Racial Concordance of Nurses and Patients Across Hospitals

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.

The aim of this study was to evaluate patient-nurse racial concordance at the hospital level in a large geographically representative hospital sample.

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.

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.

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.