Including Nursing System Factors to Address Health Disparities: A Conceptual Framework

Abstract

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.

Introduction

Paradoxically, the health system serves as both a promoter of well-being and a driver of health inequality and disparities. While designed to promote health and well-being, it often functions as a mechanism through which inequities and disparities are sustained or exacerbated. ¹ Structural barriers within health systems contribute to the disparities and inequities often experienced by minoritized populations—groups marginalized by social, economic, or political factors.^2,3 These barriers include lack of access due to insurance or geographic location, unequal resource allocation, and fragmented services. Within health systems, additional factors also contribute to disparities. These include implicit bias and inadequate cultural humility among providers, which often result in lower quality care and differential treatment for minoritized populations. ⁴ By recognizing the multifaceted role of health systems in promoting and perpetuating inequities, we can address these complex challenges.

A critical step in mitigating disparities is to examine the role of key actors within the health system. Among these key actors are nurses. Although nurses are the predominant caregivers in hospital settings, the nursing factors that may produce or reduce health inequities and disparities have not been explicated. Nurses provide around-the-clock care and spend most of their time with patients. Therefore, it is reasonable to propose that nursing organizational characteristics, such as nurse staffing, the work environment, and structural competence, are modifiable health system factors that theoretically influence the equity and outcomes of care. The nurse work environment is defined as organizational characteristics that facilitate or constrain professional nursing practice. ⁵ Structural competence is defined as the capacity to discern how clinical manifestations may be informed by systemic factors, such as policies and institutions, especially as it relates to explaining the cause of disparities. ⁶

Both system-level and nurse-level factors may influence care inequity. System-level factors impede nurses’ ability to provide high-quality nursing care. Nurse-level factors that inhibit nurses’ ability to produce good outcomes for marginalized patient populations are a lack of education about how to be culture-sensitive and patient-centered and a lack of knowledge of their own biases and the myriad ways they can covertly impact patient outcomes. This paper highlights healthcare system elements that impact nurses’ ability to provide high-quality care.

This study aimed to develop a framework to detail how modifiable nursing system factors may contribute to health inequities and outcome disparities. Such a framework could guide policymakers and administrators in promoting health equity through nursing, while supporting further research in this area.

Method

To identify or develop a framework for the role of nursing in health system-related inequities and disparities, we first summarized the literature linking nursing system features (ie, staffing and the work environment) to care inequities and outcome disparities. We used a deductive approach to select and evaluate authoritative reports and frameworks. Our selection criteria included: (1) publication by a recognized authority (eg, the National Academy of Medicine, National Institute of Minority Health and Health Disparities), and (2) a focus on health disparities, equity, or healthcare system factors. We further searched the health services research literature in PubMed for frameworks that explicate the contribution of healthcare system factors to health inequity and disparity. One framework was considered suitable. For each report and framework, we evaluated the extent to which nursing system features were included or addressed. We summarized the role of nursing as described in each source and identified the shortcomings of nursing specifications.

Finally, we adapted an existing framework by explicitly incorporating nursing system features recognized in the theoretical and empirical literature, such as staffing, work environment, and organizational structure. Our adaptation was guided by 3 principles: relevance, specificity, and context. We prioritized a framework developed for health services-related researchers and practitioners to guide health disparity research (relevance). We tailored the framework to explicitly address nursing’s unique role by replacing generic terms (eg, “providers”) in the original framework with the term “nurses” where appropriate (specificity). Additionally, we considered the organizational context of acute care settings, recognizing that disparities are shaped by the structural elements of the healthcare system in which nurses operate (context). This approach ensured that the adapted framework accurately reflects how nursing system factors contribute to disparate patient outcomes.

Results

Evidence on Nursing System Features and Health Disparities

Over the past 15 years, nursing system features have been analyzed in relation to racial outcome disparities. The literature differentiates hospital-level disparities from patient-level disparities. Hospital-level disparities refer to differences in outcomes based on where patients are hospitalized, regardless of patient race. Hospitals are usually classified as high-, medium-, or low-Black-serving hospitals (BSHs), depending on the proportion of Black patients they serve. Researchers use this classification to compare patient outcomes or nursing characteristics across hospitals that serve a disproportionately higher number of Black patients versus those that serve few Black patients. BSHs are typically defined by researchers as hospitals in the top segment (decile, quartile, or tercile) of a hospital sample based on the percentage of Black patients they serve. ⁷ By contrast, patient-level disparities refer to how differences in nurse staffing levels across hospitals are associated with different odds of adverse outcomes for patients of different races, e.g., Black and White patients.

