‘Educators need to promote inclusive care for people with dark skin tones’

Posted: 3rd June 2024

Source: ‘Educators need to promote inclusive care for people with dark skin tones’ | Nursing Times

Health inequities are avoidable differences in people’s health status in and between populations (The King’s Fund, 2022). These often manifest as variations in quality of healthcare, access to resources and health outcomes.

The health disparities experienced by people with dark skin tones highlight the need to foster inclusive practices that address these inequalities. For example, people with dark skin tones experience a higher prevalence of severe pressure ulcers compared with people with light skin tones (Oozageer Gunowa et al, 2022) and newborns with dark skin tones are being put at risk by systemic inadequacies in assessment systems, such as the Abgar score (Fair et al, 2023).

Ethnic disparities also mean that women with dark skin tones have higher maternal mortality rates and a threefold increase in the likelihood of dying from breast cancer compared with women with light skin tones.

This underscores the need for nurse educators to incorporate discussions of health inequities across skin tones into all aspects of their teaching. This means moving beyond tokenistic approaches, such as merely diversifying names in case studies, to acknowledging and addressing the profound implications of these differences. Recognising and actively engaging with these disparities is essential to achieve meaningful change in healthcare practices.

Nurses are in a pivotal position to influence patient experiences and outcomes. Harm-free care means being actively aware of and combating biases (both conscious and unconscious), stereotypes and structural inequities that could adversely affect patients. Commitment to these principles is essential to fostering an environment where all patients feel seen and cared for equitably. Concepts like race neutrality and racial colour blindness, which ignore race in social interactions and policies, although intended to avoid discrimination can inadvertently neglect the impact of racial differences on healthcare experiences and outcomes. Being ‘colour blind’ might prevent clinicians from recognising and addressing specific health needs related to racial disparities. This is contrary to the principles of equity and justice in healthcare.

The healthcare disadvantages experienced by people with dark skin tones can be due to various systemic and clinical factors (Wounds UK, 2021). One key issue is diagnostic challenges, as most nursing and medical education materials focus on symptoms as they appear on light skin tones. This leaves clinicians less prepared to accurately diagnose and treat conditions such as cyanosis or skin rashes in darker skinned people, which can lead to lower quality care, longer diagnosis times and poorer health outcomes for these patients.

It is the moral and ethical duty of nurse educators to champion students’ right to a fair and inclusive education that reflects the diversity of all population groups. As part of a quality improvement project for a Florence Nightingale Foundation Leadership scholarship, I designed a session called ‘skin tone diversity within clinical practice’ to raise student nurses’ awareness of how skin tone can influence clinical judgments and have an impact on patient care.

Skin tone bias involves both conscious and unconscious prejudgments that can affect diagnosis, treatment and overall patient care. The training focused on recognising and addressing clinical signs and symptoms across different skin tones, and on resources that can aid in this. Previously, only 53% of students had considered the impact of skin tone on patient care, but after participating in the session, there was a 31% increase in awareness of resources relating to the topic, with 97% of students saying they would incorporate the learning material into their clinical practice.

Inclusive learning, sometimes referred to as decolonising the curriculum, prompts us to consider everything from new perspectives. Failing to listen to and look after people with dark skin tones is dehumanising, resulting in discriminatory nursing practice (McCoy, 2020). Educators must consider if they have showcased diversity in their materials, used inclusive language, introduced examples from different cultures to promote dialogue and enabled students to demonstrate their understanding of issues by drawing on their own experience and culture.

Such measures will equip nurses to better advocate for and implement equitable healthcare practices that respect and respond to the diverse needs of all patients. This will not only improve patient outcomes, but will contribute to broader societal health equity.

Neesha Oozageer Gunowa is senior lecturer, University of Surrey


Fair F et al (2023) Review of Neonatal Assessment and Practice in Black, Asian, and Minority Ethnic Newborns. NHS Race and Health Observatory.

The King’s Fund (2022) What are health inequalities? kingsfund.org.uk, 17 June (accessed 14 May 2024).

Oozageer Gunowa et al (2022) Skin tone bias and wound care: highlighting the current evidence and addressing the gaps in knowledge of dark skin tones, Wounds UK; 18: 1, 22-27.

Wounds UK (2021) Best Practice Statement: Addressing Skin Tone Bias in Wound Care: Assessing Signs and Symptoms in People with Dark Skin Tones. Wounds UK.

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