Evidencing diversity: development of a structured tool for investigating teaching of pressure injury on people with darker skin tones
Intended for healthcare professionals
Evidence and practice    

Evidencing diversity: development of a structured tool for investigating teaching of pressure injury on people with darker skin tones

Neesha Oozageer Gunowa PhD candidate, Faculty of Health, Social Care and Education, Faculty of Health and Life Sciences, Oxford Institute of Nursing, Midwifery and Allied Health Research HQ, Oxford Brookes University, Oxford, England
Marie Hutchinson Professor, Southern Cross University, East Lismore, NSW, Australia
Joanne Brooke Professor, Birmingham City University, Birmingham, England
Helen Aveyard Principal lecturer for student experience, Oxford Brookes University, Oxford, England
Debra Jackson Professor of nursing, University of Technology Sydney, Ultimo, NSW, Australia

Why you should read this article:
  • To understand the role nurse educators and academics play in contributing to equity in healthcare.

  • To comprehend the need for a systematic approach towards data collection in teaching.

  • To make use of a structured tool to analyse teaching documents and observe teaching sessions.

Background Dismantling structural racism challenges nurses to consider the extent to which issues of inclusion, diversity and race are operationalised in day-to-day professional practice. This includes nurse education. To be truly effective, any examination of teaching content in nurse education needs to be investigated through document analysis plus observation in the classroom. However, tools to ensure consistency between these methods of collecting data are limited.

Aim To design a structured tool for collecting data by analysing teaching materials and observing teaching on pressure injuries and people with darker skin tones.

Discussion This novel approach of using a single tool provides a unique opportunity to explore teaching materials and what is actually taught in the classroom. The data collected can assist with comparative analysis, enabling an in-depth view of curriculum content.

Conclusion The nuanced and subtle data gathered using the complementarity of analysis between teaching materials and teaching observations in the exemplar tool presented created a unique data set for examination.

Implications for practice This tool has broad applications for nurse researchers, particularly for examining topics that are often perceived to be sensitive, such as race and skin tone. It can be used for in-depth scrutiny of classroom teaching, to develop and influence curriculum content and team discussions, and in larger studies exploring nurse education content.

Nurse Researcher. 29, 2, 17-24. doi: 10.7748/nr.2021.e1761

Correspondence

15129387@brookes.ac.uk

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Conflict of interest

None declared

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Published: 10 June 2021

Introduction

The need to dismantle structural racism challenges all nurses to consider the extent to which we really consider and operationalise issues of inclusion, diversity and race in our day-to-day professional practice (Thorne 2017). Nurse education must be inclusive and anti-racist, commit to discussions of what are often portrayed as uncomfortable topics (DiAngelo 2011), and incorporate an authentic and diverse range of examples, rather than assuming ‘whiteness as normal’. Despite a stated commitment in most nursing curricula to diversity and inclusion, the extent to which diversity is incorporated into classroom teaching is far from certain – how sensitive topics are taught is often unclear and lacks visibility (Ahonen et al 2014).

Research into how we teach sensitive topics such as the assessment of pressure injuries (PIs) in people with darker skin tones is an important topic because of the greater harm PIs cause people with darker skin tones (Oozageer Gunowa et al 2018). Investigation only of the documents used to teach this topic is insufficient – teaching materials are not a verbatim script from which nurse educators teach, they are a guide, so any research study that focuses on teaching materials will not give a full picture of teaching practice. However, the difficulties of classroom observation mean the discussion of teaching practice often looks only at documentation.

Designing and developing tools to guide the investigation of teaching practice remains challenging (Coates 2008, Hunter 2016) and rarely discussed, indicating that this has not been prioritised in recent years. As a result, tools for the assessment of classroom activity and the analysis of teaching materials in the field of diversity, particularly skin tone, are limited, with little available to guide nurse researchers in exploring the teaching materials and the respective teaching in the classroom.

