damage caused by pressure, moisture, infection and vascular conditions of the lower limb may be missed in people with dark skin tones due to variances in the presentation of skin changes across skin tones (Wounds UK, 2021). A skin assessment that includes palpating the patient's skin to assess for temperature and skin turgor, and discussing skin symptoms and skin changes with the patient is essential to underpin diagnosis in people with dark skin tones rather than relying on visual inspection alone (Dhoonmoon et al, 2023). Inability to undertake an accurate skin assessment across all skin tones negatively affects people with dark skin because early signs of tissue damage are missed and differential diagnoses are inaccurate. This is exemplified in pressure ulcers, where people with dark skin tones are more likely to present with severe pressure ulceration than their counterparts with lighter skin tones (Oozageer Gunowa et al, 2018; Bates-Jensen et al, 2021).

Nurses acquire skills in assessing patients' skin on clinical placements or through experiential learning as a registrant (Gray et al, 2019): even where there is variation in exposure to diverse skin tones, the clinical language is focused on light skin tones (Oozageer Gunowa et al, 2021). Nurse education on skin assessment outside of the practice setting is also predominantly focused on people with light skin tones (Oozageer Gunowa et al, 2021), which may be attributed to skin-tone diversity not being included in European standards of wound education (Holloway et al, 2020) or UK standards of proficiency (Nursing and Midwifery Council, 2018). However, little is known about the experiences of those teaching skin assessment to pre- and post-registrant nurses, and the barriers or facilitators that lead educators to include skin-tone diversity within their teaching of skin assessment.

Aims and objectives

This study aimed to explore the experiences of people involved in teaching skin assessment to pre- and post-registrants in both clinical and higher education settings to identify the barriers and facilitators in teaching skin and tissue assessment of patients with a range of skin tones.

Method

Study design

A cross-sectional online survey was undertaken of people involved in teaching skin assessment to pre- and post-registrants. The Checklist for Reporting of Survey Studies (CROSS) was used (Sharma et al, 2021), with additional information included for the qualitative analysis based on items from the standards for reporting qualitative research (SRQR) (O'Brien et al, 2014).

Data collection instrument

The online survey consisted of 25 questions based on the Theoretical Domains Framework (TDF) of behaviour change (Atkins et al, 2017), and four demographic questions.

The TDF is a validated, theory-informed methodological framework developed by behavioural scientists consisting of 14 domains (Atkins et al, 2017) (Table 1). Findings based on this theory-driven framework are used to inform explicit targets for relevant and effective interventions as part of a stepped approach to changing clinical behaviour (French et al, 2012). In this study, it has been used to understand the facilitators and barriers to including skin-tone diversity when teaching skin assessment to inform future interventions. The survey questions were based on target behaviours from the TDF framework (Atkins et al, 2017) agreed by the research team (Table 1). All quantitative questions in this part of the survey required a response.

The four questions related to participant characteristics asked about roles, professional registration, skin tone and ethnicity. To determine skin tone, the 19 colour blocks of the skin tones present in the Skin Tones Tool (Ho and Robinson, 2015) were presented randomly and participants were asked to self-select the one that closely matches the skin on the inside part of their upper arm.

Participants and recruitment

Participants were recruited on social media via Twitter and Facebook. The invitations to participate were shared by several professional organisations that represent specific clinical fields in nursing (Queen's Nursing Institute, Society of Tissue Viability, Royal College of Nursing (RCN) District & Community Nurse Forum, RCN Older People's Forum) and nurse education (Association of Advanced Practice Educators, Association of District Nurse Educators, RCN Education Forum).

Email addresses were also sought for all nursing leads or heads of department of the 94 nursing courses advertised on UCAS via their university website. Emails were successfully sent to senior staff members in 86 nursing departments informing them of the study and asking for their support in circulating the study invitation. This was followed up with a further email two weeks later if there was no response. All staff teaching on adult or general nursing programmes at 21 universities (22.3%) were then contacted, inviting them to participate either via email addresses listed on the university website or through an administrator at the university.

Data were collected online using Microsoft forms within Microsoft 365 throughout February and March 2023.

Ethical considerations

Participants confirmed they had read and understood the information provided and agreed for the data collected within this survey to be used for the research. All data were collected anonymously. Data were processed and stored securely using password protection and used under the terms of UK data protection law and UK General Data Protection Regulation. (Ethical Clearance Reference Number: MRA-22/23-35171).

