{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T01:02:34Z","timestamp":1792803754766,"version":"4.5.0"},"reference-count":40,"publisher":"American Medical Association (AMA)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>Patients from socially disadvantaged backgrounds experience disproportionately worse health care outcomes. Nurses provide most care to patients in hospitals and are informants of health care quality and equity.<\/jats:p><\/jats:sec>Objective<\/jats:title>To understand what hospital nurses say helps or hinders their ability to provide quality care to socially disadvantaged populations.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This qualitative study involved a directed content analysis of open-text responses from the RN4CAST-NY\/IL survey, which was conducted between April and June 2021. Participants were registered nurses licensed to work in 58 New York and Illinois hospitals identified as high-performing (25 hospitals) and low-performing (33 hospitals) for COVID-19 mortality outcomes in 2021 from a larger quantitative study. The Social Ecological Model informed the study codebook; inductive and deductive coding of the data and content analysis were conducted from March to October 2024.<\/jats:p><\/jats:sec>Exposure<\/jats:title>Direct care hospital nurses who participated in the RN4CAST-NY\/IL survey.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Open-text responses were from nurses who answered the survey question, \u201cWhat 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)?\u201d<\/jats:p><\/jats:sec>Results<\/jats:title>A total of 1084 nurses (mean [SD] age, 47.1 [18.2] years) responded to the survey. Most respondents identified as female (986 respondents [91.0%]) and were staff or direct care nurses (765 respondents [70.6%]) with at least a bachelor\u2019s degree (968 respondents [89.6%]). With regard to race and ethnicity, 127 respondents (11.8%) were Asian, 156 (14.5%) were Black or African American, 89 (8.3%) were Hispanic, 693 (64.2%) were White, and 97 (8.9%) were other races. They had a mean (SD) of 18.9 (14.0) years of experience. Six themes described what helped or hindered quality care: (1) profits over patients, (2) care continuity and hospital-community partnerships, (3) insufficient staffing and time constraints, (4) technology to address language barriers, (5) patients\u2019 determinants of health, and (6) individual nurses\u2019 beliefs and backgrounds. Nurses proposed improving health care workforce diversity, strengthening community resources for patients, and advancing tailored cultural competency education as solutions to improve care for socially disadvantaged patients.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this qualitative study and directed content analysis of 1084 open-text responses, nurses identified systemic, institutional, community, and individual clinician-level approaches to improve care for socially disadvantaged populations for equitable care delivery. Nurses\u2019 direct care experiences can inform hospital strategies to improve care for this population.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.12397","type":"journal-article","created":{"date-parts":[[2025,6,6]],"date-time":"2025-06-06T15:30:40Z","timestamp":1749223840000},"page":"e2512397","source":"Crossref","is-referenced-by-count":6,"title":["Hospital Nurse Perspectives on Barriers and Facilitators to Caring for Socially Disadvantaged Patients"],"prefix":"10.1001","volume":"8","author":[{"given":"J. Margo","family":"Brooks Carthon","sequence":"first","affiliation":[{"name":"Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia"},{"name":"The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K. Jane","family":"Muir","sequence":"additional","affiliation":[{"name":"Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia"},{"name":"The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"},{"name":"Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lee","family":"Ang","sequence":"additional","affiliation":[{"name":"Mixed Methods Research Lab, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelvin","family":"Amenyedor","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniela","family":"Golinelli","sequence":"additional","affiliation":[{"name":"Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shelli","family":"Feder","sequence":"additional","affiliation":[{"name":"Yale University School of Nursing, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ann","family":"Kutney-Lee","sequence":"additional","affiliation":[{"name":"Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia"},{"name":"The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"},{"name":"Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2025,6,6]]},"reference":[{"key":"zoi250416r1","doi-asserted-by":"publisher","DOI":"10.1177\/00469580241284959","article-title":"COVID-19 mortality disparities among socially vulnerable Medicare beneficiaries associated with the quality of nurse work environments in U.S. hospitals.","author":"Brooks Carthon","year":"2024","journal-title":"Inquiry"},{"issue":"8","key":"zoi250416r2","doi-asserted-by":"publisher","first-page":"1212","DOI":"10.2105\/AJPH.90.8.1212","article-title":"Levels of racism: a theoretic framework and a gardener\u2019s tale.","volume":"90","author":"Jones","year":"2000","journal-title":"Am J Public Health"},{"issue":"6","key":"zoi250416r3","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.12842","article-title":"Patient and hospital factors