In this article, we provide an exemplar of the design and use of a research tool to analyse teaching materials and the respective teaching in the classroom, to observe whether diversity in teaching is planned and implemented. Our novel approach used one tool to assist our analysis of teaching materials and the observation of teaching, assisting us in determining the complementarity and consistency of the text and the observational data, and providing deeper and more consistent analysis of how nurse educators teach a sensitive and otherwise invisible topic.

Background

Historically, content analysis has been used to analyse documents and the spoken word, to discover the presence or underlying meaning of words or concepts in written text or spoken language, with an emphasis on the context of the text and/or the content and structure of the language (Renz et al 2018). Stolley and Hill (1996) developed a systematic method that used content analysis to explore textual content and to examine illustrations and visual content, drawing on subtleties and nuances in the messages conveyed. This enabled the exploration of where and how information and imagery were presented, which helped explore unspoken and hidden knowledge.

Observations are more than the recording of the spoken word – they capture activities and occurrences, which helps to identify shared systems of meaning (Fry et al 2017). Observations are typically studied using thematic analysis or frequency counts rather than content analysis. In this article, we show that content analysis can be applied to the observation of teaching as well as the analysis of teaching materials: written and communicated language and text are performative, so a tool suited to analysing the content of text and language should also be suited to structured observation.

In our study, we wanted to understand how Stolley and Hill’s (1996) method could be applied to the observation of teaching and analysis of teaching material of PIs relating to skin tone diversity. We adapted Stolley and Hill’s (1996) content analysis framework to design a structured tool for classroom observation and the analysis of teaching materials regarding PI and people with darker skin tones. Applying structured lists or specific questions to be answered provides a more systematic approach to data collection, allows for replication and comparison between studies, and helps focus a clinician researcher (Jackson et al 2016). By creating an integrated, structured data collection tool, suited for document analysis and observation, we could examine the cycle of planning and teaching delivery, as well as provide a resource for comparative research across institutions.

Development

We developed the Diversity Observation Teaching Tool (DOTT) (Figure 1), based on the work of Stolley and Hill (1996) and taking heed of Coates’s (2008) and Puzan’s (2003) work concerning covert racism and white hegemony in nursing literature. The DOTT can be applied in any context and enables researchers to record written teaching plans and materials and the respective classroom teaching. We drew the terminology used to develop the DOTT’s structured questions from a combination of medical subject heading terms and terms gathered from empirical research and grey literature (Adams et al 2016). We used four main parameters relatable to Stolley and Hill’s (1996) work that had the ability to capture data across methodologies through the framework’s simplistic use of language to frame the investigation: duration analysis, context representation, portrayal in content and visual representation.

Figure 1

The Diversity Observation Teaching Tool (DOTT)

nr_v29_n2_4_0001.jpg

Duration analysis

This analysed the space and time dedicated to PIs and skin tone diversity. Firstly, the nature of the DOTT meant it was important to consider the teaching modalities used, to identify the potential teaching and learning experience (Zhou et al 2016). Subsequently, we examined the space and/or time devoted to skin tone diversity. Space quantified the amount of content in the lesson plan relating to people with darker skin tones, including PowerPoint slides or questions, as well as any other discussion of people with darker skin tones. Time focused on the time predicted in a lesson plan or the actual amount of time spent in the classroom focusing on people with darker skin tones.

Context representation

The location and context of the topic relating to people with darker skin tones is a crucial measure, as it can over time highlight structural mechanisms and white normativity that nurse educators are knowingly or unknowingly propagating (Kester 2019). Consequently, we gathered information about where people with darker skin tones are represented from the entirety of the teaching material as well as the whole of the observed teaching session. Representation of people with darker skin tones was analysed based on whether they were seen or discussed throughout the teaching session or only in specific sections. There is a lack of language relating to people with darker skin tones and white privilege is entrenched in the literature, so visual descriptors of PI presentation were also included in this section.

Portrayal in content

Exploring the content of the teaching material and teaching sessions offered the opportunity to examine how people with darker skin tones are presented and discussed. People with darker skin tones are often excluded from empirical research and seen to be invisible or of lesser importance (Oozageer Gunowa et al 2018). Therefore, it was important to identify the terms used to portray skin tone diversity.