Qualitative data analysis

This study used a hybrid inductive/deductive data analysis approach based on recommendations for analysing data using the TDF (Atkins et al, 2017). This theory-driven analysis ensures that findings remain grounded in theory to inform behavioural change interventions (Atkins et al, 2017).

Qualitative data were pseudonymised and any identifiable data or links to participant characteristics removed. Authors VC and NOG familiarised themselves with the data and generated initial codes of interesting features within the data for initial coding. VC coded the data based on these agreed codes in NVivo (v12). These codes were then grouped to form themes and aligned under the overarching domain with the 14 items on the TDF (Atkins et al, 2017). All authors reviewed the draft coding and mapping of themes to the theoretical domain's framework and suggested modifications. Themes were refined following feedback and names of the themes agreed upon among all authors.

Quantitative data analysis

Frequencies of nominal data were calculated and descriptive statistics presented. Where ordinal responses were provided, these were given a numeric value so non-parametric statistical tests could be performed. Questions relating to confidence in undertaking skin assessment between dark and light skin tones were analysed using the Wilcoxon test (W) to compare two paired groups. Where ordinal data were compared to participant characteristics, the Mann-Whitney test (U) was used to compare two unpaired groups (eg specialist clinicians to non-specialists).

Frequencies of nominal data were automatically presented in Microsoft Forms. Prior to statistical analysis, data were exported to Microsoft Excel where they were organised and ordinal descriptions given numeric codes. Data were transferred to Minitab (v19) for analysis.

Data have been collated and presented based on the domains of the TDF of behaviour change.

Results

Participant characteristics

Seventy-three participants completed the survey. All were registered nurses. Twenty-six (35.6%) predominately taught in practice and 47 (64.4%) predominately taught in higher education institutes. Most participants had skin tones from the top row of the Ho and Robinson (2015) Skin Tones Tool (n=55, 75.3%), and one-fifth (n=16, 21.9%) were specialist wound or tissue viability health professionals (Table 2).

Barriers, facilitators identified within relevant domains

The main barriers and facilitators for including skin-tone diversity within skin assessment were related to 12 domains in the TDF. The coding tree (Table 3) divides themes into barriers, facilitators and neutral findings and relates these to aspects of the TDF. The findings and these subthemes are discussed under each of the relevant domains from the TDF.

Knowledge

Most respondents had some knowledge of guidance on the influence of skin tone in skin assessment. The most frequent guidelines cited were the Wounds UK Best Practice Statement on addressing skin tone bias in wound care (n=21, 28.7%) (Wounds UK, 2021), European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance pressure ulcer definitions (n=6, 8.2%) (2019) and Mind the Gap: A handbook of clinical signs in black and brown skin (n=6, 8.2%) (Mukwende et al, 2020). Several participants accurately stated specific considerations when assessing the skin of people with dark skin tones even when specific guidelines were not mentioned. This included looking for pigmentation changes (n=7, 9.6%) and feeling the skin to look for temperature changes, oedema or induration (n=7, 9.6%).

There was an assumption that specialist knowledge of skin assessment in people with dark skin tones would be delivered elsewhere, suggesting non-wound care specialists may omit including skin-tone diversity in their teaching even though they may have some underpinning knowledge of its importance. This statement epitomises this belief:

‘The knowledge, experience and skills involved to deliver the fundamentals of skin integrity and maintenance shouldn't change, more in depth knowledge etc should come from those with that level of knowledge.’

Participant 41

Seven respondents were unaware of any specific guidance or specific considerations when assessing people with dark skin tones, three gave answers we couldn't decipher and four gave inaccurate information (n=14/73, 19.2%). Qualitative comments support this:

‘We should have the knowledge and skills, because we often care for patients with different skin tones. However, I feel my knowledge is less for different [skin] tone[s].’

Participant 12

This further indicates knowledge gaps that may exist on this topic.

Skills

Qualitative comments revealed two neutral themes related to the skills of individuals teaching skin assessment. Participants stated there were variations and complexities in the presentation of skin changes across a range of skin tones. Although this was presented as a neutral comment by some, often this was reported as ‘more challenging’ or ‘harder to detect’ on people with dark skin tones.

