Medical student Malone Mukwende has recently drawn attention to the under-representation of the black, Asian and minority ethnic (BAME) patient perspective within UK medical schools by co-authoring a handbook in collaboration with lecturers at St George's University of London and launching a campaign for change (Rimmer, 2020; Mukwende et al, 2020). The handbook provides an illustrated guide to skin conditions in people with black and brown skin (Mukwende et al, 2020).
Mukwende's quest is an admirable one, but it is difficult to understand why issues such as this have not been considered in the past, especially because of the diversity of NHS healthcare staff and the patients that they treat. It could also be considered that this is not an issue for medical schools to deal with alone but, rather, should be addressed by all health professionals, including those in nursing and midwifery.
In this article, the term black and minority ethnic (BME) will be used to align with the current terminology used in the NHS.
Standards for nurse education in the UK do not explicitly specify the inclusion of BME-related representation, such as the complexity of different skin condition presentations (Nursing and Midwifery Council (NMC), 2018a; 2018b).
It could be asserted that the NMC would expect this content to be covered without overtly stating how and when this is done. However, without explicit guidance offering direct intervention, it is still up to each individual nursing school to decide how and when they do this, if at all.
To add some context, within NHS trusts and clinical commissioning groups (CCGs) in England, 20% of the nurses, midwives and health visitors identify as BME (NHS Improvement, 2019a), which is significantly higher than the BME population of England and Wales, which is around 14% (Office for National Statistics (ONS), 2019). This increased representation is not equally spread across the different levels of nursing with BME staff being significantly underrepresented in senior management roles (NHS Improvement 2019a; 2019b).
BME representation within Agenda for Change bands significantly decreases the higher the band, with:
Band 5 and Band 6 are represented in line with population ratios but from Band 7 onwards this continues to decrease with only 3.8% at Band 9 (NHS Improvement, 2019a). Using NHS Improvement figures, the author has calculated that, between 2016 and 2018, the number of BME nurses, midwives, and health visitors working within NHS trusts and CCGs in England increased by 5219, whereas the number of those who were white decreased by 3613 (NHS Improvement, 2019a).
The NHS Long Term Plan (NHS England and NHS Improvement, 2019) and the Workforce Race Equality Standard (WRES) programme strategy (NHS Improvement, 2019a) both prioritise racial equality. A comparatively significant portion of those registered with the NMC are BME, yet we are not always educating the next generation of nurses with the skills required to be able to effectively treat the UK's diverse patient population, including themselves or their colleagues.
For example, Mukwende has highlighted the significant difference in the presentation of certain skin conditions such as Kawasaki disease in those with white skin and those with black or brown skin (Rimmer, 2020). If diagnosed early, Kawasaki disease can lead to treatment that means there is less likelihood of further complications (National Institute for Health and Care Excellence, 2019).
Why would we not want to equip our future nurses with skills such as this? After all, the NMC (2018c) has already indicated how the future nurse will be able to look to reduce health inequalities. Although there can be a huge variety of issues affecting those from a BME background, surely highlighting some of the more important issues and encouraging critical thought around these is the starting point. Once qualified, this could be integrated within nurses' mandated continual professional development, which forms part of revalidation to the NMC (2018d). Perhaps a caveat requiring each nurse to have at least one piece of evidence that they can link to equality, diversity and inclusion, such as BME condition presentations, would be a starting point. However, if this were pursued there would have to be measures in place to prevent tokenism.
It would be very easy to put all of the burden of development on the doorstep of the universities. However, we must remember that these universities work in close collaboration with partner trusts in order to fulfil the practical placement education of nursing students. One cannot exist without the other and so it then turns the spotlight on to those NHS trusts and CCGs to see what steps have been taken to educate already qualified staff. However, trusts are dealing with their own issues in terms of what has been mentioned earlier, such as improving racial equality within the working environment. These issues are not necessarily the same, but they come from the same starting point of under-representation. Perhaps we will see the importance of holistic care and treatment expanded to also specifically incorporate issues faced by those patients who are BME.
To believe that we need to overhaul education programmes throughout the UK is not necessarily true but, rather, we should be looking at them and asking ourselves whether someone of BME or any other identifying group would be able to look at the programme and see themselves reflected within it. We currently cater for the 86% of the population of England and Wales who are white, yet seemingly neglect the remaining 14% who are non-white (ONS, 2019), not to mention the 20% of the NHS population who are BME (NHS Improvement, 2019a).
Universities could increase BME representation by encouraging greater diversity within roles such as student representatives and also listening and acting upon feedback from students of all backgrounds. This feedback should also include how students feel topics related to BME communities are being covered and encourage suggestions to improve this. This inclusive teaching and enabling would allow graduates to be able to effectively treat anyone, no matter their background.
Worldwide, universities face unprecedented uncertainty at this time, therefore perhaps now is the time to take stock and figure out how to truly represent all those who we should already be representing.