Hidden biases are unconscious preferences that a person holds toward other individuals or groups of people. According to Banaji and Greenwald, 3 inculcation to cultural attitudes about ethnicity, age, gender, social class, race, nationality, sexuality, religion, and disability status from the time of birth into older adulthood contributes to hidden biases. Because hidden biases are not discussed with prelicensure nursing students in classrooms or clinical environments, nursing students are unprepared professionally to comprehend health disparities and the resulting implications of diverse patient groups receiving substandard care.

Factors Contributing to Health Disparities

Factors contributing to health disparities can include being a part of a vulnerable group (eg, veterans, older adults, children, pregnant individuals, ethnic minorities, or LGBT [lesbian, gay, bisexual, and transgender] individuals); residing in a rural or inner-city low-income area with limited access to quality, evidence-based healthcare; or having limited access to grocery stores and food markets that sell fresh fruits and vegetables, meats, poultry, fish, whole grains, and nuts. Language barriers, illiteracy, and the inability to afford insurance co-pays can also all impede patients' access to healthcare services. When patients cannot access needed care, a health inequity exists.

Application of the Nightingale Pledge to Health Disparities

The Nightingale Pledge personifies nurses' self-sacrifice in the care of vulnerable patients. Nursing students are taught how Florence Nightingale provided nursing care at a military hospital in Turkey to ill and injured soldiers during the Crimean War. Described as "the lady with the lamp," Nightingale would provide nursing care to soldiers during the night by lamplight, assessing each of the soldiers. 4 After the war, Nightingale developed the first formal training school for nurses.

Nurses have historically served vulnerable populations, well before the terminology of health disparities was developed. There are many notable examples of nurses who recognized health disparities and implemented change. Louise Schuyler provided care to soldiers during the Civil War and, after the war ended, organized the New York Charities Aid Association with the mission of improving the care that patients received at Bellevue Hospital. As a result of her work in New York, Schuyler formulated standards for the education of nursing students. Harriet Tubman, an abolitionist and nurse, helped lead slaves to freedom via the underground railroad and also served as a nurse during the Civil War with the Union Army. Lillian Wald is known as the founder of public health nursing because she developed a neighborhood-based nursing service for impoverished New York residents living on the Lower East Side. 4

Educating Nursing Students to Make a Difference

Within nursing programs, nursing students are taught to physically assess patients, contrasting normal characteristics, signs, and symptoms with the abnormal. The potential presence or absence of disease is linked with these assessment findings. Thus, if prelicensure nursing students are not taught about subtle differences among patients (eg, how to visually assess different skin tones or that darker skin tones are more susceptible to skin conditions such as hypertrophic scars and keloids), they will have difficulty applying important assessments to clinical situations involving diverse populations.

For example, with the baseline standard of normal integumentary assessments being pink coloration (ie, oral mucosa and skin) and lighter skin in several assessment textbooks, nursing students are inadvertently taught that lighter-colored or pink skin is the standard for a "normal," healthy assessment. When teaching the importance of early detection of risks for pressure injury (PI) development, evidence-based diagnostics in patients with darker skin are rarely emphasized. Hence, when prelicensure nurses with limited education in or exposure to the physical assessment of patients with darker skin begin clinical practice as new graduate nurses, they may not identify when darker skin has become compromised by poor perfusion, inadequate nutrition, weight loss, altered integrity, or loss of subepidermal moisture.

CASE REPORT

Here, the author describes a hypothetical case study to highlight the importance of deterring health disparities in populations whose healthcare has traditionally been impacted by inadequate physical assessment preparedness, prejudgments, or hidden biases. The hypothetical case was chosen to explain the complex topic of health disparities that theoretically can occur in multiple settings with a variety of healthcare providers.

A 67-year-old Black female of South African descent whose primary language is isiXhosa is admitted to inpatient treatment at an acute care hospital for COVID-19. She is employed as a seamstress in New York and is a widowed mother of two adult daughters, both of whom work as RNs. The patient presented to the hospital 1 week ago with shortness of breath, chills, fever, nausea, and vomiting, with an oral temperature of 102.1[degrees] F. The patient also reported extreme fatigue and spent most of her time in bed during her hospitalization.

With visitation to the hospital suspended because of the COVID-19 pandemic, the patient's daughters frequently called their mother's unit to check on her health status and converse with the physicians and nurses providing her care. Both daughters were assigned to COVID-19 units in the hospitals where they worked 12-hour shifts. The daughters used an online communication platform to connect with their mother face-to-face.

Although the patient's COVID-19 symptoms were improving, on day 9 of the patient's hospitalization, she began to complain of discomfort in her lower left buttock. Upon assessment, nurses reported that the skin was dry and intact. The patient shared with her daughters the discomfort that she was experiencing, and both daughters suspected that their mother could be developing a PI. They shared their concerns with the nursing staff providing care to their mother, but their concerns were politely dismissed because the staff had noted neither broken skin nor overt discolorations upon visual inspection. The patient was repositioned and turned in bed every 2 hours by nursing staff to prevent skin breakdown. While being repositioned on day 11, nurses noted an open area on the patient's left lower buttock with sanguineous drainage; a PI had developed.

Pressure Injuries

Formerly called pressure ulcers, PIs can develop gradually under a patient's skin and then rapidly cause tissue destruction, leading to an open wound or wounds. Not only do these injuries increase length of stay and healthcare costs within the acute care setting, but they also negatively impact patients' quality of life. Patients with PIs experience pain and are at risk of osteomyelitis or sepsis, which can lead to death. 5 According to Scafide et al, 6 when PIs are hospital-acquired (HAPIs), patients' quality of life is negatively impacted and organizational resources are strained.