Literature describing the disparities in BSHs is growing. For example, patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey, including likelihood of recommending the hospital, nurse communication, responsiveness, and discharge information, were 1 to 3 percentage points lower in BSHs. ⁸ These differences were statistically significant and partly explained by nursing and hospital structural characteristics. In a study of 5773 nurses, Lake et al. found that very low birthweight (VLBW) infants born in high-BSHs had higher rates of infection and discharge without breast milk than VLBW infants born in low-BSHs. ⁹ Similarly, in a secondary analysis of survey data from 1037 staff nurses in 134 NICUs, Lake et al. found significantly higher frequency of missed nursing care in NICUs with a high percentage of VLBW Black infants as compared to those with few VLBW Black infants. ¹⁰

Critical nursing system resources such as leadership communication ¹¹ and nurse staffing ¹² are worse in high-BSHs than in medium- and low-BSHs. Using survey data from a national sample of nurses from 90 hospitals, Lake et al. ¹¹ found that the percentage of nurses in high-BSHs with high moral distress was twice that of nurses in low-BSHs. Poor leadership communication in these BSHs accounted for greater nurses’ moral distress. Moreover, in another study using data from 179, 336 nurses from 574 hospitals, Lake et al. found that nurses in medium- and high-BSHs had significantly more patients than in low-BSHs. ¹² Further, data from 3101 hospitals suggested that nursing-sensitive indicators such as pressure ulcers, perioperative pulmonary embolus/deep vein thrombosis, failure-to-rescue (postsurgical death following a complication), and sepsis were all worse in high-BSHs compared to low-BHSs. ¹³ Nursing-sensitive indicators are the subset of quality outcomes that are under the purview of nursing responsibilities.

As noted above, the patient-level approach compares the outcomes of Black and White patients in terms of how nursing system features are associated with the odds of adverse outcomes. Notably, better nurse staffing has been associated with better survival rates, improved postsurgical outcomes, and reduced readmission rates for both Black and White patients, often with a more pronounced effect observed in Black patients.^{14 -17} These disparities are partially attributed to differences in nurse staffing levels, work environments, and structural hospital characteristics. Additionally, Black patients are more likely to be admitted to large, urban, high-technology teaching hospitals characterized by poor nurse work environments and higher patient-to-nurse ratios. ⁸ Optimizing nursing resources and care delivery could significantly improve outcomes, particularly for Black patients, who may be more vulnerable when being cared for by nurses with high workloads in poor work environments. Collectively, this evidence shows that poorer nursing resources and work environments disproportionately affect Black patients and contribute to racial disparities in hospital outcomes.

Another feature of the health system that affects minoritized patients is the structural competence of healthcare providers, including nurses. Structural competence refers to the ability to recognize and address the social, political, and economic structures that shape health outcomes. ¹⁸ Unlike traditional cultural competency, which focuses on individual patient-provider interactions, structural competence shifts attention to systemic factors influencing health disparities. A key aspect of structural competency is fostering a workforce that reflects the diversity of the patient population and is trained to understand how social determinants impact care delivery. This approach equips healthcare professionals with tools to advocate for systemic change, ensuring that institutions better serve diverse patient populations and work to find the root causes of health inequities. Other factors may also affect structural competence.

There is a lack of multihospital data on general structural competence or structural competence of nurses. A crude but measurable indicator (in some datasets) is the racial composition of the nursing workforce. ¹⁹ Evidence of variation in the percentage of Black nurses across a nationally representative hospital sample documented wide variation in this percentage. ¹⁹ These data show that nursing organizational features and resources vary across hospitals and correlate with the racial composition of patients and their outcomes.

The Place of Nursing in Major Health Disparity Reports and Frameworks

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, a report by the Institute of Medicine, ²⁰ established that health disparities stem from a complex interplay of systemic, institutional, and individual factors. Racial and ethnic minorities often experience lower-quality healthcare, even when accounting for insurance and income status. The report highlighted provider-level issues, such as stereotyping, biases, and clinical uncertainty, as well as system-level problems, such as fragmentation of care and unequal resource allocation. To reduce disparities, the report recommended strategies such as implementing evidence-based care guidelines, incentivizing quality care, and fostering diversity in the healthcare workforce. It emphasized the crucial role of nurses in bridging these gaps through culturally competent care, patient education, and advocacy efforts to promote health equity.

