The Color of Care

Yvette Aidoo-Forson, BSN, RN

WOC Nursing from a Woman of Color’s Perspective

I have created a new term to describe myself, a WOC squared: A WOC (Wound Ostomy Continence ) Nurse who happens to be a WOC (woman of color)! Since the subject of diversity in healthcare has received considerable attention recently, I wanted to not only share, but also encourage thoughts on this matter.

Does representation in healthcare really matter?

It can be tempting to downplay or downright dismiss the significance of diversity in healthcare. Nurses take an oath to treat all patients equally, with research-based evidence dictating our interventions. Therefore, why would melanin affect outcomes?

Here are a few reasons:

Historical events such as the Tuskegee experiment, coupled with implicit bias in healthcare still resonate, fostering a sense of skepticism for some within communities of color.
Clinical interventions that we consider best practices, have previously been based on studies primarily involving Caucasian participants.
Limited access to screening programs and other preventative services, with environmental disparities such as air and water quality also affecting outcomes.

The combination of factors listed above can be deadly. If you are not convinced, examine the mortality rates across race with conditions such as breast cancer and even our most recent adversary, COVID. Our society is a tightly interwoven fabric, with an interdependency among each other for all facets of living. Therefore, if a segment of the population disproportionally suffers as a result of inequity, eventually, we all do.

How does color affect skin and wound care?

Wound care is a highly visual specialty. We rely strongly on colors that we see within a wound and on skin to determine status and most importantly, actions. So how does color within skin affect wound care? One concrete example is with pressure injuries. There are studies showing that pressure injury severity rates are higher in patients of color because of the difficulty with detecting changes in darker skin. The consequence: pressure injuries are often missed in their earlier stages. But why does this disparity exist? Consider the following:

Limited information/pictures in nursing curriculums regarding differences between lighter and darker skin, with little attention on how various skin conditions present on dark skin.
As a woman of color, I can say that it is not unusual for a darker-skinned person to have multiple areas of natural hyperpigmentation and sometimes, the areas involve pressure points such as the coccyx, buttocks, and elbows. This can complicate the assessment process.
Erythema, bruising and other classic findings that are obvious in light skin, will either be absent in dark skin, or more subtle, instead presenting as hyperpigmentation.

As I thought about this topic, I could not help but note the irony of the situation. In an effort to provide the same level of care regardless of color, a major oversight occurred. Because as it turns out, nurses DO require an enhanced skill set to treat patients with darker skin tones.

Fortunately, in the last few years, this truth has been acknowledged in clinical practice. In the article, “Ten Tops Tips: assessing Darkly Pigmented Skin” (Black, 2020), the authors discuss the differences in detail, with strategies to improve assessment. We all know that experience is the best teacher, but depending on the demographics of where one practices, the opportunity to assess darker skin tones on a routine basis may be scarce. Therefore, educational resources providing awareness and the tools to do so become the next best option.

For these reasons, a culture of inclusion should be cultivated not only in healthcare but in university curriculums and continuing education as well. This is a welcomed trend as organizations such as National Pressure Injury Advisory Panel (NPIAP) have addressed such deficiencies by creating educational tools that highlight how pressure injuries present in darker skin.

Of note, even wound models of darker skin tones are commercially available for pressure injury education purposes.

What about ostomy care?

Unfortunately, not all ostomates get the benefit of consultation from a WOC Nurse, who can be difficult to find in general. Therefore, you can imagine an ostomate of color's surprise when a WOC Nurse, who is also of color, walks through the door! During the course of my career, feelings of frustration due to lack of resources and bias have been expressed and identified as barriers to care. As an example, delayed diagnosis related to conditions such as IBD was perceived as indicative of the stereotypes that exist in healthcare about who IBD affects.

Final Thoughts

If patients feel that their voices are not heard or worse, fear that care is inadequate, this can perpetuate a cycle of mistrust and poor outcomes. Therefore, diversity and inclusion in healthcare is critical. By developing awareness, this sets the stage for change, because we clinicians become motivated to seek tools enhancing our skill set. As a woman of color in WOC nursing, I am careful not to assume an inherent advantage in my ability to provide care to those with skin tones similar to mine. Therefore, I too, continuously seek resources that can make me a discerning clinician, with the ability to advocate for all complexions as my profession intended. I hope this essay inspires others to do the same.

References

Black, J & Simende, A (2020). Ten Tops Tips: Assessing Darkly Pigmented Skin. Wounds International 2020, Volume 11 (3), pp 8-11.

National Pressure Injury Advisory Panel Staging for Darker Skin Tones:

2020 BreastCancer.org: Breast Cancer Risk Factors-Race/Ethnicity

2022 CDC: Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity

2022 Wikipedia: The Tuskegee Syphilis Study

2021 FDA: Clinical Trial Diversity