associated with differences in mortality rates among Black and White US Medicare beneficiaries hospitalized with COVID-19 infection.","volume":"4","author":"Asch","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"2","key":"zoi250416r4","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1377\/hlthaff.2023.01037","article-title":"Neighborhoods and health: interventions at the neighborhood level could help advance health equity.","volume":"43","author":"Arcaya","year":"2024","journal-title":"Health Aff (Millwood)"},{"issue":"11","key":"zoi250416r5","doi-asserted-by":"publisher","first-page":"1380","DOI":"10.1016\/j.amjmed.2021.06.034","article-title":"Association of COVID-19 hospitalization volume and case growth at US hospitals with patient outcomes.","volume":"134","author":"Khera","year":"2021","journal-title":"Am J Med"},{"issue":"22","key":"zoi250416r6","doi-asserted-by":"publisher","first-page":"2511","DOI":"10.1001\/archinte.166.22.2511","article-title":"Quality of care for the treatment of acute medical conditions in US hospitals.","volume":"166","author":"Landon","year":"2006","journal-title":"Arch Intern Med"},{"issue":"8","key":"zoi250416r7","doi-asserted-by":"publisher","first-page":"639","DOI":"10.1136\/bmjqs-2020-011512","article-title":"Chronic hospital nurse understaffing meets COVID-19: an observational study.","volume":"30","author":"Lasater","year":"2021","journal-title":"BMJ Qual Safe"},{"issue":"19-20","key":"zoi250416r8","doi-asserted-by":"publisher","first-page":"3529","DOI":"10.1111\/jocn.14944","article-title":"\u201cYou only have time for so much in 12 hours\u201d unmet social needs of hospitalised patients: a qualitative study of acute care nurses.","volume":"28","author":"Brooks Carthon","year":"2019","journal-title":"J Clin Nurs"},{"issue":"2","key":"zoi250416r9","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1097\/MLR.0000000000001464","article-title":"Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests.","volume":"59","author":"Brooks Carthon","year":"2021","journal-title":"Med Care"},{"issue":"1","key":"zoi250416r10","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1177\/15271544211069554","article-title":"Care quality, patient safety, and nurse outcomes at hospitals serving economically disadvantaged patients: a case for investment in nursing.","volume":"23","author":"Viscardi","year":"2022","journal-title":"Policy Polit Nurs Pract"},{"issue":"6","key":"zoi250416r11","doi-asserted-by":"publisher","first-page":"1078","DOI":"10.1111\/j.1532-5415.2012.03990.x","article-title":"Nurse staffing and postsurgical outcomes in black adults.","volume":"60","author":"Carthon","year":"2012","journal-title":"J Am Geriatr Soc"},{"key":"zoi250416r13","doi-asserted-by":"publisher","DOI":"10.1097\/NNR.0000000000000821","article-title":"Hospital performance, nursing resources, and health inequities during the COVID-19 pandemic.","author":"Kutney-Lee","year":"2025","journal-title":"Nurs Res"},{"issue":"1","key":"zoi250416r14","doi-asserted-by":"publisher","DOI":"10.1016\/j.outlook.2022.11.007","article-title":"A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: implications for action.","volume":"71","author":"Aiken","year":"2023","journal-title":"Nurs Outlook"},{"issue":"1","key":"zoi250416r16","doi-asserted-by":"publisher","first-page":"E44","DOI":"10.1001\/amajethics.2025.44","article-title":"How should epidemiologists respond to data genocide?","volume":"27","author":"Echo-Hawk","year":"2025","journal-title":"AMA J Ethics"},{"issue":"4","key":"zoi250416r18","doi-asserted-by":"publisher","first-page":"216","DOI":"10.1016\/j.profnurs.2005.05.006","article-title":"Using ecological models in research on health disparities.","volume":"21","author":"Reifsnider","year":"2005","journal-title":"J Prof Nurs"},{"issue":"4","key":"zoi250416r19","doi-asserted-by":"publisher","first-page":"295","DOI":"10.1080\/1059924X.2017.1358971","article-title":"Breadth of the Socio-Ecological Model.","volume":"22","author":"Kilanowski","year":"2017","journal-title":"J Agromedicine"},{"key":"zoi250416r20","doi-asserted-by":"publisher","first-page":"8S","DOI":"10.1177\/1090198115575098","article-title":"Upending the Social Ecological Model to guide health promotion efforts toward policy and environmental change.","volume":"42","author":"Golden","year":"2015","journal-title":"Health Educ Behav"},{"issue":"2","key":"zoi250416r21","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology.","volume":"3","author":"Braun","year":"2006","journal-title":"Qual Res Psychol"},{"issue":"1","key":"zoi250416r22","doi-asserted-by":"publisher","first-page":"25","DOI":"10.5688\/ajpe78125","article-title":"NVivo 10 [software program] version 10: QSR international, 2012.","volume":"78","author":"Castleberry","year":"2014","journal-title":"Am J Pharm Educ"},{"issue":"1","key":"zoi250416r23","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1177\/0049124120986185","article-title":"The Living Codebook: documenting the process of qualitative data analysis.","volume":"53","author":"Reyes","year":"2021","journal-title":"Sociol Methods Res"},{"issue":"4","key":"zoi250416r25","doi-asserted-by":"publisher","first-page":"1944","DOI":"10.1177\/00491241231156971","article-title":"Inter-rater reliability methods in qualitative case study research.","volume":"53","author":"Cole","year":"2023","journal-title":"Sociol Methods Res"},{"key":"zoi250416r27","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1002\/ev.223","article-title":"Judging interpretations: