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Health Services Insigh

Volume 12: 1–12
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissio

DOI: 10.1177/1178632918825083

Background
The provision of high-quality medical care is vital for the
well-being of nursing home (NH) residents, especially given
trends for an increase in complex medical, psychological, and
social needs. Nursing home residents are increasingly in need
of rapid, frequent, and/or continuous medical care, presup-
posing not only available but perhaps also continual—as
opposed to fragmented—medical care provision in NHs.
The provision of this medical care is organized differently
both within and between countries, which may in turn pro-
foundly affect both the overall quality of life and care pro-
vided to NH residents.

In this article, we describe and compare the policies and
practices guiding how medical care is provided across Canada
(2 provinces), Germany, Norway, and the United States. This
study was conducted as part of a research program titled,
“Long-Term Residential Care: An International Study of
Promising Practices” that examined differences in NH/resi-
dential care across these and other countries. The term “nursing
home” is defined and used differently between jurisdictions,
sometimes not used at all in favor of, for instance, “(long-term)
care facility.” For the sake of comparison, we will in this article

use the term “nursing home” and highlight jurisdictional differ-
ences in the result section, when relevant.

Research on staff and staffing levels in NHs and equivalent
institutions has been directed primarily at registered nurses,
assisting nurses and their equivalent groups (eg, licensed prac-
tical nurses and nursing assistants). Regulations and guidelines
for these nursing standards are formalized in most jurisdic-
tions, although their scope and level of detail vary considerably
from one jurisdiction to the next.1,2 Less attention has been
directed at 2 other groups of employees at NHs: assistants (and
their equivalent groups, eg, personal care workers) and physi-
cians, respectively, constituting vital parts of the “machinery” of
the NH. Medical care in NHs, primarily provided by physi-
cians, has been particularly understudied concerning the poli-
cies and regulations affecting them. There is, in short, a dearth
of research on physician care in NHs in general3 but also in
research directed at health care system comparisons across
countries.4 These 2 elements will be addressed in this article, by
analyzing variations in regulations and guidelines as well as
practice pattern relating to medical care in selected countries.

The aim of this article is to describe and compare the dif-
ferent approaches to providing NH medical care across the

An International Mapping of Medical Care in
Nursing Homes

Gudmund Ågotnes1, Margaret J McGregor2, Joel Lexchin3,
Malcolm B Doupe4, Beatrice Müller5 and Charlene Harrington6
1Centre for Care Research, Western Norway University of Applied Sciences, Bergen, Norway.
2Department of Family Practice, Faculty of Medicine, The University of British Columbia,
Vancouver, BC, Canada. 3School of Health Policy and Management, Faculty of Health, York
University, Toronto, ON, Canada. 4Departments of Community Health Sciences and Emergency
Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of
Manitoba, Winnipeg, MB, Canada. 5Department of Gerontology, University of Vechta, Vechta,
Germany. 6Department of Social & Behavioral Sciences, University of California, San Francisco,
San Francisco, CA, USA.

ABSTRACT

Nursing home (NH) residents are increasingly in need of timely and frequent medical care, presupposing not only available but perhaps
also continual medical care provision in NHs. The provision of this medical care is organized differently both within and across countries,
which may in turn profoundly affect the overall quality of care provided to NH residents. Data were collected from official legislations and
regulations, academic publications, and statistical databases. Based on this set of data, we describe and compare the policies and prac-
tices guiding how medical care is provided across Canada (2 provinces), Germany, Norway, and the United States. Our findings disclose
that there is a considerable difference to find among jurisdictions regarding specificity and scope of regulations regarding medical care in
NHs. Based on our data, we construct 2 general models of medical care: (1) more regulations—fee-for-service payment—open staffing
models and (2) less regulation—salaried positions—closed staffing models. Some evidence indicates that model 1 can lead to less availa-
ble medical care provision and to medical care provision being less integrated into the overall care services. As such, we argue that the ser-
vice models discussed can significantly influence continuity of medical care in NH.

KeywoRdS: Nursing homes, physician, care, regulation, international

ReCeIVed: December 9, 2018. ACCePTed: December 17, 2018.

TyPe: Original Research

FuNdINg: The author(s) disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: The research for the study in this
article was funded by the Social Sciences and Humanities Research Council (SSHRC) of
Canada’s Major Collaborative Research Initiative, “Re-Imagining Long-Term Residential
Care” (grant number 412-2010-1004).

deClARATIoN oF CoNFlICTINg INTeReSTS: The author(s) declared no potential
conflicts of interest with respect to the research, authorship, and/or publication of this
article.

CoRReSPoNdINg AuTHoR: Gudmund Ågotnes, Centre for Care Research, Western
Norway University of Applied Sciences, Møllendalsveien 6, 5020 Bergen, Norway.
Email: gago@hvl.no

825083 HIS0010.1177/1178632918825083Health Services InsightsÅgotnes et al
research-article2019

https://uk.sagepub.com/en-gb/journals-permissions

mailto:gago@hvl.no

2 Health Services Insights

aforementioned 5 jurisdictions. Our analyses are presented in 2
sections. First, we describe each jurisdiction in terms of the (1)
government regulations and public policies available to guide
physician-based NH care, (2) strategies used to reimburse phy-
sicians providing NH care, and (3) different models of medical
care that can be said to follow from 1 and 2. Second, we com-
pare across jurisdictions the similarities and differences in care
approaches, including how they may affect the quality of medi-
cal care provided to NH residents.

Several authors have noted that NH residents are a vulner-
able population with comorbid and often advanced medical
conditions, predisposing their need for high-quality medical
care that is effectively integrated with other care services.5–7
Accessible, coordinated, and continual medical care services are
highlighted in the research literature as significant. The need to
continually improve the provision of medical care will most
likely increase in the future, as NHs are projected to care for a
growing number of increasingly frail older adults with substan-
tial medical needs.8

Medical care services are provided mostly by physicians.
The availability of physician services—for example, how much
time physicians spend at NHs, how often they assess residents,
and how available they are when offsite—has been shown to
significantly affect the quality of NH resident care, particularly
at end of life6,9 and with respect to hospitalization rates.10–12
Research also shows that the use of alternate physician services
or emergency departments as opposed to a regular or “house”
physicians can vary significantly between NHs.13

Moreover, given the shortage of primary care physicians,
general practitioners, geriatricians, and internists working in
NHs,14 the United States in particular has witnessed an
increase in NH medical care provided by alternative profes-
sionals such as nurse practitioners (NPs), clinical nurse special-
ists (CNSs), and physician assistants (PAs).15 Other countries
such as Norway and Germany have not experienced an increase
in the NH care provided by these alternative practitioners,
although stakeholders in Norway, for instance, have suggested
that the use of these equivalent groups may be an effective
solution to the current challenges with recruiting physicians.16

Nursing home models of medical care can be broadly cate-
gorized as open or closed.5 Nursing homes using an open med-
ical care model typically allow any willing physician to care for
residents, whereas a closed medical model only allows prese-
lected physicians to provide such care. These models may, as we
shall see, have an impact on access and quality of care.

