Improving Nursing Care in Long-Term Care Facilities for Older Adults by Addressing the Social Diversity of the Nursing Staff

Abstract

Nursing education and administration at long-term care (LTC) facilities do not pay sufficient attention to the socioeconomic and cultural diversity of the nursing staff. This commentary raises specific issues, such as lack of representation of marginalized staff members in nursing leadership and training that require immediate attention. Ignoring these issues can have detrimental effects on nursing staff and patients in LTC facilities, leading to cultural misunderstandings, biases, reduction in the quality of care, and more. This commentary adds to the current Equity, Diversity, and Inclusion (EDI) efforts in healthcare, and suggests specific measures for LTC workplaces, which are characterized by intersectionality and multiple marginality. The paper presents the CARE strategy for diversity, which encompasses: 1. C onfronting Inequality: Acknowledging inequality and discrimination at institutional and personal levels; 2. A dvancing Inclusive Nursing Curriculum through reform; 3. R epresenting Diversity in Nursing Leadership; and 4. E nhancing Nursing Staff Training and Mentorship Initiatives for marginalized staff members in LTC. There are many benefits to diversity in nursing leadership and training in LTC facilities. In the first place, attending to the special needs of senior adults from various backgrounds improves patient outcomes. Second, encouraging inclusive practices improves employee morale, builds a feeling of community of practice, lowers employee turnover, and eventually ensures the continuity of care by reducing employee disengagement. Third, healthcare professionals who undergo diversity and inclusion training acquire increased cultural sensitivity, which decreases prejudices and stereotypes and enhances relationships and communication with coworkers and patients. In conclusion, the CARE strategy for diversity presented here addresses these issues, offering actionable measures for nursing educators and LTC administrators. Because societies are aging and the nursing workforce is in great demand worldwide, it is necessary to establish a vision of LTC that transforms the marginality of the workforce by promoting the ethos of diversity and inclusion.

Introduction

Nursing staff members, including registered nurses (RNs) and nurse aides (NAs), must work harmoniously and effectively to deliver high-quality healthcare in LTC facilities but social diversity in nursing administration and training in LTC facilities has not received sufficient attention. The major obstacles to social diversity in LTC facilities are rooted in their occupational environment where the overlap between occupational hierarchy and ethnic and cultural marginalization leads to the underrepresentation of minority groups in nursing leadership. Initiatives that promote diversity in LTC facilities usually provide cultural competence training that enhances staff cohesion (Chen et al., 2020; Debesay et al., 2022). Major nursing organizations, such as the International Council of Nurses and The American Nurses Association, have been proactive in promoting diversity and inclusion, usually by publishing recommendations for how to achieve inclusive environments for patients and staff, including the promotion of diversity in leadership (ANA, 2018; ICN, 2023). For the specific work environment of LTC facilities, however, leading nursing organizations such as the Gerontological Advanced Practice Nurses Association (GAPNA's, 2024), have published a general statement without recommendations for staff. This commentary exposes the specific issues pertinent to this environment, offers a strategy for action, argues for the centrality of diversity, describes the challenges deriving from neglecting it, and suggests several solutions to address the problem.

