Student nurse teaching on pressure injuries is “overwhelmingly directed” towards caring for patients with white skin, a new study led by nursing academics has found.

These gaps in the nursing curriculum have potentially fatal consequences for people with darker skin tones and are contributing to race-related health inequalities, according to those behind the research.

“We need to teach our future generation of nurses that it’s not only about redness”

Neesha Oozageer Gunowa

They are calling for a “radical critique” of all teaching and learning in a bid to make nurse education more inclusive.

It comes at a time when racial inequalities and injustices both socially and in relation to health have been brought into the spotlight by the Black Lives Matter movement and also the coronavirus pandemic.

The study – titled Embedding skin tone diversity into undergraduate nurse education: through the lens of pressure injury – was published last week in the Journal of Clinical Nursing (JCN).

As part of the project, documentary and observational data from student nurse lectures regarding pressure injuries were collected during 2017 and 2018 from five higher education institutes in England and subsequently analysed.

While the issue of pressure injuries in people with darker skin tones was discussed in all programmes, the teaching was “brief” and “superficial”, the researchers found.

“It could have been one slide in a PowerPoint presentation, or it could a be a passing comment that a student asked, but it wasn’t really well thought through,” said Neesha Oozageer Gunowa (pictured above), a senior lecturer in community nursing at Kingston and St George’s universities in London and one of the study authors.

The research team also included Joanne Brooke, professor of nursing at Birmingham City University, and Australian nursing academics Debra Jackson and Marie Hutchinson.

Lack of awareness of the different ways pressure damage may present in people with darker skin tones meant problems were being identified in these patients at a later stage, when serious complications including death were more likely to occur, Ms Oozageer Gunowa told Nursing Times.

Ms Oozageer Gunowa said the evidence showed pressure injuries in people with darker skin tones were being picked up for the first time when already at a grade 3, when an open wound would be forming.

She said a key issue was the focus on redness as an early indicator of pressure damage.

“The terminology leads towards Caucasian language as looking for redness, looking for the change in colour,” said Ms Oozageer Gunowa, a district nurse by background and a Queen’s Nurse.

“We can’t assume that we treat everyone the same, because not everyone is the same”

Neesha Oozageer Gunowa

“So, clinicians automatically would look for the redness, because that is what they are prompted to look for, and they might not consider the other options, or it might be too late before they start thinking of other options.”

She added: “It’s creating that health inequality and health inequity.”

One of the problems was a lack of research on this topic, as shown by a literature review carried out by the same researchers in 2017 and published in the JCN, noted Ms Oozageer Gunowa.

While the needs of people with darker skin tones were “slowly” being included in clinical pressure injury guidance, Ms Oozageer Gunowa said lack of research meant it was “hard to establish what needs to specifically be done”.

She said she hoped their work could help raise awareness of the issue and place it onto the agenda of more researchers, nurse educators and practice assessors.

“We need to teach our future generation of nurses that it’s not only about redness, it’s about identifying a bigger picture; that systems and processes are not applicable to everyone and that we can’t rely on a colour-blindness approach,” she added.

“We can’t assume that we treat everyone the same, because not everyone is the same, and we need to acknowledge that there are inequalities and inequities between population groups.”

She said Black Lives Matters had shown that people often struggled to talk about skin colour and race, but taking an active approach in making healthcare more inclusive was a tangible way for nurses to show “allyship”.

“We talk about allyship – being a clinician with allyship would actually be to be aware of these issues and to actively engage and encourage students to be aware of this issue,” urged Ms Oozageer Gunowa, who is carrying out the research as part of her PhD at Oxford Brookes University. She recently wrote about the topic for Nursing Times.

The next phase of the project is to look at the part played by nurse educators themselves.


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