Abstract
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 ulcer prevention is a routine aspect of nursing care; yet there is evidence of inequity in relation to patient assessment and clinical care, with a higher prevalence of pressure ulcers in people with dark skin tones. Despite limited literature being available surrounding the topic of pressure ulcers and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health inequity within the nursing curriculum to ensure that the teaching of pressure ulcer prevention is inclusive. Aim: The aim of the study was to critically evaluate the educational preparation of registered nurses in Higher Education institutions in relation to pressure ulcer assessment and identification, particularly focusing on skin tone diversity. Method: A sequential mixed method collective case study design has been applied. The first phase of the study, after the development of an observation and documentary analysis tool, assessed whether pressure ulcer identification and assessment in undergraduate nurse education programmes considered skin tone diversity through the analysis of educational material and teaching observations at five Higher Education institutions in England. The Higher Education institutions were recruited through a purposive sample, following ethical approval (University Research Ethics Committee Registration No: 171077). The preliminary findings informed the second phase of the study as per the requirements of a sequential mixed method study (Creswell, 2014). The second phase included semi-structured interviews with a nurse educator and focus groups with students at each of the previously selected Higher Education institutions. Informed consent was obtained before data collection and participants were informed that involvement in the study would not have an impact on either their employment or their educational programme. Findings: The first documentary analysis phase of the study confirmed all Higher Education institutes overwhelmingly directed teaching and learning activities about pressure ulcers towards people with light skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with dark skin tones and pressure ulcers. There was no discursive language or awareness of colour or colour blindness. In the second phase of the study, classroom learning was predominately framed through a white lens with White normativity being strongly reinforced through teaching and learning activities. This reinforcement of White normativity was evidenced through four main themes: i) dominance of whiteness in the teaching and learning of pressure ulcers in undergraduate nurse education ii) the impact and implications of whiteness as the norm in pressure ulcer teaching on student nurses iii) the role of external inputs on the teaching and learning of pressure ulcers in on-campus undergraduate nurse education iv) suggestions for change in educational practice of skin tone diversity: improvements within the classroom. Conclusion: Nurses responsible for the design and delivery of teaching and learning experiences for students of nursing need to ensure meaningful teaching and learning experiences that facilitate future nurses to interrogate their complicity within a system of White dominance. Anti-racist pedagogy and the radical critique of all teaching and learning activities are needed to help explore, improve and meaningfully include skin tone diversity and inclusivity in nurse education.