Two decades later, Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All, ²¹ shifted focus to systemic factors that lead to health disparities and advancing health equity. Health disparities are perpetuated by systemic inequities within both healthcare systems and broader societal structures, including structural racism and oppression. The report emphasized that these inequities result in unequal access to care, poor health outcomes, and economic burdens, especially for racially and ethnically minoritized populations. Strategies for reducing health disparities involve addressing social determinants of health, scaling evidence-based interventions, ensuring accountability, and advancing equity-focused policies at all levels of healthcare delivery. Nursing plays an important role in these efforts, given its proximity to patient care and capacity to advocate for systemic reforms that promote equitable, high-quality care tailored to diverse patient needs. The report included examples of nursing involved in community-centered care, fostering trust, and advancing culturally competent practices to mitigate inequities.

The Future of Nursing (FON) 2020-2030: Charting a Path to Achieve Health Equity 2020–2030, ²² emphasized the critical need to leverage the potential of the nursing workforce at all levels and across settings in order to build a more equitable healthcare system. Nurses are recognized as bridge builders and collaborators who engage and connect with individuals, communities, and organizations to promote health and well-being. Historically rooted in social justice and community health advocacy, nurses are positioned to change our healthcare system toward an equitable future. To achieve health equity, the committee also sees the nursing profession as central to engaging in the complex work of aligning public health, healthcare, social services, and public policies to eliminate health disparities.

The FON envisioned a diverse, innovative nursing workforce equipped to address major health challenges. These include structural racism, the growing aging population, gaps in access to primary care, behavioral and mental health, high maternal mortality, and the unequal burden of disease in specific communities.

Nurses play a central role in advancing health equity by addressing the social determinants of health, providing care with structural humility, and collaborating across sectors. Structural humility is defined as a clinician’s ability to acknowledge forces oppressing or marginalizing minoritized communities that influence communication and health outcomes at higher levels than individual interactions. ²³ Removing institutional and regulatory barriers, supporting nurse well-being, and fostering equity-centered education can optimize nurses’ ability to drive meaningful change. These efforts are especially important in underserved settings, emergencies, and in preventative care, where they can lead to improved health outcomes for all. According to the FON, key areas for strengthening nursing were workforce, leadership, education, well-being, and emergency preparedness response.

The National Institute on Minority Health and Health Disparities (NIMHD) Research Framework ²⁴ is a comprehensive model that posits that health disparities are influenced by a complex set of interconnected factors. These include biological, behavioral, sociocultural, physical/built environment, and healthcare system influences. The framework also suggests that these factors operate across the individual, interpersonal, community, and societal levels. To address health disparities, this framework uses a multidimensional approach that considers both the social determinants of health and biological factors. It encourages interventions targeting different domains and levels, helping researchers identify knowledge gaps and opportunities for future studies.

Within this framework, nurses can address health disparities within the healthcare system through patient care, advocacy, education, and research across interpersonal, community, and societal levels. For example, they can utilize the framework to assess how social determinants affect patient outcomes and to develop culturally tailored care plans for the diverse needs of minority populations. Nursing research can contribute significantly by identifying effective interventions and policies to promote health equity. Nurses play a pivotal role in delivering high-quality care and influencing healthcare policies, both of which are fundamental in shaping the structure and effectiveness of the healthcare system. By addressing either of these areas, nurses can position themselves as key change agents to reduce disparities in the healthcare system.

Researchers Kilbourne and colleagues ²⁵ published a framework conceptualizing healthcare disparities from a health services research perspective. The Kilbourne framework acknowledged provider factors as the key determinants of disparities within the healthcare system. Kilbourne et al.’s conceptual framework to advance disparities research delineates 3 phases of an overarching disparity research agenda: detecting health disparities, understanding determinants of disparities, and reducing disparities through interventions and policy. This framework emphasizes the crucial role of healthcare systems in addressing and reducing health outcome differences, particularly among minority populations. It proposes multiple levels of potential determinants, including the healthcare system, patients, providers, and clinical encounters.

Individual patient- and provider-level factors influence interactions at the point of care during clinical encounters, such as through provider communication. Meanwhile, system-level factors, such as payment models, care coordination, comprehensiveness of services, management, staffing, and organizational culture, are theorized to influence health disparities on a broader scale.

All 3 authoritative reports and the NIMHD framework recognized the critical role of nursing in advancing healthcare equity through patient care, advocacy, and interventions addressing the social determinants of health. None of these frameworks, however, explicitly considered nursing system factors, such as nurse staffing, work environment and structural competence, as contributors to health inequities and outcome disparities. Nor did Kilbourne et al.’s paper ²⁵ explicitly call attention to the potential of nursing system factors to influence healthcare disparities. Therefore, our approach expands upon prior frameworks by further defining nursing as nursing system features and health system factors to include nursing.

