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

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.