More broadly, governmental regulations and public policies
regarding medical services in NHs, whether local, regional, or
national, have generally not been studied, certainly not with the
aim of cross-national comparisons (see also the work by Wendt
and colleagues4). Given the importance of medical service
practices and models, and financial systems found in recent
research, it is appropriate to compare these variations across
select international jurisdictions.

Such an approach can provide information that has value
for helping consumer advocates, NH providers, and policy-
makers understand both the scope and jurisdictional differ-
ences in how medical care is provided in NHs and for
considering the benefits and potential challenges associated
with these different care approaches.

Methods
Conceptual framework

This study used the conceptual framework of Wendt and col-
leagues4 for conducting health care system comparisons. This
model identifies 3 major dimensions of health care systems: (1)
financing, (2) service provision, and (3) regulation. The state,
nongovernmental actors and the market can all be involved in
health care, so a research framework should combine these
aspects with the aforementioned dimensions in a systematic
way. This approach allows researchers to develop a typology
that can be used to compare selected counties.

Data

All coauthors of the study are part of the larger research project
titled “Long-Term Residential Care: An International Study of
Promising Practices.” As part of this initiative, coauthors col-
lected from their jurisdictions descriptive data about the
involvement of physicians (and other medical care providers) in
providing medical care, specifically identifying the general pol-
icies, employment types, and reimbursement models governing
NH medical care. Data were collected from official legislations
and regulations, academic publications, and statistical data-
bases, in each jurisdiction. In several of the jurisdictions, key
informants were interviewed to obtain additional information
to add to publicly available data or to supplement with data
that were not publicly available.

Data were collected from Norway, Germany, the United
States, and Canada. The delivery of health care is a provincial
matter under the Canadian constitutions, and as such there are
large differences in NH medical care models across provinces.
Therefore, we have chosen to treat British Columbia (BC) and
Manitoba as 2 separate Canadian jurisdictions. Data are there-
fore presented across 5 jurisdictions.

Based on the conceptual framework of Wendt and colleagues4
for health care system comparison, our authorship team created
a template to guide data collection and interpretation within
each region. We described and compared medical services in
NHs focusing on 3 major dimensions: (1) regulations and pub-
lic policies governing use, (2) financing systems, and (3) service
provision (eg, medical practice patterns and models). For pur-
poses of relevance and applicability to our current topic, these
key themes were further operationalized into subthemes.

For government regulations and public policies, 4 areas
were examined: (1) level of governance and type of regula-
tion, (2) level of detail, (3) coverage of regulation (eg, all

Ågotnes et al 3

versus select NHs), and (4) accountability and sanctions. For
the medical practice patterns and models, 5 areas were exam-
ined: (1) type of medical care providers (physician, other pro-
fessional groups), (2) type of employment (employed or
self-employed, employed by whom), (3) distribution of type
of medical care providers, (4) staffing model (open versus
closed), and (5) regularity of medical services. For the financ-
ing system, 2 dimensions were examined: (1) overall financial
system and (2) payment form for the medical care provider.
The data collected from each subdimension were analyzed
by creating a grid/table for purposes of comparison. A sim-
plified version of this grid is provided in the “Results” section
of this article.

In addition to providing comparable data across jurisdic-
tions, the template grid was used to highlight the number and
range of documented policies and care practices related to
medical services in NHs. Because of the wide diversity of
health care systems, the collection and comparison of data
across jurisdictions were, in some instances, difficult. Policies
regarding medical care in NHs and similar institutions have,
for instance, different objectives, scopes, and level of detail.
Rather than seeing this as a weakness, we treat these differ-
ences as point of analysis in themselves: How do they differ, on
what grounds and to what consequence?

Results
Norwa

Government regulations and policies. In 2017, there were
approximately 955 NHs in Norway, with a total of 40 494 beds,
making the average size of NHs 42.17 Approximately 83% of
beds were long-term, whereas 17% were short-term (including
beds for rehabilitation). Total number and proportion of short-
term beds have increased over the past decade. 68% of all resi-
dents were 80 years or older in 2017.17

Similar to most medical and long-term care services for
the elderly, NHs are a municipal responsibility in Norway.
Most NHs are publicly owned and operated, a minority are
private nonprofit and relatively few are private for-profit. The
municipalities are, by law, responsible for delivering “neces-
sary medical care” for people residing within their borders,18
regardless of the NH ownership model. Municipalities there-
fore have a pivotal role in facilitating the way in which physi-
cians care for NH residents. This responsibility is often
delegated, at least in part, to NHs, although this occurs to a
different extent for public and private NHs, in the sense that
physician care for many public NHs is provided for through a
central office in a municipality, whereas many private NHs
can choose to be part of such schemes, or not. The actual
responsibility of securing medical care for residents is, as such,
a matter to be solved by the municipalities and the institu-
tions, rather than by the respective residents (and their fami-
lies) or the federal government.

Within Norway, there are no national regulations that stip-
ulate the minimal coverage required by NH physicians (eg,
minimum frequency of contact with residents), their employ-
ment “type” (eg, working directly for the NH or for the munici-
palities as a general practitioner), nor their reimbursement
strategies. Nursing homes are, however, required by federal law
to provide physician medical care to residents by having a phy-
sician’s services “connected to” all institutions.19 Although NHs
are also obliged by federal law to have “procedures in place” to
secure the medical care of residents,19 regulations do not spec-
ify what this entails and what being “connected to” means.

Financing systems. Norway has universal health care coverage
that includes all long-term care services paid for by municipali-
ties. Physicians who are paid by individual NHs and those who
are paid by municipalities receive a fixed salary that does not
depend on the number and type of patients they see, and NHs
are reimbursed by the municipality for their physicians’ salary
cost. Physician salary in the public sector is also highly regu-
lated, meaning that differences in the salary level of NH- and
municipal-employed physicians are in most instances minimal.
Overall, therefore, the decision to have an NH- versus munici-
pally employed physician is based on practical decisions rather
than cost-efficiency.

Medical practice patterns and service models. Physicians provid-
ing medical care in NHs can (1) be employed and work for the
facility directly or (2) work as general practitioners through an
operation agreement with a municipality. All physicians
employed as general practitioners in a municipality are required
to allocate 20% of their work (7.5 hours/week) to “public
duties,”20 of which NHs are one of several options. Beyond
these high-level guidelines, NH legislation does not mention
or specify the role, function, or duties of physicians, having a
form described as unspecific “framework acts.”21 Consequently,
most NH residents do not have a specific, identifiable physi-
cian ascribed to them, nor are municipalities obliged to provide
physicians in NHs at all times. Municipalities can, for example,
provide medical services in emergency departments in the eve-
nings, during the night, or on weekends.

About 50% of NH medical care in Norway is performed by
physicians employed directly by the NH, whereas the remain-
der is provided by general practitioners employed by munici-
palities.22 Physicians employed directly by institutions tend to
have far larger positions/full-time equivalents compared with
their counterparts.13 This means that most NHs in Norway
have physicians employed by the community, whereas only
some employ full-time physicians. Also, while some evidence
shows that the volume of physician care time has increased
dramatically over time in Norway (from 0.27 hours of care
weekly per resident in 2005 to 0.55 hours of such care in
2017),23 others have shown that this volume of care varies con-
siderably (ie, up to 3-fold) from one municipality to the next.24

4 Health Services Insights

Unlike other jurisdictions, NHs in Norway typically do not
have Medical Directors (ie, physicians in charge of organizing
the medical care provided by others) nor do they employ equiv-
alent providers such as PAs and NPs.