We posit that explicitly adding nursing to a research framework would create the potential to understand the nursing system factors as contributors. For example, nurses cannot be expected to drive equitable outcomes if they are working in under-resourced health facilities with a poor work environment and inadequate staffing. These conditions limit their capacity to provide high-quality care. To ensure the full impact of nursing, it is essential to integrate nursing system features, including staffing, leadership, and structural competence, into these frameworks rather than placing expectations solely on individual nurses to relieve health disparities.

The Kilbourne Framework Adapted to a Nursing Focus

We found the Kilbourne framework suitable to adapt by incorporating nursing system features. We sought a framework with health services elements to align with our focus on nursing system features. A prominent framework we considered, the socio-ecological framework, conceptualized the individual at the center of circles of influence, including the organization. Our goal was to explain why disparities occur and how nurses could help mitigate them, which required interfacing the nurse-patient dyad and featuring the health care delivery system. We thought the mechanism of disparities was that system features influence what happens in the clinical encounter. The center of the Kilbourne model has the clinician-patient encounter and overarching the dyad is the health care delivery system. Other frameworks we considered, e.g., the socioecological model, did not have the patient/provider dyad as the center nor health care system factors explicitly included.

To integrate nursing into this conceptual framework (Figure 1), we included key nursing constructs, including nurse staffing, the work environment, structural competence and its proxy, and the racial composition of the nurse workforce. These elements are italicized in the figure. We theorize that poorer nursing resources (staffing and work environment) and less structural competence contribute to racial disparities across and within hospitals. For example, the literature shows better nurse staffing reduces mortality among Black older adults who suffer in-hospital cardiac arrest. ¹⁷ Similarly, poorer outcomes for very low birthweight infants in BSH were explained by poorer nurse work environments. ⁹ We also replaced the term cultural competence from the original Kilbourne framework with the currently preferred concept of cultural humility.

Figure 1.

Kilbourne framework adapted to include nursing factors.

As per Kilbourne, ²⁵ disparities within health systems often originate in the clinical encounter, where provider communication and cultural humility play a critical role in shaping care quality. The factors affecting the clinical encounter are patient beliefs, preferences, race, ethnicity, culture, familial context, education, resources, and biology. Nurse factors include nurse’s knowledge, attitudes, competing demands and bias. Overarching health system factors specific to nursing are staffing, the work environment, structural competence and workforce racial composition. These overarching factors may operate through the clinical encounter or separately (eg, across-hospital variation in staffing) to produce disparities. Depending on the level of nurse staffing or the quality of the work environment, the competing demands on the nurse will vary, which will affect the clinical encounter. This patient-nurse encounter is also affected by the level of structural competence, which can shape provider attitudes and bias and is manifest in nurses’ knowledge of patients’ social and structural contexts. The workforce racial composition is also theorized to affect the clinical encounter by affecting trust and cultural concordance. Together, these nursing system factors interact with patient characteristics such as race, culture, and socioeconomic status to shape the quality of the clinical encounter and contribute to outcome disparities.

Our adaptation highlights modifiable nursing features of healthcare systems and clinical encounters so that minority populations can receive equitable health outcomes. By understanding the nursing factors that contribute to disparities in healthcare between vulnerable and non-vulnerable groups, researchers can implement and evaluate nursing system interventions that reduce healthcare disparities. This adapted framework suggests that nursing resources and structural competence, or its proxy, nurses’ racial composition, are key factors in health outcome disparities that can be modified to better address nursing-sensitive patient outcome disparities.

We theorize variations in nursing resources may affect care equity and disparity across and within hospitals. Variations in nursing resources across hospitals could affect the outcomes of all patients in each hospital, regardless of race. However, Black patients often receive care at different hospitals than white patients do, and these hospitals may have poorer nursing resources. This uneven distribution contributes to racial disparities at the population level when hospitals that predominantly serve Black patients are under-resourced.

Within hospitals, the same level of nurse staffing or the work environment a hospital, however, may have differing effects on Black and White patients that may contribute to within-hospital disparities. Better staffing is a protective factor that reduces within-hospital racial disparity. An implication of nursing factors contributing to across- and within-hospital racial disparities is a potentially compounded disparity if hospitals that Black patients access predominantly have worse nurse staffing than other hospitals.