We also needed to consider under what topics people with darker skin tones are included in the classroom, as this would offer an insight into whether they are integrated into the curriculum or as a level of complexity and variability to the norm: were people with darker skin tones included throughout the teaching material or were they marginalised and positioned as an extra, separate or complex component?

Classroom observation allows for detailed session analysis, by breaking down each component into smaller chunks and exploring its underlying meaning (Vindrola-Padros and Vindrola-Padros 2018). Consequently, this section was broken down to help determine if all the topics were intentional or incidental: were they formalised in the teaching document or raised as questions by students in the classroom?

Visual representation

Photographs and images influence students’ perceptions and are important components of teaching (Norris 2012), so we designed the DOTT to examine images. A baseline was developed by determining the number of images presented and the number depicting people with darker skin tones. Using a detailed colour chart measuring hues, values and chroma would have been futile, as images in teaching materials often come from internet sources, so can sometimes be poor quality (McCreath et al 2016). We therefore based DOTT’s image differentiation and categorisation on Fitzpatrick (1988), which focused on physical traits and clear visual differentiation of skin colour.

The most effective way of improving learning is to mix didactic and interactive education (Forsetlund et al 2009, Arends 2015), so it was important to capture this data with the DOTT. We needed to consider the visual representation of people with darker skin tones across teaching modalities – for example, when using teaching props such as mannequins (Conigliaro et al 2020).

Validation

Two tissue viability nurses and two nurse educators reviewed the initial version of the DOTT, providing usability feedback and tool validity. We selected the tissue viability nurses because of their specialist interest, knowledge of the topic and expectations of undergraduate teaching content. We chose the nurse educators to ensure the DOTT’s practicability and applicability to various settings across various approved education institutions (AEIs), such as classrooms and skills rooms.

Feedback from the nurse educators indicated teaching concerning PIs often did not stand as an independent session and was usually incorporated into a larger teaching session, such as wound care or anatomy and physiology; we therefore included the ‘session title’ and ‘learning outcomes’ in the DOTT. More detailed recording of timings was also required, as the timing schedule originally appeared superficial and did not answer the identified question concerning teaching content.

Following the changes and after obtaining approval from Oxford Brookes University’s research ethics committee, we piloted the DOTT at an AEI. We contacted the pilot site’s head of school, detailing our requirements for participants. A nurse educator from the pilot site contacted us and consented to the pilot being conducted at the AEI. The nurse educator then gave us the teaching materials and lesson plans delivered to first year undergraduate nursing students.

We chose to study the session ‘An introduction to wound care’. After analysing the teaching materials and plans for the session, the lead researcher observed the respective teaching activity, which took place in a traditional classroom and a nursing simulation suite. The researcher did not collect data from the students, instead focusing on the teaching content and material; by using the DOTT, it was reinforced that teaching cannot be accurately assessed from teaching materials alone.

After the pilot, we refined the DOTT to include a checklist for the terminology and a box for field notes to allow for flexibility in collecting data when observing teaching. We removed the space component from the tool, due to the difficulty of quantifying all teaching modalities. As a result, the lesson plan for a session should be used alongside the teaching material, to identify the time dedicated to each part.

Results

Table 1 provides an insight into components of the DOTT in practice and shows the valuable data we collected using it when exploring the inclusion of skin tone diversity in undergraduate PI teaching.

