By Dave Muoio 

High workloads, time constraints, misalignment of financial incentives and individuals’ health literacy are among the chief roadblocks for hospitals’ delivery of high-quality care to socially disadvantaged patients, according to more than 1,000 surveyed nurses.

On the other hand, adoption of new technologies that can help overcome language barriers and programs linking hospital care to community support services were emphasized by the nurses as key resources when caring for these patients.

The free-text responses characterized in the qualitative study, published Friday, also pointed to individual healthcare workers’ beliefs and backgrounds as driving factors, for better or for worse. Some outlined biases and racism toward the disadvantaged patients from colleagues or their own frustrations when providing care to undocumented patients, while others outlined the need for cultural competency training and a diverse workforce that reflects the demographics of those being served.

The researchers said their analyses of the responses outline potential strategies to advance hospitals’ delivery of equitable care, as identified by the industry’s more abundant group of clinicians.

Such approaches are valuable, because socially disadvantaged patients experience worse outcomes when hospitalized, a trend that only worsened during the COVID-19 pandemic when these patients had a 50% higher risk of death.

“Because socially disadvantaged patients have more constrained resources, including inadequate transportation, housing instability, or fewer material resources, their nursing needs are heightened during acute hospitalization, requiring more complex nursing care,” researchers wrote in the journal. “If nurses are unable to meet the needs of socially disadvantaged patients, disparate outcomes may result owing to care deficits.”

The analysis reviewed the responses to a single open-text question included in a broader 2021 survey: “What helps (or hinders) your ability to provide quality care to vulnerable populations? (e.g. low SES, housing insecurity/homeless, racial/ethnic minorities, immigrant, limited English proficiency)?”

The responses were collected from 1,084 nurses from 25 high-performing hospitals and 33 low-performing hospitals with a mean 14 years of experience as a nurse. Most were female, staff or direct care nurses, white and had at least a bachelor’s degree.

The qualitative analysis identified six system-, community-, institutional- and individual-level themes from the responses.

Profit over patients

Nurses from both high-performing and low-performing hospitals outlined a mismatch between financial incentives and delivery of equitable care, with those hailing from the latter being more critical of hospital administration for their priorities. Both groups said systemic bias also had an effect on clinicians’ well-being and morale.

Care continuity and hospital-community partnerships

Nurse respondents outlined social workers’ crucial role connecting socially disadvantaged patients with community resources and the positive outcomes stemming from social service departments. Those at higher-performing hospitals more often said they were concerned about patient care continuity, while those at lower-performing hospitals were more specific with examples of programs that helped these patients.

Technology to address language barriers

Nurses across the board recommended language access services and, particularly, technologies to those with language needs such as English proficiency or auditory impairment. Low-performing hospital nurses more often outlined language barriers, while high-performing hospital nurses more often discussed difficulties accessing such services and technologies.

Insufficient staffing and time constraints

Heavy workloads, little time and a shortage of staff were constant across the respondents, with researchers noting staffing levels specifically was among the most frequently raised issues of the survey. High-performing hospital nurses more often discussed time constraints, and low-performing hospital nurses more frequently mentioned staffing level concerns.

Patient determinants of health

Nurses described a broad set of individual factors related to their patients’ demographics, such as health literacy and family support, as playing a role in care delivery. Nurses from high-performing hospitals more often mentioned the patients’ lack of trust due to prior healthcare interactions.

Individual nurses’ beliefs and backgrounds

Responses revealed biases among respondents’ healthcare workforce colleagues and themselves that could affect care. Here, researchers touched on reports of racism among providers and quoted specific response in which a nurse said they were “frustrated” that their hospital would use its limited resources for undocumented patients “who haven’t paid a dime in taxes.” Still, nurses broadly said they aimed to provide the same quality of nursing care to all their patients. Nurses from both hospital categories pointed to a need for a more diverse workforce to better connect to their patient populations, with those at high-performing hospitals more often reporting a need for increased cultural competency training.

Researchers acknowledged limitations in their analysis that could hamper its generalizability—namely, that the responses were collected from hospitals in New York and Illinois alone during a pandemic and that the write-in portion survey was optional and could have received an outsized response from nurses more heavily invested in care for the socially disadvantaged. Still, they wrote that the findings could inform hospitals’ strategies to improving care for these patients.

An accompanying invited commentary published in the journal from Monica McLemore, Ph.D.—a professor at the University of Washington Schools of Nursing, Public Health, and Women, Gender and Sexuality Studies—warned of “assumptions” about socially disadvantaged patients’ nonclinical needs, a need for greater distinction among different types of hospitals’ characteristics and capabilities, and whether it’s appropriate to permanently address these patients’ social needs within healthcare alone.

With those in mind, however, she still described the analysis as “an important contribution that serves as foundational work to understand the barriers and facilitators to addressing social needs in clinical care. These data should inform our understanding of the most effective ways to provide these services.”