Discussion

This framework adaptation provides researchers with foci to investigate and generate evidence to inform policy change directed at reducing care inequity and disparities through nursing systems features. Most urgently, the nursing system features elucidated in the adapted framework should become prominent in all health disparity frameworks focused on health system factors. If these features are not part of authoritative frameworks such as the NIMHD framework, they will not be part of policy discussions.

The framework has implications for national and state policymakers, especially those at the CMS, the Joint Commission, and professional nursing organizations. Policymakers at the national level should implement multiple measures to ensure sufficient nursing resources and supportive work environments in hospitals. These could include incentivizing equity through the payment system by incorporating nursing elements into equity performance measures that the Centers for Medicare and Medicaid Services (CMS) link to payments. We recommend nurse staffing and work environment measures at the hospital level, similar to those reported by or being proposed by the Leapfrog Group. ²⁶ The Leapfrog Group, which represents employers and publicly reports patient safety ratings of hospitals and ambulatory surgery centers, currently reports registered nurse hours per patient day in medical or surgical units, which is a nurse staffing measure, and has proposed to report nurse work environments using the Practice Environment Scale—5, ²⁷ a validated 5-item short form derived from the Practice Environment Scale of the Nursing Work Index, ⁵ which has had national endorsement since 2004 as a quality measure. ²⁸ Registered nurse hours per patient day is also a nationally endorsed measure. ²⁹ Registered nurse hours are commonly measured from facility human resources and utilization (patient days) records. The work environment metric entails surveys of registered nurses providing direct patient care, aggregated to the facility level.

The CMS’s current suite of quality measures related to inpatient hospital care includes hospital inpatient measures sets (ie, healthcare-associated infections (HAI)), claims-based measures (ie, payment measures), and hospital inpatient quality program measures (ie, hospital-acquired condition reduction program measures). These are linked to the payment penalties and incentives. None of the measures included features of nursing.

The implication of our adapted framework for hospital administrators is to consider nursing system features, such as the racial composition of the nursing workforce, as integral to strategies to provide equitable care. These elements, however, are often overlooked in organizational equity efforts. For example, a national analysis of hospitals’ strategic plans found that many institutions prioritize leadership diversity, community engagement, and cultural competence, but do not specifically address nurse staffing or the nursing work environment as part of their equity initiatives. ³⁰ This suggests that administrators may not realize the potential of nursing system factors in advancing health equity. Also, they could benchmark their staffing levels and work environment scores through participation in voluntary nursing indicator databases, such as the National Database of Nursing Quality Indicators. ³¹

Several researchers have examined nursing resources in various health settings that serve vulnerable populations. Findings show that these resources are poorer in facilities where people primarily rely on Medicaid coverage for care. ³² The role of nursing system factors contributing to health disparities in federally qualified health centers and safety net hospitals, which serve geographically underserved areas, remains understudied. This adapted framework can support studies to generate the evidence needed for resource allocation to safety net hospitals or federally qualified health centers to provide sufficient staffing and work environments. Within this framework, we advocate focusing on nursing resources and structural competence to provide more equitable care to these populations. Future research should utilize robust measurement approaches for structural competence. A broader research agenda could build upon the evidence already compiled in selected conditions to examine how nursing system factors relate to disparities in a range of nursing-sensitive patient outcomes.

Our study had several limitations. We focused on nursing only, although other health care providers’ system features may likewise contribute to care inequity. The focus solely on acute care settings may limit generalizability to other healthcare contexts where nursing disparities research is needed. We expect the adapted framework to apply to other healthcare contexts. Additionally, while we reviewed authoritative reports and frameworks, we did not conduct a systematic review. Therefore, there may be additional relevant literature or frameworks than those included. By selecting prominent authorities, our findings reflect the most widely available and consulted reports.

Conclusions

We authors assert that to reduce health inequities and disparities that originate from within health systems, we must utilize our most plentiful frontline professional caregivers: nurses. Despite their central role, authoritative reports and research frameworks on disparities have not acknowledged nursing system features as key factors in disparity mitigation. The adapted Kilbourne framework addresses this gap with a sizable empirical evidence base by specifying nursing system features, i.e., staffing, the work environment, and structural competence, as the bases for potential care inequity and outcome disparities.

This adapted framework provides guidance to policymakers, hospital administrators, and researchers. The potential impact of this framework would be to reduce disparities through expanded research, policy development, and administrative action. In practice, it could lead to an increase in structurally competent communication and cultural humility of nurses.

For policymakers, the framework offers nursing system elements that warrant monitoring, public reporting, and possibly payment modification to address across-hospital disparities. Through addressing the nursing system elements in this framework, administrators could contribute to reducing disparities.