There was some recognition that a prerequisite to developing skills of clinical assessment across skin tones required practice exposure:

‘I think the person teaching should have relevant knowledge and experience of assessing people with dark skin tones. I think all practitioners involved in assessing skin should have experience of assessing a wide variety of skin tones.’

Participant 47

The lack of exposure presented a barrier for some respondents, such as those working in areas with a population of people with predominantly light skin tones or those no longer working in direct patient care settings.

Goals, intentions and consequences

Two-thirds of participants already included skin-tone diversity in their teaching (n=47, 64.4%). Of those who did not, nine participants (12.3%) reported they were developing resources to include this and 15 (20.5%) were considering the practicalities of teaching this. Only two were not thinking of covering this topic in their teaching, but they felt it was covered elsewhere in the programme. These domains identified key facilitators of the inclusion of skin-tone diversity in teaching (Table 3). Across all three domains qualitative comments included those relating to inclusivity and equity principles. However, other key areas were mentioned, such as the consequences of not teaching skin-tone diversity relating to poor patient outcomes and experiences, the need to improve students' ability and experiences, and teaching best practice in physical assessment of the skin (Table 3). One potential barrier existed in teacher intentions relating to the desire to treat everyone equally (equality). This may neglect the variations in clinical presentations and subtle visual signs of skin changes in some skin tones.

Professional identity

Participants felt the responsibility to teach students about skin integrity lay with either: any nurse in practice (n=63, 86.3%), tissue viability specialist nurses in practice (n=62, 84.9%), or tissue viability specialist nurses in universities (n=62, 84.9%). Fewer respondents thought it was the responsibility of those with a specific educational role such as any educator at university (n=57, 78.1%), practice educators (n=57, 78.1%) or practice supervisors (n=51, 70.0%).

Irrespective of the barriers they faced elsewhere, there was a clear professional accountability demonstrated by participants to include skin-tone diversity in their teaching. There was a perception that inclusivity in teaching and learning is important for all, and educators have the responsibility and accountability to know about this (Table 3).

Several participants recognised the requirement to develop their own knowledge and skills on this topic, through their professional development, in order to teach this topic and often demonstrated professional responsibility and commitment to this, as exemplified by one respondent's comment:

‘It's down to me a clinician to research darker skin and the elements within this topic to be able to bring out different aspects … As a white person, I made it my aim to try and gather as much info about different colour skin tones to be able to treat ALL people.’

Participant 44

This quote highlights the professionalism of respondents in addressing their own knowledge gaps on this topic.

Beliefs about capabilities

Participants were significantly less confident in assessing dark skin tones than light skin tones across all aetiologies (Figure 1). This was especially noticeable among non-specialist tissue viability healthcare educators for chronic venous insufficiency and peripheral arterial disease, where 50.9% were certain only about a few aspects of the assessment when assessing people with dark skin tones. However, it was noticeable across all aetiologies and experience, with statistically significant differences in confidence found throughout. However, some of the participants' characteristics also impacted confidence. Confidence among specialist tissue viability nurses (from practice or working in a higher education institution) was significantly greater in assessing people with dark skin tones across all aetiologies than their non-specialist counterparts (Figure 2). There was also a trend for individuals with dark skin tones to be more confident at assessing skin changes in dark skin tones than light skin tones. However, the sample size of participants with dark skin tones was too small to undertake a statistical analysis.

Optimism

Twenty-nine participants in the study (39.7%) were confident that student and junior nurses are taught skin assessment across a diverse range of skin tones by other members of staff. Three (4.1%) were completely unconfident, seven (9.6%) were fairly unconfident and 16 (21.9%) were somewhat unconfident.

Reinforcement

Two-thirds of participants (n=51, 69.8%) felt supported by their colleagues to teach skin assessment across a range of skin tones. Qualitative comments from participants indicated that there has been a recent drive to include skin-tone diversity, which facilitated educators to include this both in and outside of direct patient care settings (Table 3).

Environmental context and resources

Most participants (n=67, 91.8%) used photographs to support their teaching of skin and tissue assessment. However, the lack of available photographs was a barrier to including people with dark skin tones within teaching, with educators reporting adapting case studies to the resources they have available.

‘Photos of darker skin tones and the damage [are] more difficult to obtain, without copyright. My photos are mostly white skin as the photos turn out better. The low level skin changes are difficult for amateur photographers to pick up on darker skin tones. High level damage is easy [to see] across all skin tones.’

