Nursing homes with the highest proportion of Black residents have the greatest number of hospitalizations and emergency department visits, according to a new study led by researchers at NYU Rory Meyers College of Nursing.
Staffing levels likely drive the differences in hospitalizations and emergency department visits among nursing homes, the researchers report in the Journal of the American Geriatrics Society.
Studies show that nursing homes serving high proportions of Black residents may experience poor healthcare outcomes. To better understand nursing homes’ environmental and structural characteristics that may lead to these outcomes, the researchers examined data from 14,121 U.S. nursing homes using national datasets from 2019.
They found that, compared to nursing homes with no Black residents, nursing homes with at least 50% Black residents had lower ratios of registered nurse (RN) and certified nursing assistant (CNA) hours per resident per day and greater ratios of licensed practical nurse (LPN) hours per resident per day. As the proportion of Black residents in nursing homes increased, hospitalizations and emergency department visits also increased.
Nursing homes serving Black residents were also more likely to be located in urban settings, for-profit in the South, and have more Medicaid-funded residents.
“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,” says Jasmine Travers, PhD, RN, assistant professor at NYU Rory Meyers College of Nursing and the study’s lead author.
“Staffing is a modifiable area in which federal and state agencies should take action to eliminate disparities in quality of care among nursing homes,” adds Travers.
Hospitals serving more patients at risk for complications during childbirth are less likely to have enough nurses to care for patients during labor, delivery, and recovery, according to a new study in Nursing Outlook.
The findings reveal one of many factors that may contribute to poor maternal health outcomes in the U.S. for the most vulnerable childbearing populations, including Black mothers and those insured by Medicaid.
Nurses play a central role in the 3.6 million births in U.S. hospitals each year. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) issues guidelines on nurse staffing levels for maternity units; its 2010 guidelines call for one nurse to one birthing person during many parts of labor, two nurses at birth, one nurse for each mother-newborn pair during the first few hours after birth, and one nurse for every three pairs of mothers and babies after that period. These same nurse-to-patient ratios were included in the AWHONN nurse staffing standards published in 2022.
Recent data show that patients at high risk for severe maternal complications are more likely to give birth in teaching hospitals and have Medicaid as their insurer. In addition, teaching hospitals—often safety-net hospitals providing a significant amount of care to low-income and uninsured patients—are also more likely to have high volumes of births. In this study, the researchers aimed to determine nurse staffing levels at hospitals with vulnerable maternity patients, using high-birth volume and teaching status as proxies for high-risk patients.
The researchers surveyed 3,471 registered nurses from 271 hospitals across the country. Nurses were asked about staffing levels on their maternity units during labor, delivery, and recovery using AWHONN guidelines. The researchers compared nurses’ responses on staffing with hospital characteristics from the American Hospital Association Annual Survey.
Overall, nurses reported strong adherence to AWHONN staffing guidelines in their hospitals, with more than 80% of respondents saying that their unit frequently or always met the staffing guidelines. Adherence to guidelines was particularly high for specific stages of labor, including a nurse being continuously present at the bedside during second-stage labor (93.3%) and one-on-one care during epidural initiation (84.1%). However, adherence was lower for having a dedicated nurse for postpartum recovery in the two hours right after delivery (71.8%), one-on-one care for mothers with high-risk conditions (72.6%), a nurse dedicated to fetal heart rate monitoring (61.3-77.2%), and one-on-one care during oxytocin administration in labor (54.6%).
Analyzing hospital characteristics, the researchers found that teaching hospitals and hospitals with higher birth volumes, neonatal intensive care units, and higher percentages of births paid by Medicaid were associated with lower staffing guideline adherence—all of which have been shown to serve high-risk maternity patients.
“These gaps in staffing are particularly troubling for our most at-risk patients,” added Lyndon. “Many maternal complications can be prevented or quickly addressed through timely recognition of risk factors and clinical warning signs, and, when issues are identified, the escalation of care and coordination with the care team—but this is only possible when there are enough nurses monitoring patients.”
The researchers note that one possible cause of nurses in these types of hospitals having more patients than recommended may be poor reimbursement from Medicaid for childbirth services.
“Studies show that Medicaid pays hospitals less than half of what commercial insurers pay for a birth. This inequity in reimbursement creates a fiscal challenge in hospitals with a high percentage of maternity patients insured by Medicaid,” says Kathleen Rice Simpson, PhD, RNC, FAAN, a perinatal clinical nurse specialist in St. Louis, MO, and the study’s lead author. “Better funding for teaching and safety-net hospitals caring for high-risk maternity patients could support better nurse staffing.”
In addition, the researchers encourage the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission to consider safe staffing requirements for inpatient maternity care, similar to CMS working to establish minimum staffing regulations for nursing homes to promote patient safety.
Dean Amar is an accomplished leader, advanced practice psychiatric nurse, and researcher studying sexual and dating violence. She joins NYU from the University of Nevada, Las Vegas (UNLV) School of Nursing, where she has been dean and a tenured professor since 2018.
NYU Welcomes Dean Amar
“Angela Amar comes to NYU’s Rory Meyers College of Nursing with an outstanding reputation as a researcher, a nursing educator, and an advocate for the profession. She particularly impressed us with her distinguished record of leadership, not only at UNLV but also at Emory and Boston College, and especially her focus on advancing diversity and inclusion in the profession, her concentration on student success, and her attention to faculty development, “ says NYU President Andrew Hamilton. “We were struck, too, by how strategically she was able to transform her vision, ambitions, and goals for UNLV’s School of Nursing into reality, with improvements in research funding, publications, student success, and faculty hiring.”
Before her tenure as dean of the UNLV School of Nursing, Dean Amar joined the faculty of Emory University’s Nell Hodgson Woodruff School of Nursing in 2012, where she served as an assistant and then associate dean between 2013 and 2017. She developed forensic nursing programs for Emory, Boston College, and Georgetown, establishing a nationwide educational model on forensic nursing for nursing schools. Dean Amar’s scholarship on sexual and partner violence focuses on improving care and support for survivors of violence and trauma when they enter the healthcare system.
Dean Amar is a widely published author. Her books, articles, and book chapters include A Practical Guide to Forensic Nursing (2015, Sigma Theta Tau International Honor Society of Nursing; with Sekula); “Gender Violence Prevention in Middle School Male Athletics Programs” (2020, JAMA Pediatrics, with Laughon); “Bullying Prevention: a Summary of the Report of the National Academies of Sciences, Engineering, and Medicine” (2016, with others); “Administrators’ perceptions of college campus protocols, response, and student prevention efforts for sexual assault” (2014, Violence and Victims; with others); and “Gender Differences in Attitudes and Beliefs Associated With Bystander Behavior and Sexual Assault” (2014, Journal of Forensic Nursing; with others). She is the recipient of numerous honors and awards, including receiving the 2022 Nursing Leader Award from the Asian American Group and Las Vegas India Chamber of Commerce; being selected for the American Association of Colleges of Nursing Wharton Executive Leadership program; and receiving the 2017 Lillian Sholtis Brunner Award for Innovative Practice in Nursing, Alumni Award, from the University of Pennsylvania’s School of Nursing. She is a fellow of the American Academy of Nursing, a Distinguished Fellow of the International Association of Forensic Nurses, and a Fellow of the National League for Nursing’s Academy of Nursing Education.
She earned her BSN (1987) and MN (1992) from the Louisiana State University Medical Center’s School of Nursing and her PhD from the University of Pennsylvania (2003), and is licensed as an RN in several states, is a board-certified advanced forensic nurse, and is certified as an adult psychiatric and mental health advanced practice nurse.
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