Summary
•• Local/municipal responsibility;
•• Potential for variation;
•• General practitioners perform duty-work in NHs;
•• Few specific regulations/legislation;
•• No fee for service;
•• Closed model.

The United States

Government regulations and policies. In 2016, there were 15 452
registered NHs in United States, with an average of 109 beds
per facility.25 About 86.5% of beds were long term, whereas
13.5% were short term; 85.5% of all residents were 65 years or
older in 2014.26

Medical care in US NHs is driven largely by federal laws
and regulations, although all states have licensing laws. These
regulations do not vary by NH ownership type (public, for-
profit, or nonprofit). Most of the NHs in the United States are
private for-profit. Some states have additional requirements
guiding the provision of medical services beyond the federal
regulations, whereas other states have the same requirements as
laid out by the federal government. Physicians and other health
professionals must, for instance, be licensed in each state, which
is regulated by the state professional boards. The US NH leg-
islation was passed in 198727 to strengthen federal regulatory
requirements for all NHs that are certified to received federal
funds (in 2016, this represented 96% of all US NHs).25 Nursing
homes that do not receive federal funds (ie, take only privately
paid patients) do not have to meet federal certification stand-
ards but do have to meet the minimum state licensing laws and
regulations. The specificity of regulations regarding medical
services has increased over time26,28–30 and the general regula-
tory guidelines have also increased.

The federal regulations for skilled nursing care require that
each NH resident must have an attending physician (Section
483.30).29,30 The regulations state tha

A physician must personally approve in writing a recommendation
that an individual be admitted to a facility. Each resident must
remain under the care of a physician. A physician, physician assis-
tant, nurse practitioner, or clinical nurse specialist must provide
orders for the resident’s immediate care and needs.

Furthermore, it is stated that “The facility must ensure that (1)
the medical care of each resident is supervised by a physician
and (2) another physician must supervise the medical care of
residents when their attending physician is unavailable.

”

The US federal regulations require that each resident must
be seen by a physician at least once every 30 days for the first

90 days after admission, and at least once every 60 days thereaf-
ter. At the option of each resident’s physician, required visits in
skilled nursing care facilities, after the initial visit, may alter-
nate between personal visits by the physician and visits by a PA,
NP, or CNS. The US federal regulations also require that each
resident’s physician or equivalent must at each visit: (1) review
the resident’s total program of care, including medications and
treatments; (2) write, sign, and date all progress notes; and (3)
sign and date all orders.

The US federal regulations also require each nursing facility
to provide or arrange for the provision of physician services
24 hours a day in the case of an emergency. Physicians may
delegate tasks to a PA, NP, or CNS. Finally, US federal regula-
tions require that every facility must designate a physician to
serve as Medical Director who is responsible for (1) imple-
menting resident care policies and (2) coordinating medical
care in the facility. Federal law does not specify the amount of
time or payment policies for physicians and Medical Directors.

Once residents are no longer paid for by Medicare (for aged
and long-term disabled beneficiaries), but are paid by Medicaid
(for low-income individuals) or pay privately, their care can be
provided solely by a NP where the state practice authority
allows it. A total of 23 US states currently have legislated full
practice authority for NPs.31 States may have additional licens-
ing requirements for Medical Directors and clinicians practic-
ing in NHs that go beyond the federal requirements. For
example, California has a requirement that NH residents must
be seen, at a minimum, every 30 days.

Financing systems. The state-federal Medicaid program and
the federal Medicare program have separate NH program pay-
ment policies. Medicare only pays for short NH stays (ie, reha-
bilitation and nursing care, usually up to 100 days).15 In 2016,
about 62% of residents were paid by Medicaid, 13% by Medi-
care, and 25% by private insurers or private individuals.25

Medicaid pays for long-stay low-income residents, whereas
other long stay residents with higher income levels must pay
privately out of pocket. Both the Medicare and Medicaid pro-
grams pay NHs based on specified per diem rates but these
rates do not include payments for medical services. Rather, the
payment for medical services is made generally on a fee-for-
service basis, based on the type of service provided, and pay-
ments are generally made directly to the medical provider.
Medical providers who are employed by the facility may elect
to have payments delegated to the NH or be paid directly.
Private insurers and managed care companies also have their
own payment policies for physician visits to NHs. Payment
policies and rates may vary by the type of medical provider (eg,
MDs, NPs, PAs, and CNSs). Some state Medicaid programs
pay NPs, PAs, and CNSs directly for services, whereas other
states reimburse them through physicians.

Medical practice patterns and service models. Nursing home
facilities or chains of facilities may set their own policies

Ågotnes et al 5

regarding Medical Directors and medical services as long as
they meet applicable federal and state policies. Most physicians
who provide NH services practice in the community and pro-
vide services to NH residents on a part-time basis. Nursing
homes may directly employ physicians and other health profes-
sionals to provide medical care on a part or full-time basis and
physicians may be salaried or paid on a fee-for-service basis.
When a resident does not have an attending physician, the
resident (or family) may ask the NH’s physician or Medical
Director to serve as an attending physician.

Nursing homes have the flexibility to set their own policies
in terms of whether they have open or closed staff models,
employment arrangements, medical staff certification, and
numbers of different types of medical staff.

From 2000 to 2010, the average number of primary care
physicians providing care in NHs decreased from 3.5 to 2.9 per
facility, and similarly, the number of specialty physicians (eg,
cardiologists) has decreased from 1.4 to 0.8.32As the number of
physicians have decreased, we could expect that the amount of
time spent by physicians has also decreased, but there are no
available data kept on hours spent. In contrast, the number of
NP visits per bed year increased from 1 to 3 in the 2000 to
2010 time period. The wide variability of NP/PA visits per bed
across states may be in part related to the state policies regard-
ing scope of practice requirements.15,32 Overall, in 2010, pri-
mary care and specialist physicians made about 9 and 2.2 visits
per US NH bed, respectively.

Summary
•• Combination of federal and state legislation/regulation;
•• Increasing regulation;
•• Complex/differentiated payment schemes;
•• Nursing homes have relative autonomy;
•• Physicians do not have monopoly on medical care;
•• Open or closed model, depending on institution.

British Columbia

Government regulations and policies. British Columbia has 292
publicly funded NHs (the small number of user-pay private
facilities are not included), with a median size of 80 (ranged
from 4 to 300). Virtually all beds are long term with the excep-
tion of a small number of hospice and respite beds. An esti-
mated 3.6% of the population 70 years and older reside in NHs
in BC. Nursing homes in BC are regulated through a combina-
tion of provincial legislation and credentialing through the
regional Health Authority (for facilities owned and operated by
health regions or hospitals) and the provincial physician profes-
sional regulatory body (the BC College of Physicians and Sur-
geons). Both legislation and regulation are at the provincial
level. Several pieces of provincial legislation guide physician
care in NH facilities. This legislation differs slightly depending
on ownership (public versus private for-profit/nonprofit).