Brief Review

The Occupational Context of Long-Term Geriatric Care

According to the United Nations, Department of Economic and Social Affairs (United Nations, 2020), life expectancy in all the countries is forecast to rise. Because Western societies are aging, nursing care at LTC facilities has become a significant part of healthcare provision. At the same time, there is a shortage of the nursing workforce, which prompts labor-related migration to economically-developed countries (Ahmed et al., 2020; Delp et al., 2010). LTC facilities provide around-the-clock basic bodily services to patients. Nursing is the dominant occupation at these facilities, where physicians have official medical responsibility. RNs are in charge of the delivery of the medical treatment and of the ongoing work of the NAs. NAs form the service core of LTC facilities, providing for the basic needs of patients such as feeding, bathing, toileting, and assisting immobile patients from their beds to wheelchairs and move them safely around the facility. They also assist nurses in various bedside treatments. Working conditions of medical staff auxiliaries, such as NAs, are extremely harsh, as they provide services to patients with various degrees of disabilities. Because of the increase in life expectancy, many patients at LTC facilities suffer from cognitive impairment, dementia, or Alzheimer's disease, which subjects NAs to high physical and psychological workloads (Nichols & Vos, 2021). The nursing workforce in LTC facilities as a whole suffers from pay disparities, as RNs are paid less than their counterparts in other nursing fields (Spetz et al., 2021; Wagner et al., 2021). The precariousness and job insecurity of the NA occupation stem from systemic issues such as the low wages prevalent in the care occupation in general (Dill & Duffy, 2022), limited career advancement, harsh working conditions, and high emotional demands (Roitenberg, 2021). At the same time, forecasts predict that the occupational tier of NAs will expand greatly because of increasing life expectancy and demand for high-quality personal care in old age (Bureau of Labor Statistics, 2016).

Nursing, Work Hierarchy, and Social Hierarchy in Long-Term Geriatric Care

The occupational and organizational structure of nursing homes and LTC facilities is characterized by a clearly defined division of roles and responsibilities. Long-term care facilities are organized with a strict vertical chain of command: medical doctor, who is the head of the ward, chief of nursing, RNs and practical nurses, and NAs (Ostaszkiewicz et al., 2016). Although physicians are legally and medically accountable, nursing is hegemonic in these facilities, and nurses are in charge of the other occupational tiers (Jervis, 2002; Urban, 2014). Scholars suggest that hierarchies in LTC facilities are structured around the differentiated contact of nursing staff with “pollution” (Jervis, 2002). The individuals who perform the dirty work tasks usually have low occupational esteem and status (e.g., Ashforth & Kreiner, 1999). The division between dirty and clean care work has always been present, but it has become further and more strongly differentiated in the last two decades between RNs and NAs, as the former redesigned their roles to perform extensive administrative work and documentation of the medical care (Jervis, 2002; Twigg, 2000). Care facilities are sites of “structural intersectionality” and multiple marginalities (Browne & Misra, 2003). Workers with several marginalized identities (e.g., female migrants of non-hegemonic race or ethnicity) are represented disproportionately in service occupations, such as long-term-care (Browne & Braun, 2008; Duffy, 2007; Storm, 2023), while cultural diversity is underrepresented in nursing in long-term care leadership (Nair & Adetayo, 2019). Moreover, intersections of identity and socio-economic class channel individuals into low-skill occupations, like cleaning and care, often viewed as “dirty” and undesirable (Browne & Misra, 2003). Minority groups are underrepresented in high-level positions in long-term care and Nursing school faculty, which also lacks diversity. While the medical field promotes neutrality and egalitarianism, research shows nurses subtly reject these values, assigning different work ethics to marginalized ethnic groups (Roitenberg, 2020).

Challenges of Not Addressing the Social Diversity of the Nursing Staff at LTC Facilities

A key task in LTC facilities is transferring clinical knowledge and skills from RNs to NAs (Montayre & Montayre, 2017). Nurses play a vital role in this process, yet nursing administration often overlooks the workforce's social diversity. This neglect is concerning for several reasons. First, inadequate cultural and equity competence can cause misunderstandings among nursing staff from different backgrounds, reducing team cohesion and increasing burnout, turnover, and disengagement (Nwobia & Aljohani, 2017). These issues harm care quality and have economic impacts on care organizations (Patel et al., 2018). Second, communication between nurses and aides must be efficient to avoid compromised patient care, but linguistic diversity may lead to a fragmented and unsafe work environment (Xu, 2008). Third, stereotypes and prejudices may result in workplace discrimination if proper training is lacking, weakening teamwork and care standards. Fourth, aides from marginalized groups may become dissatisfied if cultural competence is ignored, leading to higher turnover rates and impacting institutional stability and care continuity (Patel et al., 2018; Roitenberg, 2020). Fifth, many older adults also come from marginalized backgrounds, so a lack of cultural sensitivity among nurses and aides can lead to miscommunication and misbehavior, negatively affecting patient care. Without diversity training, these disparities can result in unequal healthcare delivery and reinforce health inequities among older adults from different social backgrounds (Paradies et al., 2015).