Participant 58

In the direct patient care environment, patients were selected for teaching opportunities based on clinical need or patient availability and not because of their skin tone.

Social influences

Many educators covered skin-tone diversity when teaching skin assessment based on their own clinical experience (n=48, 65.7%), their own education (n=37, 50.7%), and the demographics of patients in their locality (n=36, 49.3%). There appeared to be a clear recognition of the need to teach skin-tone diversity in skin assessment when working in multicultural areas but it was also raised as a reason for a lack of inclusivity in areas with predominantly light skin-toned populations, both when teaching skin assessment in practice and outside of direct patient care.

There also remained some awkwardness or embarrassment from teachers when teaching about the assessment of people with dark skin tones and an acceptance that whiteness is the norm, with some teaching staff or students not questioning the presentation of skin changes on dark skin.

‘They [students] tend not to think about it. They rarely challenge written or spoken statements about “skin looking blue”, even if they themselves are not white!’

Participant 65

Although students with dark skin tones may not question skin assessment being taught through a ‘white lens’, there were comments from some participants about the importance of learners with dark skin tones feeling that they are seen and represented in the teaching resources so that they have a sense of belonging. Reliance on teachers or clinicians with dark skin tones to highlight where practice is not inclusive was also reported:

‘My university had two Black lecturers who raised the issue and the [department] responded by buying Black and Brown mannequins and patches.’

Participant 6

Listening to the experiences and perceptions of inclusion from colleagues with dark skin tones was considered by participants to be advantageous to improve education provision.

Behavioural regulation

Self-regulation of behaviour for some related to their perception that skin tone does not matter when teaching skin assessment. This may be because the inclusion of skin tone in teaching is not then embedded in practice. However, some educators did not acknowledge skin presentation varied across skin tones, illustrated by this statement.

‘I do not care about race, religion, looks, skin tones. I'm concerned about the PATIENT as a human being.’

Participant 44

Several people reported that they had the ability to seek help to modify their behaviour on teaching skin assessment across all skin tones. However, frequently this meant consulting with clinicians with more experience and relying on staff members with dark skin tones to support this topic.

Discussion

The survey findings indicated that most participants were aware of the importance of including people with both dark and light skin tones when teaching skin assessment, and they demonstrated professional accountability, interest and commitment to ensuring their students and colleagues know how to undertake skin assessment across a range of skin tones. However, the findings also identified several areas that are barriers or challenges to including skin-tone diversity in teaching skin assessment.

Many educators lacked confidence in these skills themselves. This may be associated with international guidelines omitting signs and symptoms specific to dark skin tones for a range of conditions, such as infection (Swanson et al, 2022), chronic venous insufficiency (De Maeseneer et al, 2022; Lurie et al, 2020) and peripheral arterial disease (Aboyans et al, 2018), causing a reliance on acquiring these skills in person through experiential learning during practice exposure. Although not considered specifically for skin assessment, experiential learning is often relied on in wound care to develop nursing knowledge and skills (Welsh, 2018; Gray et al, 2019). This causes gaps in knowledge and a lack of application of evidence-based practice (Welsh, 2018). Therefore, improved evidence-based clinical guidance to support skin assessment across all skin tones is needed. However, the survey results suggest that tissue viability nurse specialists may have the experience that enables them to be more confident in assessing dark skin tones than non-specialist clinicians and therefore may be a good source of information to support practice.

Having highlighted the importance of updating clinical guidance, even when guidelines on assessment exist that identify the signs and symptoms in dark skin tones, such as in the pressure ulcer guidelines by the EPUAP/NPUAP (2019), the survey's findings demonstrated that the confidence of teachers varied between their assessments on people with dark and light skin tones. Previous studies also indicated that the inclusion of dark skin tones in a clinical guideline did not result in skin-tone diversity being taught in skin assessment (Oozageer Gunowa et al, 2021). This shows that the availability of clinical guidance alone is insufficient for ensuring the inclusion of skin-tone diversity in teaching.

The scarcity of appropriate wound and skin images was a clear barrier to the inclusion of dark skin tones for teaching outside of direct patient care. This is an international problem that requires addressing, with a dearth of images depicting skin changes for people with dark skin tones in textbooks (Louie and Wilkes, 2018; Pusey-Reid et al, 2023) and within top-ranking international peer-reviewed journals (Diao and Adamson, 2022; Wilson et al, 2021). This bias has led to a white predominance in nursing and healthcare resources, and ignorance of the impact skin-tone diversity has on the presentation of skin changes. However, it is acknowledged that more resources are becoming available that depict skin changes in people with dark skin tones such as the freely available text (Mukwende et al, 2020).