Legislation pertaining to nongovernmental NHs (ie, non-
publicly owned) is governed by the Community Care and
Assisted Living Act residential care regulation. This Act spec-
ifies that NH licensing (called residential care facilities in BC)
must be done by Medical Health Officers (physicians with
special training and a degree in Public Health). Legislation
governing NHs owned and operated by a health authority
(34% of all publicly funded beds) is regulated through a differ-
ent piece of legislation—The Hospital Act. Physicians provid-
ing care in publicly owned and operated NHs (including
hospital-attached facilities) must also go through a credential-
ing process that involves providing proof of an up-to-date
license, medical malpractice insurance, and annual completion
of training modules.

According to the Residential Care Regulation under the
Community Care and Assisted Living Act, operators must ensure
that residents are only given medication that has been pre-
scribed or ordered by a NP or physician.33 All facilities there-
fore require residents admitted to a facility to have an identified
physician, who may be the same physician that a resident had
when living in the community (open model) but more com-
monly is a physician assigned by the facility (closed model),
drawn from a group of physicians whom the facility has identi-
fied as being willing to see new patients in addition to the ones
already being cared for.

There is no legislated standard for the frequency of physi-
cian visits or 24/7 availability for emergencies; however, conti-
nuity of care and provision of after-hours coverage in the event
of an emergency is an expectation of the College professional
regulatory body that licenses physicians. There are a number of
organized channels through which standards are encouraged.
Examples of these include Accreditation Canada—an accredi-
tation system for facilities and a new physician-run residential
care improvement initiative. The latter initiative, titled, “the
Residential Care Improvement Initiative,” is a provincially
funded incentive program that pays physicians a bonus for pro-
viding the following: (1) proactive scheduled visits to residents,
(2) attendance at a patient and family annual care conference,
(3) meaningful medical reviews, and (4) 24/7 availability and
attendance on-site when required. Participation in the program
is voluntary; however, since its introduction in 2015, uptake by
family physicians providing NH care has been growing.

Financing systems. Nursing homes’ care is paid for publicly by
provincial governments in Canada. Physicians are paid mainly
by the provincial remuneration agency (Medical Service Pay-
ment BC), the physician is a private contractor and bills the
agency for a visit and other types of services including a lower
level of remuneration for indirect care through phone calls to
family members and NH staff. The level of the physician’s pay-
ment is therefore a function of the number of residents a physi-
cian provides care for and the frequency of the visits and other
services provided to any given resident. Generally, it is rare for

6 Health Services Insights

a physician to only work in NHs. Most would do this for 1 or
2 days per week and then do other work the rest of the time.

Medical practice patterns and service models. Most NHs are pro-
vided with public funds to hire a part-time Medical Coordina-
tor (usually this is a leadership role for 1-2 half days per week)
and is usually (but not always) a physician who also provides
care to a number of residents in the NH. The agreements with
and appointment of the Medical Coordinator is through the
health authority Medical Director of Residential Care and not
with the NH itself.

Responsibility and accountability to the individual resident/
family are covered in the Physicians and Surgeons Regulations
regarding doctor/patient care. Each NH then has its own way
of formalizing the relationship it has with physicians. In some
cases, the NH will ask the physician to sign a “contract” agree-
ing to certain standards. In most of the situations, physicians
are private contractors, paid on a fee-for-service basis for their
services by the province and providing care to residents in a
given NH based on informal or more formal agreements
depending on the NH.

All community-based family physicians whose patients are
to be admitted to an NH are asked to complete a 1-page form.
This includes a brief summary of the patient’s medical issues,
functional status, advance care directives, and whether or not
the physician is willing to continue providing care to the
resident.

The frequency of visits in 2013 ranged from 5.3 to 8.7 per
resident per year across the province’s 5 health regions with a
provincial average of 7.2 visits per year.

Summary
•• Provincial governance;
•• Some variation in regulation connected to ownership;
•• Most physicians also work elsewhere;
•• Physicians are considered private contractors;
•• Medical Coordinator;
•• Open model or a combination of open and closed.

Germany

Government regulations and policies. In 2015, there were
approximately 13 600 NHs in Germany, with an average size of
63.34 About 63.4% of all institutions offer only long-term care,
whereas 8% offer a combination of long-term and short-term
care; 18% offer short-term care exclusively, whereas 11% offer
a combination of short-term and/or long-term care in combi-
nation with other services, beds only available during night-
time, for instance. 89% of all NH residents are 70 years or older.

Most of the NHs in Germany are owned by nonprofit com-
panies (53%), whereas 42% of all NHs are private for-profit
and only 5% are publicly owned.34 Medical services in NHs are
regulated federally by the statutory long-term care insurance
(LTCI) law and the statutory health care insurance laws.35,36

Nursing care medical care services in Germany are regulated
by the National Associations of Statutory Health Insurance
Funds (Spitzenverband der gesetzlichen Krankenkassen) and
the Associations of Statutory Health Insurance Registered
Doctors (Kassenärztliche Vereinigung). These associations
guarantee that NHs work collaboratively with general practi-
tioners to ensure that high-quality medical care are provided to
the residents. If the medical service is not guaranteed in this
way, the NHs could also employ a general practitioner at the
facility (§ 119b).35

Overall, these contracts should coordinate and structure the
relationship between physicians and care staff to improve med-
ical provision, for example, through coordinating care visits
with physicians by specifying a contact person/physician.

After an LTCI reform, NHs have to prove (§ 114)36 how
they provide physician-based medical services, ie, how often
physicians visit, the level of cooperation with pharmacies, etc.
According to § 12 Abs. 2 SGX XI34, care insurance funds
should advise NHs about a cooperation contract between gen-
eral practitioners and the NHs.

Financing systems. Physicians’ services are paid for by the health
care insurance fund. Payment is measured based on reported
services using a fee-for-service model. The payment model has
limitations and a ceiling on total amount to be “billed” and only
certain types of medical services qualify for reimbursement.

The health care insurance fund is needs based, although an
increasing number of services, considered “not absolutely rele-
vant,” are not covered in it. Health care needs are mostly funded
by the health care insurance system, comprising a health care
system elsewhere described as a “social insurance model,” in
which social insurance contributions ensure universal coverage.4
Still, an increasing share of health care provision is paid for
privately. The NHs pays a lump sum that covers parts of the
nonmedical cost.

Medical practice patterns and service models. Medical services for
NH residents are considered the same as for individuals living
at home, and residents can choose their physician freely.

General practitioners in private practices provide most of
the medical services in NHs. The availability of general practi-
tioners and specialists is often limited in NHs. In 2010, practi-
tioners in private practice were responsible for 92% of the
medical provision in NHs. Only one-quarter of the facilities
had written contracts with general practitioners.37 There is an
unequal geographical distribution of physicians that results in
gaps in service provision, especially in rural regions.

In an average-sized NH, approximately 25 general practi-
tioners (in private practice) would provide medical care to its
residents. It is not always certain that every resident has a gen-
eral practitioner.38 Availability of physicians after working
hours depends on the individual physician, but is not organ-
ized. Most NHs have to call emergency medical services on a
regular basis.

Ågotnes et al 7

Summary
•• Nonprofit NHs;
•• Governed and financed through national health

insurance;
•• Fee for service with restrictions;
•• Autonomy of residents is emphasized;
•• General practitioners with private practice;
•• Open model.

