Assuming Caucasianess in Pressure Injury Research: A Literature Review

Saturday, 29 July 2017

Neesha Oozageer Gunowa, MSc
Oxford Institute of Nursing and Allied Health Research (OxINAHR), Oxford Brookes University, Headington, Oxford OX3 0BP, United Kingdom
Marie Hutchinson, PhD, RN, RM
School of Health and Human Sciences, Southern Cross University, Lismore, Australia
Joanne Brooke, PhD, RN, CPsychol
Oxford Institute of Nursing Allied Health Research, Oxford Brookes University, Oxford, United Kingdom
Debra Jackson, PhD, RN, FACN
Oxford Institute of Nursing, Midwifery & Allied Health Research (OxINMAHR), Headington, Oxford, United Kingdom


Systematically examine research literature about people with darkly pigmented skin in relation to pressure injuries.

A pressure injury, previously known as a pressure ulcer, is an injury to an area of skin and/or underlying tissue often on a bony prominence which may be caused by pressure, shear or other factors (EPUAP, 2016). Despite best efforts, pressure injuries are a significant cause of harm to patients, and in addition to the human suffering, which may include pain and psychological distress they cost the United Kingdom National Health Service billions of pounds a year (Dealey et al., 2012) The importance of effective skin assessment and early recognition of skin damage is an essential step in reducing the burden of harm to patients (NPUAP and EPUAP, 2009). Yet all current skin assessment strategies assume that a patient is Caucasian (NICE, 2014).


After establishing inclusion and exclusion criteria a comprehensive electronic database search was undertaken of PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane and British Nursing Index between 1990 – May 2016. Variations of the following terms: ‘pressure injury’, ‘pressure ulcer, ’deep tissue injury’ ‘bed sore’, ‘decubitus’, ‘ethnicity’, ‘race’, ‘skin tone’ and ‘skin colour’ were used after being audited by a healthcare librarian.


It was identified that there is a dearth of literature exploring pressure injury risk amongst people with darkly pigmented skin, as 12 relevant articles were identified through the criteria set. All the articles were quantitative studies mostly based on secondary analysis of data in the United States of America, using set categories of skin colour such as black or white. The studies incorporated a large number of subjects, one of which analysed data from 2,936,146 residents (Ahn et al, 2016)

Employing a component ratings assessment (National Collaborating Centre for methods and Tools, 2008) the studies were assessed as weak or moderate due to issues of reliability, tool validity and methodology. The focus of the research was statistical rather than acknowledging and exploring overall skin tone variances and individual experiences.


Most of the studies reviewed excluded early stage pressure injuries as the assumption of identification was seen to be difficult and often unreliable, particularly in people with darkly pigmented skin. A recurrent theme in the findings of these studies confirmed that people with darkly pigmented skin were more likely more likely to develop severe pressure injuries as they are seen to be difficult to identify. The literature review also revealed that there is very little empirical research to guide and support health professionals, patients and carers to reduce pressure injury in black and ethnic minority communities resulting in significant health inequalities and implications for nursing practice.