How Nursing Home Staff Biases Drive Inequitable Care

By Jasmine Travers, PhD, MHS, RN, AGPCNP-BC
April 5, 2022

Jasmine Travers is an assistant professor at New York University Rory Meyers College of Nursing. Her research focuses on mitigating disparities in access and use of in-home and facility-based long-term care for older adults.

For many of us who care deeply about long-term care, a highlight of President Biden’s recent State of the Union address was his commitment to improving care in nursing homes. Biden has also made a broader and bold commitment to ensuring that all Americans live in a society that is accessible, inclusive and equitable.

Pause. Let’s hang on to that part about equity for a bit. 

Achieving equity in nursing homes is going to take more than increasing staffing and oversight, as proposed in Biden’s plan. A recent study published in JAMA Internal Medicine by Ruth Palan Lopez, Susan Mitchell and others identified systemic factors that led to inequitable care for Black nursing home residents. 

Specifically, the researchers conducted 169 interviews with staff across 14 nursing homes in four states to understand why advanced care planning for nursing home residents with advanced dementia varies by race. Their interviews found that:

  • Staff in all nursing homes said they assumed family members of Black residents would be reluctant to engage in advanced care planning and preferred more aggressive care. 

  • Staff spoke about Black families having trouble “letting go” and staff being “afraid to approach” these family members to talk about advanced care planning.

  • As a result, advanced care planning discussions with family members for Black residents occurred less often than for white residents.

Why is this a problem? Advanced care planning is critical to keeping residents comfortable throughout their nursing home stay. But research shows Black residents are more likely to receive aggressive care like insertion of feeding tubes and transfer to hospitals, care which does not promote comfort and has limited clinical benefit for patients with advanced dementia. As the authors note, staff members should talk with all family members to learn their life experiences and preferences and not assume that all Black family members will want aggressive care for their loved ones.

The authors also recommend that nursing home leaders train staff to address these biases, including standardizing care planning, educating staff about evidence-based care, addressing the root causes of biases and highlighting how biases lead to inequities in care. Policymakers at the state and federal level can work to fund and facilitate staff training and share best practices to highlight this barrier to equitable care in nursing homes. These are the kinds of efforts we will need to achieve President Biden’s goal of high quality, more equitable nursing home care for all.

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