Manitoba

Government regulations and policies. Medical care in NHs
(called personal care homes) in Manitoba is regulated by the
provincial ministry (Manitoba Health, Seniors, and Active
Living [MHSAL]). Manitoba has 122 licensed NHs compris-
ing 9586 beds. Admission to an NH in Manitoba (and also
across Canada) is generally “permanent” and residents are not
typically reintegrated into the community, except for a small
proportion of people (<1%) who receive intermittent NH care as respite for informal care providers.39 Although about 16% of all NHs (and beds) are designated as for-profit in this province, this varies tremendously across Manitoba from about 40% of all NH beds in larger urban centers to no for-profit NHs located in rural and remote regions.40 Nursing homes in Mani- toba also vary tremendously in size and structure; most urban NHs are large (220+ bed) stand-alone facilities, almost half of all rural NHs are juxtaposed to a hospital and 43% of rural NHs have fewer than 30 beds.40 Overall, almost 60% of all NH residents in Manitoba are 85+ years old, and women 85+ years old comprise 47% of all NH days.41

The Continuing Care Branch of MHSAL ensures compli-
ance with the provincial NH standards and oversees the annual
licensing of all registered NHs in Manitoba.42 Greater details
about these standards, including how they are applied and
interpreted, are provided elsewhere.2 As part of the provincial
NH standards, each NH in Manitoba is required to have a
Medical Director who must be a licensed and practicing physi-
cian. Medical Directors are responsible for coordinating the
physician care in each NH; a physician must also be available to
examine each resident as often as the resident’s condition
requires, and all staff and residents must have access to a physi-
cian 24 hours per day and 7 days per week to provide emer-
gency care and consultation as required.43 Additional legislation
exists between MHSAL and Doctors Manitoba (the voluntary
provincial physician membership body) outlining NH physi-
cian responsibilities to provide telephone or personal coverage
to NH residents during after-hours (from 5 pm to 8 am).44

Financing systems. Most physicians in Manitoba, including
those providing care in NHs, are remunerated using the fee-
for-service method (ie, where the physician bills the province
directly for each care episode). Although these fees are highly
standardized by the type of care provided, physicians are

permitted to charge a larger fee when caring for patients who
have complex chronic and multimorbidity needs. As most NH
residents have complex and chronic needs, physicians in Mani-
toba are generally instructed to bill each routine visit (eg, to
examine, assess, or evaluate the resident’s condition and give
advice as necessary to the resident and/or the nursing staff con-
cerning care management) using this chronic care fee.45 In
addition, while most community-based physicians are required
to cover their clinical overhead costs from these fees, NHs do
not charge physicians any overhead costs. In addition to being
eligible to submit fee-for-service claims, after-hours on-call
physicians receive an additional form of reimbursement. To
help provide this additional payment, the province of Mani-
toba provides each health region with an annual stipend of US
$119 per licensed NH bed or US $11 922 per facility (which-
ever amount is greater). This amount is divided quarterly across
on-call physicians according to the volume of after-hour care
they provide.44

Medical practice patterns and service models. Almost all NH
physicians in Manitoba also practice independently in the
community and provide NH care on a part-time basis. Most
NH physicians in Manitoba are general practitioners (also
called primary care physicians). Although not required, a small
percentage of these providers have a Care of the Elderly certifi-
cation offered by the College of Family Physicians of Canada,
the accreditation body for family physicians in Canada.46 Only
a small number of NPs provide NH care. Although these are
salaried positions, the NP contract with MHSAL does not
include “after-hours” care, meaning that each NP must work
with a physician who is willing to provide this type of care.
There are no other types of physician-equivalent NH providers
in Manitoba. Although this province does have a small number
of geriatricians, most work in day hospitals and/or as a resource
(eg, via the Geriatric Program Assessment Team) to acute care
hospitals and to NH physicians who request help with complex
cases.

Physician care in Manitoba NHs is usually confined to
chronic disease management and/or to acute care matters when
residents experience exacerbations of their chronic diseases.47
In addition, most physicians usually participate in weekly
rounds with nursing teams and, in consultations with a nurse
and pharmacist, conduct a quarterly medication review for each
resident and deal with medication changes as required.
Although physicians usually do not participate in additional
team (eg, end-of-shift) meetings, they are required to docu-
ment each resident consultation as part of a common (ie, shared
by all providers) and standard charting strategy. As a rule, phy-
sicians also do not participate in resident/family care confer-
ences. Family members can, however, arrange to meet with
physicians, usually when physicians are on-site conducting
resident rounds. Finally, while legislation in Manitoba does not
stipulate any minimal amount of physician care required per

8 Health Services Insights

resident, evidence shows that 81% of NH residents in Manitoba
are visited by physicians at least 10 times annually.48

Summary
•• Provincial governance;
•• Considerable internal variation, for instance, regarding

NH size;
•• “After-hours” medical care covered by regulation;
•• Mostly part-time NH physicians;
•• Medical Director;
•• Open model.

Comparative analysis
Variations in government regulations and public
policies

Government regulations and policies pertaining to the func-
tion and role of medical care at NH vary considerably across
the included jurisdictions (Table 1). The government regula-
tions are in place at different levels of governance, local/munic-
ipal, regional/state/province, or national/federal, more often
than not, in combination. In Norway, policies are established at
the municipal level, whereas in Germany, policies are estab-
lished at the district and federal level. The BC and Manitoba
policies are at the provincial level, whereas the United States
establishes its policies primarily at the federal level. Who con-
trols the procurement and practices of medical care and what
governance implies therefore varies across jurisdictions.

Perhaps more importantly in this context, the regulations
specifically targeted at medical services in NHs have different
overall foci; they are, in short, differently formed especially

regarding level of detail (Table 1). Some, Norway, for instance,
can be described as framework acts, whereas others, the United
States in particular, are far more detailed. The United States
(and to a lesser extent Manitoba and BC) has the most detailed
legislation requiring that all residents should have an attending
physician. In the United States, the attending physician is, fur-
thermore, required to formally admit residents to the institu-
tion, provide continuous care, and document the medical health
development of the resident. If physicians are not available,
NH institutions are obliged to provide a substitute. In Norway,
meanwhile, these different responsibilities are framed within a
rather vague definition of having a physician connected to an
institution. Furthermore, some regulations in the United States
may vary by payment program, but all NHs must meet mini-
mum state laws and regulations. This variation in the level of
detail in regulation can, as such, lead to internal variation as
well as cross-jurisdictional variation. Finally, how regulations
are audited, or, in other words, the accountability for securing
adequate medical services, varies greatly.

Variations in f inancing systems

Norway, Manitoba, and BC have government payment for
medical services in NHs, whereas Germany has a social insur-
ance system that uses multiple insurance payers (which is salary
based and covers almost the entire population). The United
States has a multiple payer system, primarily public but also
some paid by private health insurance companies.

In Norway, physicians receive a fixed salary to provide medi-
cal services, whether directly from the municipalities or from
the NH. In Germany, social insurance, especially the health

Table 1. Government regulations and public policies for medical services in NHs.