Healthcare Team Response

When the physician notified the patient and her daughters of the PI diagnosis, no explanation was provided. The patient and her daughters shared that they had voiced concerns to nursing staff, but to no avail. Nursing staff repeatedly reported that the patient's dark brown skin was dry and intact.

Nurses' visual assessments of the patient's skin were accurate. However, recognizing subtle changes in darker complexioned skin can be difficult if the provider is unfamiliar with assessing a variety of skin tones. Although visual assessment is the primary method used to assess patients' skin, it is not an effective means for the early detection of deep-tissue PIs in persons with dark skin. The National Pressure Injury Advisory Panel 7 uses anatomic features to determine the degree of tissue loss and stages PIs from 1 to 4, with categories of medical device-related PI, unstageable, and deep-tissue PI. 7,8

A stage 1 PI has a localized area of nonblanchable erythema. This is usually assessed by changes in skin firmness, temperature, and sensation. The skin assessment of persons with darker skin becomes a healthcare disparity issue because when nurses are not trained to assess darker skin, they do not know that melatonin does not blanch. 6,7

Current interventions for PI prevention include skin care (ie, incontinence care, application of skin barrier topicals, and decreasing exposure to moisture), visual assessment, ensuring that patients have adequate nutrition and are hydrated, turning and repositioning, and offloading. When nurses and other healthcare providers are educated on how to assess patients with dark-colored skin, they may be more likely to implement the aforementioned prophylactic strategies and use interventions such as applying silicone foam dressings on bony prominences to prevent PI development in at-risk patients. 5,9,10 When the patient in the hypothetical case scenario first complained of discomfort at the left lower buttock site, nurses should have consulted with the wound, ostomy, and continence nurse so that he/she could conduct a thorough examination that included other diagnostic modalities (ie, thermography and subepidermal moisture measurement).

Case Study Continuation

The physician ordered a wound care consult, and the PI was examined by a wound, ostomy, and continence nurse. The patient was diagnosed with a stage 3 deep-tissue PI. A small crater was present in the depths of the tissue. No bone, tendon, fat, or muscle was visible. No tunneling was present. The wound was debrided, and an alginate wound dressing was prescribed to keep the wound moist and facilitate healing. The patient was prescribed vitamin C 500 mg, zinc 50 mg, a multivitamin, and a high biologic diet to promote wound healing. The patient was discharged to the care of her adult daughters 4 weeks after the PI developed, and the wound healed within 3 months at home.

DISCUSSION

Clinical and Statistical Evidence

The Agency for Healthcare Research and Quality 10 found that each year in the US, more than 2.5 million Americans in acute care settings develop HAPIs. These injuries extend the length of hospitalization because they are associated with infection, pain, and, ultimately, mortality and morbidity. Scafide et al 6 examined how the early detection of HAPIs by nurses and healthcare providers could reduce the incidence of PIs. They completed a systematic search of the Cochrane, CINAHL, and Web of Science databases and evaluated the resulting articles using the John Hopkins Nursing Evidence-Based Practice Rating Scale. Objective methods to diagnose HAPIs found in the 18 journal articles included laser Doppler (n = 1), subepidermal moisture measurement (n = 5), thermography (n = 7), reflectance spectrometry (n = 2), and ultrasound (n = 5). These diagnostics can determine the degree of alteration in skin integrity and supplement nurses' and healthcare providers' visual assessments of skin.

Hospital-acquired PIs are considered a nurse-driven indicator. Healthcare facilities have determined that nurses-by virtue of the direct care they provide to patients, such as applying skin barrier topical ointments and creams, applying dressings, managing nutrition, and repositioning-can prevent HAPIs within healthcare facilities. When nurses have been taught to assess variations in skin color (eg, use of Munsell color charts to objectively measure skin tones) in conjunction with the aforementioned nursing treatment interventions, patients with darker skin tones, who statistically have higher mortality and morbidity 9-13 attributed to HAPIs, may have better health outcomes.

CONCLUSIONS

Nurses often witness disparities in healthcare in the varied patient populations to whom they provide care, such as uninsured or low-income patients residing in areas with limited access to healthcare. Nurses are trained to recognize the healthcare needs of patients in their care. However, patients who speak a different language from their healthcare providers, have a different skin tone or socioeconomic status, or have a diverse gender presentation may fall victim to unconscious biases and health disparities.

Differences Should Not Impede Healthcare Delivery

Differences in physiologic presentation should not impede RNs' or nursing students' application of clinical judgment and critical thinking when assessing, diagnosing, implementing, and evaluating patients' healthcare needs. It is imperative that nurse educators prepare prelicensure nursing students for the assessment and treatment of all people. In doing so, health disparities may be eliminated and the Nightingale Pledge upheld.

REFERENCES

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2. The truth about nursing. Lystra Eggert Gretter: the Florence Nightingale Pledge. www.truthaboutnursing.org/press/pioneers/lystra_gretter.html#pledge&gsc.tab=0. 2020. Last accessed November 21, 2021. [Context Link]

3. Banaji MR, Greenwald AG. Blindspot: Hidden Biases of Good People. New York, NY: Delacorte Press; 2013. [Context Link]

4. Taylor C, Lillis C, Lynn P, Bartlett JL. Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care. 9th ed.Philadelphia, PA: Wolters Kluwer; 2019. [Context Link]

5. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Haesler E, ed. EPUAP, NPIAP, PPPIA; 2019. [Context Link]

6. Scafide KN, Narayan MC, Arundel L. Bedside technologies to enhance the early detection of pressure injuries: a systematic review. J Wound Ostomy Continence Nurs2020;47(2):128-36. Ovid Full Text Bibliographic Links [Context Link]