As a Canadian, I usually do not comment on U.S. politics. Recently, though, I presented a workshop entitled, “Prescriptions without limit: breaking barriers with inclusion, equality, diversity and accessibility,” in the United States at the same time I was hearing on the news of the U.S. government’s direction to remove all references to DEI (Diversity, Equity and Inclusion) from government websites, institutions and curriculums. This governmental policy certainly provided an interesting context for this presentation.
In the context of the presentation, the view of DEI was consistent with other common definitions — “organizational frameworks that seek to promote the fair treatment and full participation of all people, particularly those groups who have historically been underrepresented or subject to discrimination” [Wikipedia].
A good example of this, relevant to the provision of Complex Rehab Technology, is pressure injury prevention and management. People with darkly pigmented skin have higher pressure injury rates and higher-pressure injury severity.1 One of the contributing factors to this statistic is health care providers have been educated to look for skin redness as an early sign of skin damage related to pressure, which is not easily detected in people with darker skin tones. Since the pressure related skin damage isn’t consistently detected, these individuals do not receive access to the same care that is triggered in people with lighter skin tones when redness appears.
To receive equal access to pressure injury prevention initiatives and equipment, the approach health care providers take to detect early signs of pressure related skin damage needs to change such that this damage is detected regardless of the client’s skin tone. Fortunately, there is work occurring in this area. In the meantime, we can learn from people with dark skin tones who have pressure injuries. People with dark skin tones report early indicators of skin damage related to pressure include skin discoloration (including, a darker or lighter hue, additional colors such as purple, blue and red), pain, swelling or temperature change and that the changes may be subtle.2 As CRT providers we need to include these indicators in our assessments when considering the risk of pressure injuries in our clients.
Clearly, using skin redness as the primary indicator of pressure related skin damage is a biased approach to detecting early signs of pressure injuries. Learning that there may be biases in the early detection of pressure injuries, our next question should be, “what are the biases that I may hold, that limit the opportunities or may have negative health outcomes for my client?” This is a difficult question for one to answer, as our biases may be invisible to us. One way to examine these is to notice when we fail to tell clients about equipment that may be of benefit. Consider why the equipment is not being offered. Because they can’t afford it? Because they will never use it? Because?
Cultural humility defined as “a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances … and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations”3 can be a helpful approach to overcome biases we may hold. An example of cultural humility was shared in the first issue of DIRECTIONS in 2025 in the article “But there’s no funding for that.” Rather than limiting equipment options because the clinician or CRT provider believes the client cannot afford it, say, “There are several types of equipment that could be helpful for you. Would you like to hear about all the options, or just those where you would likely qualify for some funding?” This approach opens opportunities for the client and empowers them to make the decisions that they believe are the most appropriate for them – limit themselves to the equipment that is funded, ask for assistance from friends and family, advocate for new funding sources… or something else.
Although I was worried about presenting a DEI topic in the United States in political context at that time, the presentation went well and together we had some great discussions. Once again, I was reminded that regardless of what country we come from, we have more in common with each other as providers of CRT than differences. Challenges with funding are common, although our funding agencies are different. Addressing clinical issues such as postural instability or risk for pressure injuries are the same, even if the equipment we can access is different. The perspective of being mindful of potential biases and empowering our clients with choices is also a perspective we share.
References:
- Oozageer Gunowa N, Hutchinson M, Brooke J, Jackson D. Pressure injuries in people with darker skin tones: A literature review. Vol. 27, Journal of Clinical Nursing. Blackwell Publishing Ltd; 2018. p. 3266-75.
- Oozageer Gunowa N, Oti KA, Jackson D. Early identification of pressure injuries in people with dark skin tones: Qualitative perspectives from community-based patients and their carers. J Clin Nurs. 2024;
- Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117-25.
Linda may be reached at Linda.Norton@motioncares.ca.
Linda Norton, B.Sc.OT, MSc.CH, Ph.D., OT Reg (Ont) is an occupational therapist who is passionate about the provision of appropriate seating and mobility equipment and the prevention of chronic wounds. Her diverse experience in various settings including hospital, community, and industry, and in various roles including clinician, educator, manager, and researcher, gives Linda a unique perspective. Wound prevention and management are also Linda’s passions. She has completed the International Interprofessional Wound Care Course (IIWCC), a Master’s in community health focusing on pressure injury prevention, and a Ph.D. in Occupational Science focusing on chronic wounds.