Possible Nursing Managerial and Training Remedies Related to the Social Diversity of the Nursing Staff in LTC Facilities

Addressing diversity issues in nursing management and training in LTC facilities requires a comprehensive approach. The following steps outline a strategic framework that I refer to as:

The CARE Strategy for Diversity

C onfronting Inequality: Acknowledging inequality and discrimination at the institutional and personal levels is the first step in fostering organizational change (Green et al., 2022). This goal should be stated publicly by the management of LTC organizations through vision statements that acknowledge inequality and discrimination and declare the intention to follow up the changes in organizational policies.

A dvancing an Inclusive Nursing Curriculum: Reforming nursing curricula to include courses on diversity and cultural competence, emphasizing inclusive culture (Cary et al., 2020). Nursing educators must update present training programs with diverse content, perspectives, imagery, and language that will promote empathy, reduce bias, and enhance cultural awareness (Fadoju et al., 2021; Hardeman et al., 2018; Ufomata et al., 2021). Former experience with such programs (Fatahi et al., 2023; Khan et al., 2022) proves that student feedback is crucial for bridging theory and practice.

R epresenting Diversity in Nursing Leadership: Encouraging diverse candidates for leadership roles in LTC facilities can create a more inclusive workplace (Phillips & Malone, 2014). Diverse leadership fosters representation and inspires marginalized staff to pursue organizational and personal goals. Nursing organizations can encourage this goal by using certificates that offer recognition for pursuing it.

E nhancing Nursing Staff Training and Mentorship Initiatives: Regular workshops and seminars organized by operational management on inclusivity and cultural competence should be part of ongoing staff training, fostering social connections within diverse teams. In addition, pairing experienced nurses with new hires, particularly from marginalized groups, helps bridge social gaps, provides support, and encourages future leadership in long-term care facilities. Nursing organizations can provide funding opportunities for organizations of LTC that are committed to enhancing nursing staff training and mentorship.

Besides the commitment to principles of justice, it is important to assess the tangible benefits of EDI programs in healthcare practices (Buh et al., 2024). Randel (2025), who conducted a review of 188 studies of inclusion in workplaces, found individual-level outcomes (enhanced job satisfaction, engagement, etc.) and group-level outcomes (improved performance and creativity). It has already been established that experiences of inequality among LTC personnel decrease worker retention (Shaw et al., 2024), which is one of the main challenges facing the LTC workforce (Bourgeault et al., 2020). Inclusion in the workplace improves quality of care in healthcare organizations through enhanced job satisfaction (Brimhall & Mor Barak, 2018; Shen et al., 2018) but also through other mechanisms such as better patient-health worker concordance.

Specific measures in the CARE strategy require financial investment, such as Advancing Inclusive Nursing Curriculum (2), and recruiting funding as incentives for the goal of Enhancing Nursing Staff Training and Mentorship Initiatives (4). The CARE strategy, however, primarily reallocates and optimizes existing resources by addressing gaps in inclusivity and diversity that currently lead to staff dissatisfaction, turnover, and burnout, which are costly to organizations. By fostering an inclusive workplace climate, the CARE strategy may reduce resource loss from frequent turnover and the recruitment and training new hires, ensuring a stable workforce with minimal additional investment.

Conclusion

Disregarding social diversity in nursing education and administration at LTC facilities leads to bias, cultural misunderstandings, staff dissatisfaction, and unequal patient care. The CARE strategy for diversity provides a pathway to minimize these issues and foster a more inclusive environment. Embracing diversity in nursing education and leadership improves care for seniors from varied backgrounds and enhances patient outcomes. Additionally, an inclusive environment boosts staff morale, fosters community, and reduces disengagement and attrition, ensuring long-term service quality.