LEvEL AND TypE LEvEL Of DETAIL NHS COvERED

Norway federal authority allocates
responsibility and oversight to
local municipalities

Unspecified/framework act/interpretive All NHs

Germany federal authority allocates
responsibilities to district
jurisdictions

Unspecified/interpretative All NHs with public funding
(provision contracts

)

US federal regulations and state
licensing regulations

Specified (for instance, type and frequency
of visits and documentation)/prescriptive.
Requirements have increased over tim

All NHs who receive federal
funds (96%). State regulations
cover all other NHs

Manitoba provincial provincial standards ensure that each
resident’s medical care is supervised by a
physician, that residents are seen by a
physician as often as their condition
requires, and that both professional NH staff
and residents have access to a physician for
advice and input 24 h a day

All licensed NHs

British
Columbia

provincial General standard that a resident needs to
be attached to an MD to be admitted to an
NH. Some variation in credentialing of MDs
who work in private (contracted nonprofit
and for-profit vs public facilities)

All licensed NHs

Abbreviations: MDs, Medical Directors; NHs, nursing homes.

Ågotnes et al 9

care insurance fund, pays a clearly regulated and specified fee
for service to physicians. Manitoba and BC have fee-for-ser-
vice payment based on fixed fees agreed on by the province and
the respective professional voluntary physician associations
(VPAs). The United States pays physicians primarily on a fee-
for-service basis with the fees set separately by each payer. State
Medicaid program fees vary widely. In the United States, the
fee rates also vary by provider type where physicians are paid
higher fees than alternative care providers. Only a few NHs pay
salaries to medical care providers.

In summary, each jurisdiction has its own unique regula-
tions and financing system, representing a unique way in which
medical services at NHs are facilitated and shaped. But how is
it shaped? What consequences can the variations in regulation
and policies entail for medical/physician services in NHs?

Variations in medical care practices and service
models

The differences in form and level of detail of legislation and
regulations, to whom they are addressed, and the financing sys-
tems, all appear to have significant consequences for the role of
medical care providers (most often physicians) in NHs (see
Table 2). How physicians and other medical care providers are
“connected to” an NH, as a more or less autonomous agent, var-
ies. Elsewhere, this has been described as the extent to which
NHs can control physician resources32 and appear to vary con-
siderably among jurisdictions.

Physicians have, for instance, different forms of relation-
ships with NHs across different jurisdictions: a salaried posi-
tion at, and therefore answerable to, an NH institution, a
governing body allocating physicians’ services to institutions, or
with individual residents. Physicians can, in other words, be a
part of the operation of an institution or independent of it, the
latter often as general practitioners “following” a patient from
one setting (the home) to the next (the institution).

In cases where a physician has an individual and autono-
mous responsibility for a resident/patient, as in the case of gen-
eral practitioners “following” a patient when moving to an NH
institution, physicians can be paid for the specific services they
perform, a visitation, for instance—an amount which can or
cannot be itself regulated—paid by an outside agent (a provin-
cial or federal institution, for instance). Such an arrangement
stands in opposition to being paid an hourly rate, or an amount
relative to a portion of a full-time equivalent, paid by or through
the NH institution. Although the former arrangement may
have advantages in terms of physicians being able to follow
patients from “cradle to grave,” there is a trade-off whereby
such an arrangement tends to discourage physicians from
becoming part of the NH provider team as evidenced by previ-
ous work looking at “open models.”

Related and perhaps consequential to the relationship that
physicians have with NHs, “size of position” (full-time equiva-
lents) for physician engagement with NHs can and do vary

considerably; from full-time to smaller, part-time positions,
often in combination with primary employment or independ-
ent practice elsewhere, to employment relationships only meas-
ured (and reimbursed) by the hour.

There also appears to be variations among jurisdictions in
terms of accountability (see also Doctorsmanitoba45). The
overall “schemes” of accountability vary considerably among
jurisdictions, as does the role of the physician within these
schemes—some are directly involved, some are indirectly
involved, and some are involved only through a “Medical
Director.”

In summary, regulations and guidelines for physician medi-
cal care in NHs vary within and among jurisdictions and influ-
ences (1) physician accessibility and (2) how physicians engage
with NHs in different ways in the relevant jurisdiction. Given
the significance of physician medical care in NHs, such a vari-
ation can be interpreted as disquieting.

Discussion
This study has shown that medical care service in NHs varies
widely across jurisdictions in terms of government regulations
and policies. These variations are far greater than regulations
and policies regarding nursing care49 and, consequently, can
lead to wider variations in practice patterns for medical/physi-
cian care compared with nursing care.

Although it is problematic to generalize based on the limi-
tations of our data, some general tendencies can be outlined.
The level (both number of and how specific they are) of regula-
tions seems to be connected to payment schemes for the medi-
cal care providers: jurisdictions with more regulation tend to
employ a fee-for-service scheme, whereas jurisdictions with
fewer regulations tend to have more salaried positions.
Furthermore, jurisdictions with more regulation and fee for
service tend to have open staffing models, whereas jurisdictions
with less regulation and salaried positions tend to have closed
staffing models. As such, 2 general models (to be understood as
analytical models, rather than models completely overlapping
with one or more of the included jurisdiction) can be outlined:
(1) more regulations—fee for service—open staffing models
and (2) less regulation—salaried positions—closed staffing
models. Of interest, and in need of further research, our evi-
dence seems to suggest that these models can produce different
forms of medical care/patient interaction. Model 1 seems to
lead to less available medical care provision and to medical care
provision being less integrated into the overall care services
provided at NHs. Given the aim and scope of this article, we do
not have data to draw conclusions about these tendencies but
would rather outline some areas in need of further research
regarding (1) ownership and (2) continuity of care.

First, a considerable difference is found among jurisdictions
regarding specificity and scope of regulations, in which the
United States and Norway can be described as opposing outli-
ers. We have seen that the number and level of detail in regula-
tions have increased in the United States, whereas similar

10 Health Services Insights

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Ågotnes et al 11

developments have not occurred in Norway. Other included
jurisdictions seem to have opted for a “middle-ground” between
these 2 extremes. Another significant difference between the
United States and Norway, not thoroughly discussed in this
article, is provider ownership: most of the NHs in the United
States are private (most of these again are private for-profit),
whereas most of the NHs in Norway are public. Interestingly,
the other included jurisdictions have a more even, although
internally different, distribution of ownership patterns. The
difference among jurisdictions regarding (1) specificity and
scope of regulations and (2) ownership patterns seems, in other
words, to be similar. As such, the differences outlined in the 2
suggested models can be related to patterns of ownership. The
role and significance of ownership are, at any rate, significant,
and should be pursued by researchers specifically regarding
implications for regulating long-term care services and other
health care services.49

Second, a considerable difference found in this article is
how, as a consequence of the discussed regulations and poli-
cies, medical care providers appear to be differently “associ-
ated” with other care professionals. The extremes can be
described as, on one hand, an autonomous agent visiting a
patient with no connection to the care institution, and, on the
other hand, a medical care provider employed by the institu-
tion as an NH “house physician.” What, again, do these differ-
ences imply for the quality of care for NH residents? An
obvious implication is that the latter “arrangement” will lead
to continuity of medical care as physicians and other medical
care providers will have larger positions (or full-time equiva-
lents) directly connected to an NH and therefore, one would
assume, spend more time there. This can, again, contribute to
several factors associated with increased quality of medical
care in general, such as having fewer physicians in total at an
institution,6,50,51 having more “timely attendance” in the event
of a medical emergency,50,51 and generally an increased “com-
mitment” to an institution.3,14 As such, we argue that the ser-
vice models discussed can significantly influence continuity of
medical care in NHs. This is significant not only for the qual-
ity of care between physicians and residents but also for the
level of familiarity between physicians and (other) staff at
NHs and between physicians and next of kin.9,13

