John F. Rizzo

Nurses are the principal caregivers in acute care. Evidence links nursing to patient outcome disparities. Conceptual frameworks addressing health inequities, however, overlook nursing factors including staffing, work environment, and structural factors. This paper addresses this gap by presenting a framework postulating nursing system factors as contributors to inequities, distinguishing it from frameworks focusing mainly on individual or social determinants. The literature demonstrates that hospitals with better nurse staffing and work environments have lower mortality and complication rates, particularly among vulnerable populations. Additionally, nursing factors vary by hospital and correlate with patient racial composition and outcomes. Authoritative reports and frameworks on healthcare disparities from the National Academies of Sciences, Engineering, and Medicine and the National Institute on Minority Health and Health Disparities were reviewed. The role of nursing in each was summarized. Kilbourne et al.’s framework was adapted to propose that disparities in patient outcomes are shaped by the organizational context of nursing, for example, nurse staffing, work environment, structural competence, and the patient-nurse clinical encounter. Nursing’s impact on equitable care and outcomes should be central to health disparity frameworks. This framework implies that policymakers include nursing elements in equity performance measures and incentivize them through payment systems. Administrators should consider nursing system features as integral to equitable care. Research on the framework assertions is warranted to inform health equity strategies through nursing. By highlighting mechanisms through which nursing factors contribute to disparities, this framework motivates health equity research and policy in acute care settings.

Background: A structurally fluent workforce is essential to demonstrate structural competency—the ability to recognize and address how social, political, and economic structures affect health. Such a workforce understands the role of external factors and social determinants in health inequities. Evidence shows that minority patients receive better care from a diverse workforce. The racial composition of hospital nurses and its correlation to patients remains unreported. Objective: The aim of this study was to evaluate patient–nurse racial concordance at the hospital level in a large geographically representative hospital sample. Methods: A cross-sectional descriptive study design was employed using the 2015 Annual Registered Nurse Survey of the National Database of Nursing Quality Indicators and 2019 Medicare patient data. Concordance was measured by subtracting the hospital nurse percentage from the patient percentage. We defined Black-serving hospital (BSH) status by classifying hospitals into categories (25/50/25) by low, medium, and high representation of Black patients. Descriptive and correlation statistics were calculated on nurse and patient race and their concordance at the hospital and BSH levels. Results: Among 574 hospitals, the proportion of Black nurses was significantly lower than that of Black patients, with considerable variation across hospitals. The representation of Black nurses and patients was strongly associated with hospitals that served more Black patients and generally employed more Black nurses. When grouped into low, medium, and high BSHs, the percentage of Black nurses differed considerably across the categories. High BSH had the greatest discordance. Discussion: Although Black nurses and Black patients are often clustered in the same hospitals, there are relatively few Black nurses in hospitals where Black patients primarily receive care. This study underscores the urgent need for healthcare institutions and policymakers to prioritize building structural competency and diversifying the nursing workforce, particularly in hospitals serving higher Black patient populations. Future research is warranted on whether patient–nurse racial concordance or a nursing workforce more reflective of the patient population it serves reduces disparities.

Background: In hospitals that serve disproportionately patients of Black race, here termed Black-serving hospitals (BSH), nurse staffing is worse, mortality rates are higher, and nursing-sensitive indicators may be worse than in other hospitals, but this evidence has not been compiled. Objective: The study objective was to examine whether nursing-sensitive indicators, which measure changes in patient health status directly affected by nursing care, differ in hospitals where Black patients predominantly access their care, as compared to other hospitals. Methods: To fulfill the objective, a cross-sectional design using publicly available 2019 to 2022 Hospital Compare, 2019 Medicare Provider Analysis and Review (MEDPAR), and case mix index (CMI) file databases were used. Four nursing-sensitive indicators were evaluated: pressure ulcer, postoperative sepsis, perioperative pulmonary embolus/deep vein thrombosis, and death rate among surgical inpatients with serious treatable complications (“failure to rescue”) in hospitals classified into high, medium, and low BSHs according to the percentage of patients of Black race in the MEDPAR data. Mean outcome differences across BSH categories were assessed through analyses of variance and regression models, which controlled for hospital CMI. Results: The 3,101 hospitals were predominantly urban nonteaching hospitals in metropolitan areas. Although 12% of hospitals had Magnet designation, BSHs were disproportionately Magnet (14%). The outcome rates were 0.59 for pressure ulcers, 3.38 for perioperative pulmonary embolus/deep vein thrombosis, 143.58 for failure to rescue, and 4.12 for sepsis. Rates were significantly higher for pressure ulcers, perioperative pulmonary embolus/deep vein thrombosis, and sepsis in high BSHs. The mean failure to rescue rate was similar across low-to-high BSHs and did not show significant differences. These results were unchanged in models adjusting for CMI. Discussion: The evidence suggests that several nursing-sensitive indicators are worse in high BSHs. Research linking nursing-sensitive indicators to nursing resources such as staffing is needed to explicate the mechanism underlying these findings. Poorer nursing-sensitive indicators in combination with poorer nurse staffing in high BSHs presents a priority for policy and management intervention.

Aims: To better understand perceived stress and burnout levels among registered nurses, certified nursing assistants, certified nurse leaders, and nurse practitioners and describe clinician characteristics associated with their perceived stress and burnout during the COVID‐19 pandemic and concurrent racial unrest in Philadelphia. Design: A descriptive, cross‐sectional design was used to collect data on demographics, perceived stress, and burnout levels among a convenience sample of nursing clinicians. Methods: Data were collected using the 4‐item Perceived Stress Scale (PSS‐4) and Copenhagen Burnout Inventory (CBI) to assess perceived stress and burnout. SAS was used to tabulate and calculate PSS‐4 and CBI scores and descriptive data. Chi‐squared and Fisher Exact tests were used to measure statistical association between variables. Results: The study revealed a significant association between gender and self‐reported tiredness, with women reporting greater fatigue than men. African American participants reported that things rarely went their way on Item 3 of the PSS‐4. Approximately, 70% of nursing clinicians experienced work‐related burnout and 85% of experienced clinicians, 5 or more years, expressed more doubts about their capacity to continue to work with patients. Conclusions: Nurses experienced the stress of caring for COVID‐19 patients and in some cases victims of the racial unrest in their communities. Nursing clinicians are not immune to the turmoil outside of the hospitals within their own communities. Relevance to Clinical Practice: This study underscores the major impact the pandemic, racial unrest, and perceived stress had on nurse clinicians, emphasizing the need for proactive strategies to support their well‐being and decrease burnout.