Table 1

Insight of data gathered from the DOTT

DOTT questionDataDocument analysisStructured observation
6Educator numbersUnclear number of educatorsTwo educators for half of the session
Duration analysis
8Teaching modalities
  • » Lecture

  • » Case study

  • » Lecture

  • » Workbook

  • » Case study

  • » Teaching props (mannequin)

9Overall session title includedYesYes
10Session title focusing on skin tone diversityNoNo
11Overall learning outcomes includedNoNo
12Learning outcomes focusing on skin tone diversityNoNo
15Space/time devoted to people with darker skin tonesNoAbout three minutes
Context representation
17Throughout or specific section representing people with darker skin tones
  • » Specific section

  • » Last Power Point slide

  • » Specific section

  • » Last PowerPoint slide

  • » Student question

16Visual descriptors of PI presentationNone
  • » Pinkness

  • » Erythema

  • » Redness

  • » Dusky

  • » Purple

Portrayal in content
19Terms used to portray darker skin toneDark skin tone
  • » Skin colour

  • » Dark skin colour

  • » Darkly pigmented skin

  • » Ethnicity

20Skin tone diversity portrayal intentional or incidental?DeliberateDeliberate and incidental
21Incidental in what way?N/A
  • » Question(s) initiated by student(s)

Visual representation of skin tone diversity
22Images presentYesYes
23Total number of images5151
24Images of people with darker skin tones11
26Teaching propsNone identifiedYes – mannequins with skin tone diversity
27Teaching props used to focus on darker skin toneNoNo

Discussion

It is important to acknowledge that curricula documents are often the only teaching resources used for institutional purposes, such as programme revalidation and quality assurance (Nursing and Midwifery Council 2018). Document analysis solely draws on textual content, which is influenced by not only who creates knowledge but also where the knowledge comes from. Bringing together document analysis and observation gives researchers the ability to draw out more data and more nuanced and subtle issues.

The DOTT demonstrates that the content observed was broader and points were expanded on further than in the teaching material (Table 1). However, information was lost in translation between the teaching materials and practice, with the written teaching materials differing from what was observed.

The DOTT highlighted where the text was limited and where racial sensitivities and colour blindness often arose, such as when exploring ‘visual descriptors of PI presentation’ and ‘terms to portray skin tone diversity’. Nurse educators used a white-centric language that excluded the presentation of PIs among people with darker skin tones. This was not evident in the teaching materials.

Students rely on and believe in the information presented by educators, which can result in an inherent pattern of ignorance (Coates 2008, Jack et al 2017). The narratives in the classroom set precedents for nursing students at the start of their careers. They absorb the information presented. By superficially or briefly dealing with diversity, AEIs send a message that this is not an important issue, reinforcing colour blindness and white privilege.

With experience and exposure to care delivery, nursing students may develop the confidence and awareness to analyse critically what they have been taught. However, we cannot assume this will happen. If students are not exposed to diversity in the classroom initially, their level of knowledge will remain limited and focus on people presenting as Caucasian.

Limitations

As only one observer collected data, inter-rater reliability was not established in this study. This could be undertaken in subsequent research.

Conclusion

Although some believe that content analysis cannot collate measurable data linked to observable events (Krippendorff 1989), we believe the structured approach provided by using the DOTT is effective. The DOTT enables researchers to clarify and enhance the complexity of skin tone diversity in classroom teaching (Bowen 2009) through the complementarity and consistency of two methods – document analysis and structured observation – used by the tool to collect data separately; this enables researchers to gather unique but holistic case data.

Researchers can create unique data sets for examination from the nuanced and subtle observations gathered from teaching materials and teaching observations.

Data from the examplar showed that education concerning PIs is superficial and tokenistic in nature, inadvertently perpetuating colour blindness despite curriculum statements indicating otherwise.

Nurse educators and academics have a role to play in contributing to equity in healthcare. The DOTT provides a way to explore the planned documented curriculum and the operationalising of the curriculum as it plays out in teaching and learning activities.

We have highlighted a need and a means for in-depth exploration of diversity in nursing education. The DOTT can enable nurse educators to truly compare intentional curriculum content with actual educational content delivered to students.

Key points

  • Nurse educators and academics have a role to play in contributing to equity in healthcare

  • Nurse education must be inclusive and anti-racist, and commit to discussions of what are often portrayed as uncomfortable topics

  • This tool provides a means to explore the planned documented curriculum and how it plays out in teaching and learning activities

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