In summary, available research literature indicates that avail-
ability of physicians influences quality of NH care,6,9-12,50,51 in
addition to having impact on collaboration and interaction
between physicians and other agents,3,9,13,14 again potentially
influencing quality of care. Still, research addressing how medi-
cal care provision, in its various forms, related to quality of care
for NH residents, resembles a map with many gray areas. Because
of the scope of this research article, including analyses of several
jurisdictions and a wide array of regulations and guidelines, we
do not have sufficient data to draw conclusions about the impli-
cations for quality of medical care within the respective jurisdic-
tions. Still we have found considerable differences and important
implications for medical care provider engagement at NHs in

general, implications that resonate with the available research
literature. Our study also points to some areas in need of further
research. We recognize the need for routinely collected sets of
data in understanding models of medical care and evaluating
their effects on quality of care. Furthermore, patterns of owner-
ship in the NH sector and the relationship to regulation of med-
ical care and models of medical care appear as equally significant
and understudied. Finally, how regulation/legislation affects con-
tinuity of medical care has been a major focus in this article and
should be pursued further by researchers, addressing effects on
quality of care for NH residents in a more detailed manner than
achieved through this article.

Conclusions
In conclusion, the observed forms of regulation and policies
do seem to affect the role and function of physicians in NHs
in the included jurisdictions, especially related to whether or
not a medical care provider operates as a more or less autono-
mous caregiver toward a patient (who happens to reside in an
NH), or whether the physician is an ingrained part of the
medical services provided at an NH. However, because of con-
siderable internal variation, as seen, drawing conclusions about
the respective merits of the different systems is challenging:
promising and less promising aspects seem present in most, if
not all, jurisdictions. In contrast to regulations and policies
guiding service provision for registered nurses and other nurs-
ing groups, physician medical care at NHs is largely unregu-
lated, and where regulations exist, they are vastly different.

Acknowledgements
The authors would like to thank our team and colleagues on
the “Re-Imagining Long-Term Residential Care”-project, for
collaboration and support, primary investigator Pat Armstrong
and project coordinator Wendy Winters, in particular. They are
also grateful to Albert Banerjee, Giles Pinette, Annegret
Wehmeyer, Frode Fadnes Jacobsen, and Robert James for valu-
able information and advice on different stages of this paper.

Author Contributions
All authors contributed to the design of the research, to the
data collection, to the analysis of the results and to the writing
of the manuscript.

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39. Doupe MB, Day S, McGregor MJ, et al. Pressure ulcers among newly admitted
nursing home residents: measuring the impact of transferring from hospital. Med
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40. Doupe M, Brownell M, Kozyrskyj A, et al. Using Administrative Data to Develop
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49. Harrington C, Choiniere J, Goldman M, et al. Nursing home staffing standards
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50. McGregor M, Pare D, Wong A, et al. Correlates of a “do not hospitalize” desig-
nation: in a sample of frail nursing home residents in Vancouver. Canadian Fam
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https://helsenorge.no/Kvalitetsindikatorer/kvalitetsindikator-pleie-og-omsorg/legetimer-for-beboer-i-sykehjem#Se-resultater

https://aanp.org/legislation-regulation/state-legislation/state-practice-environment

http://www.bclaws.ca/civix/document/id/loo91/loo91/96_2009

https://www.destatis.de/DE/Publikationen/Thematisch/Gesundheit/Pflege/PflegeDeutschlandergebnisse5224001159004 ?__blob=publicationFile

http://www.gesetze-im-internet.de/sgb_11/BJNR101500994.html#BJNR101500994BJNG000100307

http://mchp-appserv.cpe.umanitoba.ca/reference/LOC_Report_WEB

http://www.oag.mb.ca/wp-content/uploads/2011/06/audits_of-_govt_ops_nov_2009

https://web2.gov.mb.ca/laws/regs/current/_pdf-regs.php?reg=30/2005

https://doctorsmanitoba.ca/compensation-advocacy/billing/on-call/personal-care-home-after-hours-on-call-coverage/

https://doctorsmanitoba.ca/compensation-advocacy/billing/visits/personal-care-home-visits/

https://www.cfpc.ca/uploadedFiles/Education/COE_KF_Final_ENG

https://www.gov.mb.ca/health/documents/physmanual

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individual use.

ARTICLE IN PRESS

Geriatric Nursing 000 (2019) 1�7

Contents lists available at ScienceDirect

Geriatric Nursing

journal homepage: www.gnjournal.com

Nursing home work environment, care quality, registered nurse burnout
and job dissatisfaction

Elizabeth M. White, PhD, APRN*, Linda H. Aiken, PhD, RN, Douglas M. Sloane, PhD,
Matthew D. McHugh, PhD, APRN
Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA

A R T I C L E I N F O

Article history:
Received 12 June 2019
Received in revised form 15 August 2019
Accepted 19 August 2019
Available online xxx

* Corresponding author. Present Address: Center for
Research, Brown University School of Public Health, Box
Providence, RI 02912, USA.

E-mail address: elizabeth_white@brown.edu (E.M. W

https://doi.org/10.1016/j.gerinurse.2019.08.007
0197-4572/$ � see front matter © 2019 Elsevier Inc. All r

A B S T R A C T

The objective of this cross-sectional study was to examine the relationships between work environment, care
quality, registered nurse (RN) burnout, and job dissatisfaction in nursing homes. We linked 2015 RN4CAST-
US nurse survey data with LTCfocus and Nursing Home Compare. The sample included 245 Medicare and
Medicaid-certified nursing homes in four states, and 674 of their RN employees. Nursing homes with good
vs. poor work environments, had 1.8% fewer residents with pressure ulcers (p = .02) and 16 fewer hospital-
izations per 100 residents per year (p = .05). They also had lower antipsychotic use, but the difference was
not statistically significant. RNs were one-tenth as likely to report job dissatisfaction (p < .001) and one- eighth as likely to exhibit burnout (p < .001) when employed in good vs. poor work environments. These results suggest that the work environment is an important area to target for interventions to improve care quality and nurse retention in nursing homes.

ights reserved.

Keywords:

Nursing home
Registered nurses
Work environment
Burnout
Quality

Gerontology and Healthcare
G-S121(6), 121 S. Main Street,

hite).

ights reserved.

