Study Highlights Gaps in Diverse Skin Representation in Nursing Textbooks

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Recent studies highlight an urgent need to address "visual racism"—the inadequate representation of dark skin tones in medical education, which has contributed to disparities in healthcare outcomes.¹ This bias, manifesting in delayed or missed diagnoses for individuals with darker skin, stems from a lack of training in recognizing dermatologic conditions in various skin tones. For dermatology clinicians, the repercussions can be particularly significant, as skin color affects the presentation and diagnosis of numerous skin conditions. A recent study analyzed pediatric nurse practitioner (PNP) textbooks, revealing critical gaps in skin of color representation, and discusses the implications for dermatology professionals.²

Background

Medical education materials have historically failed to adequately represent skin of color, which often results in a healthcare workforce less prepared to recognize disease presentations in diverse patient populations. This disparity is perpetuated by clinical training materials that over-represent lighter skin tones while neglecting darker skin tones, particularly for non-stigmatized conditions. Addressing this gap is crucial, as the National Academies of Sciences and Engineering has underscored the role of nursing, and healthcare providers more broadly, in supporting health equity and fostering inclusive patient care.³ 

Study Overview

The recent study examined 8 widely used PNP textbooks to evaluate the representation of Fitzpatrick skin types, specifically types IV-VI, which represent darker skin tones. The study followed Strobe guidelines and used a quantitative, observational approach to assess images, illustrations, and videos within these textbooks, coding them based on Fitzpatrick scale standards. This analysis included a variety of medical content, beyond dermatology, to gauge how consistently diverse skin tones were represented across different health conditions.

Out of 2,112 images analyzed, researchers found only 28% depicted darker skin tones, while illustrations and video content showed even lower representation (2.5% and 9%, respectively). Notably, they stated conditions associated with stigmatized health issues, such as child abuse, infectious diseases, and sexually transmitted infections, showed disproportionately high representation of dark skin images. The study stated this misrepresentation perpetuates stereotypes and may exacerbate implicit bias, ultimately influencing healthcare professionals’ perceptions of disease prevalence across different racial and ethnic groups.

Implications for Practice

The study noted these findings underscore the critical need to improve clinical training materials that include diverse skin tones, as accuratediagnosis and appropriate care for patients with darker skin rely heavily on visual training. Researchers stated that dermatologic conditions, such as melanoma, present differently on dark skin and may be overlooked or misdiagnosed without proper training. Further, they noted visual bias in educational resources can hinder the ability of future clinicians to identify early signs of skin cancers and inflammatory conditions in diverse patients, leading to delayed treatment and poorer outcomes.

As specialists who diagnose conditions based largely on visual assessment, the study suggested that dermatology clinicians must advocate for inclusive representation in clinical and educational resources. Integrating images of dermatologic conditions across all Fitzpatrick skin types in textbooks, online resources, and training modules could improve diagnostic accuracy and patient outcomes.

Conclusion 

The study stated the under-representation of dark skin in medical education materials perpetuates disparities that affect patient care, especially in fields like dermatology, where visual diagnosis is paramount. Addressing this bias is critical not only for educational equity but also for improving healthcare outcomes among diverse populations. Researchers stated that dermatology clinicians, educators, and healthcare institutions must collectively work to dismantle "visual racism" in medical education, ensuring that all skin tones are equitably represented.

References

1. Kamath P, Sundaram N, Morillo-Hernandez C, et al. Visual racism in internet searches and dermatology textbooks. J Am Acad Dermatol. 2021;85(5):1348-1349. doi:10.1016/j.jaad.2020.10.072
2. Huntsman A, Pavek A, Shen N, et al. An analysis of the diversity of skin colour representation in paediatric nursing practitioner textbooks. J Adv Nurs. doi: 10.1111/jan.16614
3. National Association of Pediatric Nurse Practitioners. 2020. About Pediatric Nurse Practitioners. National Association of Pediatric Nurse Practitioners. Accessed November 13, 2024. https://www.napnap.org/about-pediatric-nurse-practitioners/.