Visual Representation of Clinical Conditions Across Skin Tones in Nursing Textbooks: A Quantitative Image Analysis

As the U.S. population becomes increasingly diverse, the persistent underrepresentation of dark skin tones in nursing educational materials constitutes a critical concern. The foundational textbooks used in prelicensure nursing programs often fail to illustrate how clinical conditions present on darker skin, thereby undermining students' assessment and diagnostic competence and perpetuating health care disparities.

This study aimed to evaluate how prelicensure nursing textbooks visually represent clinical conditions across diverse skin tones, with a focus on the extent to which dark skin tone images are included and the implications of this for diagnostic preparedness.

This quantitative, image-based study analyzed photographic and graphic (drawn or computer-generated) images from 23 chapters in 13 widely used prelicensure nursing textbooks. Images were categorized by skin tone using the Fitzpatrick skin phototype scale and evaluated for the clear depiction of clinical conditions. Interrater reliability was assessed using Cohen κ, which yielded values between 0.78 and 1.00, indicating substantial to perfect agreement.

Of the 1,116 images reviewed, only 7% depicted dark skin, while 76% depicted light skin. Of the 432 photographs representing clinical conditions, 10% featured dark skin. Graphic illustrations reflected even greater disparities, with only 2% showing dark skin. Conditions for which diagnosis relies heavily on visual assessment, such as cellulitis, melanoma, and allergic reactions, were rarely depicted on dark skin. Nearly half of all photographic images did not depict a discernible clinical condition.

This study identifies a pervasive visual bias in nursing textbooks that privileges light skin as the clinical norm. The underrepresentation of dark skin perpetuates structural inequities in health care education and decreases nurses' ability to recognize clinical conditions across diverse populations. Nursing curricula must be intentionally revised to include clinically accurate imagery across all skin tones. Doing so warrants priority status as part of nurses' professional and ethical commitment to health equity and patient safety.