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How Staffing Problems Cause Racial Health Disparities in Nursing Homes

Nursing homes with a larger Black patient population see more hospitalizations and ED visits than those serving mostly White patients.

Nursing homes serving mostly Black patients employ fewer registered nurses than facilities serving mostly White patients, a staffing issue that researchers from NYU said could be driving racial health disparities in nursing home settings.

Overall, nursing homes with mostly Black patients had fewer RNs and certified nursing assistants (CNAs) on staff compared to mostly White nursing homes, but they did staff more licensed practical nurses, who tend to go through less extensive training and mostly handle direct patient care.

Researchers indicated that these staffing differences could be behind some of the differences in clinical outcomes between mostly White and mostly Black nursing homes. As it stands, nursing homes serving a mostly Black patient population typically have higher emergency department visit rates as well as higher hospitalization rates than facilities treating a mostly White patient population.

In an assessment of 14,121 nursing homes using 2019 datasets, the researchers corroborated that evidence. The higher the proportion of Black patients served in the nursing home, the higher the emergency department visit and hospitalization rates.

And that trend was complemented by differences in staffing makeup.

Nursing homes serving mostly Black patients had 50 percent lower RN and CNA hours per patient per day than facilities treating mostly White residents. In contrast, mostly Black nursing homes had higher ratios of LPNs.

RNs typically go through more extensive schooling and education, with most RNs needing a minimum of an associate’s degree in nursing. Because of that, RNs are able to do more symptom and treatment assessment. Meanwhile, LPNs usually complete a specialized nursing course, equipping them to do less assessment and more direct patient care.

The researchers said the differences in staffing could have led to racial health disparities in care outcomes. Having fewer RNs on staff may have limited the quality of care administered in certain nursing homes, indicated Jasmine Travers, PhD, RN, assistant professor at NYU Rory Meyers College of Nursing and the study’s lead author.

“As lower use of RNs has generally been associated with increased emergency department visits and hospitalizations of nursing home residents, it is likely that the relative scarcity of skilled workers largely drove the differences in hospitalizations and emergency department visits in nursing homes with greater proportions of Black residents,” Travers said in a press release.

Staffing models are adjustable, Travers added as a silver lining to the study’s results.

“Staffing is a modifiable area in which federal and state agencies should take action to eliminate disparities in quality of care among nursing homes,” Travers noted.

However, in an industry increasingly characterized by burnout, modifying staffing models might not be so simple. Healthcare organizations do not have a large pool of applicants for hire, so it might be difficult to staff up on RNs and potentially advanced practice providers, like nurse practitioners (NPs).

Per April 2023 figures, the nation’s healthcare industry can expect up to 900,000 RNs to leave the workforce by 2027. That’s after it saw nearly 100,000 nurses leave the workforce following the pandemic.

Reasons for leaving include stress, burnout, and retirement.

Like other sectors in healthcare, nursing homes need to consider recruitment strategies to ensure nurses and other staff stay in the field. But to complement that, state and federal policymaking may also support greater growth in the nursing workforce.

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