but is it rigorous? trustworthiness and authenticity in naturalistic evaluation.","volume":"114","author":"Schwandt","year":"2007","journal-title":"New Dir Eval"},{"issue":"3","key":"zoi250416r28","doi-asserted-by":"publisher","first-page":"301","DOI":"10.1177\/1558689817743108","article-title":"Pillar integration process: a joint display technique to integrate data in mixed methods research.","volume":"13","author":"Johnson","year":"2019","journal-title":"J Mixed Methods Res"},{"issue":"6","key":"zoi250416r29","doi-asserted-by":"publisher","first-page":"554","DOI":"10.1370\/afm.1865","article-title":"Integrating quantitative and qualitative results in health science mixed methods research through joint displays.","volume":"13","author":"Guetterman","year":"2015","journal-title":"Ann Fam Med"},{"issue":"5","key":"zoi250416r30","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1097\/MLR.0000000000000519","article-title":"Unmet nursing care linked to rehospitalizations among older black AMI patients: a cross-sectional study of US hospitals.","volume":"54","author":"Brooks-Carthon","year":"2016","journal-title":"Med Care"},{"issue":"3","key":"zoi250416r31","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1002\/nur.22121","article-title":"Better nurse work environments associated with fewer readmissions and shorter length of stay among adults with ischemic stroke: a cross-sectional analysis of United States hospitals.","volume":"44","author":"Brom","year":"2021","journal-title":"Res Nurs Health"},{"issue":"4","key":"zoi250416r32","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1002\/nur.22388","article-title":"Validation of a short form of the practice environment scale of the nursing work index: the PES-5.","volume":"47","author":"Lake","year":"2024","journal-title":"Res Nurs Health"},{"issue":"5","key":"zoi250416r33","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1097\/MLR.0000000000001109","article-title":"A meta-analysis of the associations between the nurse work environment in hospitals and 4 sets of outcomes.","volume":"57","author":"Lake","year":"2019","journal-title":"Med Care"},{"issue":"7","key":"zoi250416r34","doi-asserted-by":"publisher","first-page":"1299","DOI":"10.1377\/hlthaff.2010.1118","article-title":"Contradicting fears, California\u2019s nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals.","volume":"30","author":"McHugh","year":"2011","journal-title":"Health Aff (Millwood)"},{"issue":"4","key":"zoi250416r35","doi-asserted-by":"publisher","first-page":"904","DOI":"10.1111\/j.1475-6773.2010.01114.x","article-title":"Implications of the California nurse staffing mandate for other states.","volume":"45","author":"Aiken","year":"2010","journal-title":"Health Serv Res"},{"issue":"1","key":"zoi250416r36","doi-asserted-by":"publisher","first-page":"160","DOI":"10.1111\/j.1468-0009.2011.00658.x","article-title":"Impact of nurse staffing mandates on safety-net hospitals: lessons from California.","volume":"90","author":"McHugh","year":"2012","journal-title":"Milbank Q"},{"issue":"2","key":"zoi250416r37","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1016\/j.outlook.2021.09.007","article-title":"The impact of California\u2019s staffing mandate and the economic recession on registered nurse staffing levels: a longitudinal analysis.","volume":"70","author":"Dierkes","year":"2022","journal-title":"Nurs Outlook"},{"issue":"6","key":"zoi250416r38","doi-asserted-by":"publisher","first-page":"322","DOI":"10.1097\/NNA.0000000000001154","article-title":"Diversity, equity, and inclusion in the 2023 Magnet\u00ae Application Manual.","volume":"52","author":"Bryant","year":"2022","journal-title":"J Nurs Adm"},{"issue":"1","key":"zoi250416r39","doi-asserted-by":"publisher","DOI":"10.1016\/j.outlook.2022.11.007","article-title":"A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: implications for action.","volume":"71","author":"Aiken","year":"2023","journal-title":"Nurs Outlook"},{"key":"zoi250416r12","doi-asserted-by":"crossref","first-page":"31","DOI":"10.4135\/9781483398341.n5","volume-title":"Mixed Methods Research: A Guide to the Field","author":"Clark","year":"2016"},{"key":"zoi250416r17","doi-asserted-by":"crossref","DOI":"10.1037\/10518-046","volume-title":"Ecological Systems Theory","author":"Bronfenbrenner","year":"2000"},{"key":"zoi250416r24","first-page":"581","volume-title":"The Oxford Handbook of Qualitative Research","author":"Salda\u00f1a","year":"2014"},{"key":"zoi250416r26","doi-asserted-by":"crossref","DOI":"10.1016\/0147-1767(85)90062-8","volume-title":"Naturalistic Inquiry","author":"Lincoln","year":"1985"},{"key":"zoi250416r40","volume-title":"Qualitative Research in Nursing and Healthcare","author":"Holloway","year":"2023"},{"key":"zoi250416r15","unstructured":"Department of Health and Human Services. Guidance for CMS cell suppression policy. January 1, 2020. Accessed May 1, 2025. https:\/\/www.hhs.gov\/guidance\/document\/cms-cell-suppression-policy"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2835062\/brooks_carthon_2025_oi_250416_1748614543.83093.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,6]],"date-time":"2025-06-06T15:30:42Z","timestamp":1749223842000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2835062"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,6]]},"references-count":40,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2025,6,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.12397","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,6]]}}}