In some situations, there was a reliance on people with dark skin tones to highlight where skin-tone diversity was not included in teaching and to be used as a resource to support colleagues with light skin tones. Seeking advice from colleagues may be a valuable resource as our findings have indicated that respondents found it easier to assess skin tones similar to their own. However, in a survey with a greater number of staff with dark skin tones, staff reported a decrease in confidence assessing pressure damage on people with dark skin tones, regardless of their own ethnicity (Kariwo et al, 2023). Additionally, relying on colleagues with dark skin tones to highlight issues may be limited due to the barriers in career progression for nurses from ethnic minorities (Ross et al, 2020) or some feeling unable to speak up about changing existing practice due to previous experiences of working in the NHS making them feel bullied or ignored (Ross et al, 2020). People with dark skin tones may also feel fatigued from the emotional disconnect and defensiveness they may have experienced in the past when talking about structural racism (Eddo-Lodge, 2021). Therefore, it is essential there is a collaborative approach from all staff, regardless of skin tone, to identify and highlight where the inclusion of skin-tone diversity in skin assessment teaching is lacking to benefit patient outcomes.

Frequently, participants completing the survey wanted to ensure all patients, regardless of skin tone, were treated equally, selecting patients on clinical need and interesting cases rather than teaching common conditions on a range of skin tones. This ‘colour blindness’ in case-selection is a barrier to ensuring skin-tone diversity is taught, especially in areas with predominantly light skin tones where exposure to people with dark skin tones may be limited. Not acknowledging skin colour as an important component of clinical presentation can lead to the learner not appreciating the variations in clinical presentation (Wounds UK, 2021), not acknowledging these differences (Oozageer Gunowa et al, 2021), and reinforcing white normativity in nurse education (Oozageer Gunowa et al, 2021). However, if teaching intentions support best practice criteria in skin assessment across all skin tones, encompassing feeling for warmth, turgor, and patient-reported changes in sensation, symptoms (pain or itch) or appearance (Dhoonmoon et al, 2023), all patients would benefit from a more detailed and accurate assessment to aid clinical diagnosis.

Researcher characteristics and reflexivity

All researchers are registered nurses currently working in a higher education institution, with a range of clinical experiences (secondary, tertiary and community care), from areas with diverse multicultural populations seeing patients with a variety of skin tones. One author (JG) also currently works in a patient-facing role.

Generalisability and limitations

The self-selecting nature of this sample may not be representative of all those who teach skin assessment to students and registered nurses, as many participants would have seen the advert to participate through the professional networks in which they were engaged on social media.

Conclusions

The findings indicate that there is some awareness of the importance of including diverse skin tones in teaching. However, even within this self-selecting sample of engaged nurse educators, further resources are necessary to overcome a historic unconscious bias that has led to a lack of teacher confidence, photographic resources and evidence-based guidelines of clinical presentations in dark skin tones. There is also a need to teach best practice criteria in skin assessment for all patients and include examples from patients with diverse skin tones when teaching skin changes of common conditions, especially in areas with a population that has predominately light skin tones, to ensure variation in clinical presentation is recognised.

KEY POINTS

• The need to include diverse skin tones in teaching skin assessment is recognised as important
• Many nurses who teach skin assessment lack the confidence to include assessment of people with dark skin tones in their teaching
• Historic unconscious bias has led to a lack of resources for teaching skin assessment in people with dark skin tones (eg copyright-free images)
• Efforts to treat everyone equally results in ‘colour-blindness’ in teaching, leading to knowledge gaps in skin assessment of people with dark skin tones

CPD reflective questions

• Reflect on the key components of skin assessment. How confident do you feel to conduct a skin assessment encompassing patient history taking, observation and palpation?
• How do you include patients with dark skin tones and their families in understanding and recognising skin changes that occur due to a variety of conditions encountered in your practice?
• How do you include people with dark skin tones when teaching students or colleagues about skin assessment in your practice? Could this be improved?
• How could you influence other colleagues to improve their skin assessment of people with dark skin tones in your clinical area?