Introduction

Care quality varies widely across nursing homes.1,2 A 2014 report
from the Department of Health and Human Services Office of Inspector
General found that from 2008�2012, 22% of Medicare beneficiaries
receiving post-acute care in nursing homes experienced adverse events,
resulting in an estimated $2.8 billion annual excess spending on hospital-
izations.1 Registered nurses (RNs) provide important clinical leadership
and oversight in nursing homes to prevent such events from occurring
and ensure that residents receive appropriate care. In their roles as direc-
tors of nursing, supervisors, and charge nurses, RNs are responsible for
supervising other nursing personnel, coordinating care, conducting resi-
dent surveillance, interfacing with medical staff, and overseeing infection
control, wound care, and quality improvement programs.3,4

The ability of RNs to carry out these roles is largely influenced by
the work environment in which they practice.5 In good work envi-
ronments, RNs have adequate staff and resources, supportive manag-
ers, strong nursing foundations underlying care, productive
relationships with colleagues, input into organizational affairs, and
opportunities for advancement.6 Extensive research has shown that
hospitals with these features have better patient outcomes including
lower mortality, reduced length of stay, and higher satisfaction,7�10

as well as lower RN burnout and job dissatisfaction.11�13 Nursing
home RNs report higher rates of burnout and job dissatisfaction than
RNs employed in any other setting, including hospitals,14 and are
often unable to complete necessary care due to insufficient time and
resources.15 Burnout and job dissatisfaction are both key drivers of
staff turnover,13,16 a significant problem in nursing homes that has
been consistently linked to worse care quality.17�20

Nursing home work environment studies have been limited in
both scope and number. The relationship between RN staffing—one
component of the work environment—and quality has been studied
extensively, but results have been mixed.21�25 There have been
many critiques of the staffing literature, the largest being that most
studies used facility-reported staffing data which are prone to report-
ing bias.22�25 Another factor explaining why RN staffing has been
inconsistently associated with quality may be that staffing is so low
in some nursing homes that small increases do not lead to signifi-
cantly more RN oversight of residents. Additionally, staffing improve-
ments alone may have limited influence without other elements of
good work environments being in place.7 Supportive leadership, RN
involvement in organizational decisions, safety climate, and team-
work have been linked to better nursing home quality.26�31 Only one
study sampled RNs independently of their employers to reduce
response bias at the organizational level, and used a comprehensive
measure of work environment.32,33 No studies have examined the
impact of work environment on RN burnout in nursing homes.

The purpose of this study was to examine the empirical relation-
ship of work environment with care quality, RN burnout, and job

mailto:elizabeth_white@brown.edu

https://doi.org/10.1016/j.gerinurse.2019.08.007

http://www.ScienceDirect.com

http://www.gnjournal.com

ARTICLE IN PRESS

2 E.M. White et al. / Geriatric Nursing 00 (2019) 1�7

dissatisfaction in nursing homes. We hypothesized that nursing
homes with better work environments would have lower rates of
pressure ulcers, antipsychotic medication use, and hospitalizations,
and fewer RNs with job dissatisfaction and burnout. This study is the
first to use multi-state RN survey data with the Practice Environment
Scale of the Nursing Work Index (PES-NWI),6 a comprehensive
National Quality Forum-endorsed measure, to examine the relation-
ship of work environment with care quality and nurse outcomes in
nursing homes.6,12,34,35

Methods

Design and data sources

This study was a cross-sectional secondary data analysis of three
linked datasets from 2015: (1) RN4CAST-US nurse survey data, (2)
LTCfocus, and (3) Nursing Home Compare. We used RN4CAST-US for
measures of the work environment, RN characteristics, and RN out-
comes; LTCfocus for provider characteristics and the hospitalization
measure; and Nursing Home Compare for the pressure ulcer and
antipsychotic measures.

RN4CAST-US
The RN survey was conducted to investigate relationships

between nursing resources, care quality, and patient and nurse out-
comes, across a large number of healthcare organizations. From Janu-
ary to December 2015, Aiken and colleagues surveyed a 30% random
sample of licensed RNs in four states (CA, NJ, FL, and PA) � a total of
231,000 RNs.39 Surveys were mailed and emailed to RNs using con-
tact information on file with state boards of nursing. RNs were asked
to provide their employer’s name and address in order to link their
responses to their employer, and were sent multiple reminders and
offered small incentives to participate. This sampling approach per-
mits study of many organizations, while eliminating potential bias
that comes with surveying RNs via their employers.

The final response rate was 26%, reflecting a growing trend in sur-
vey non-response36 and lack of information prior to sampling on
whether and where RNs were currently employed. To evaluate for
response bias, Aiken et al. completed a non-responder survey on a
random sub-sample of 1400 non-responders, yielding an 87%
response rate.37 These individuals received a shorter survey, more
intensive attempts to contact, and a cash incentive. This double-sam-
ple approach is considered to be the gold standard for assessing non-
response bias.38 There were no significant differences in the meas-
ures of interest between long-term care RN responders and non-res-
ponders. Survey methods are described in detail elsewhere.37,39

LTCfocus
This publicly-available dataset from Brown University has pro-

vider characteristics of all Medicare and Medicaid-certified nursing
homes in the US. LTCfocus merges data from the Minimum Data Set
(MDS), the Certification and Survey Provider Enhanced Reports (CAS-
PER) system, Medicare claims, Nursing Home Compare, and other
sources to generate information at the facility, county, and state lev-
els.40 The 2015 facility-level LTCfocus file was downloaded from
http://ltcfocus.org.

Nursing Home Compare
Nursing Home Compare data are extracted from MDS, CASPER,

and Medicare claims, and are updated on a quarterly basis. To ensure
temporal congruency, we used second quarter data to match with
LTCfocus, which calculates its prevalence estimates based on data
from the first Thursday of each April. We merged the provider infor-
mation file with the MDS second quarter quality measure files down-
loaded from the 2015 archived files at https://data.medicare.gov.

Study population

We identified RNs from the parent survey who worked in nursing
homes by cross-matching respondents’ employers’ names and
addresses with a list of all Medicare and Medicaid-certified nursing
homes. This created a sampling frame of 1540 RNs (2.6% of respond-
ents) who were employed in 1008 nursing homes in CA, FL, NJ, and
PA. We excluded RNs who did not complete the work environment
measure in the survey (n = 311), but found no statistically significant
differences in other variables of interest between RNs with and with-
out missing data on that measure. We further excluded RNs who
were the sole employee of a nursing home represented in the survey
(n = 555), since aggregated reports from multiple employees per
nursing home produced a more reliable facility-level measure of the
work environment.12 This yielded a final sample of 674 RNs
employed in 245 nursing homes. The nursing home and RN sample
sizes also varied somewhat by outcome because cases were deleted
when outcome data were missing.

Variables and measures

Work environment
The 31-item Practice Environment Scale of the Nursing Work

Index (PES-NWI) is a comprehensive National Quality Forum-
endorsed measure6,12,34,35 that has been previously validated in nurs-
ing homes.33 It is derived from questions on the RN survey, and has
five subscales: (1) nurse participation in organizational affairs; (2)
nursing foundations for quality of care; (3) nurse manager ability,
leadership, and support of nurses; (4) staffing and resource ade-
quacy; and (5) collegial nurse-physician relationships. RNs report the
degree to which various elements are present in their work setting
using a four point Likert scale, where higher scores indicate more
favorable responses. We found each subscale mean, averaged them
across all RNs in each facility to create facility-level subscale scores,
and then averaged the subscale scores in each facility to create a facil-
ity-level composite scale score.6,41 We grouped nursing homes with
composite scores and subscale scores to contrast those in the lowest
25th percentile (which we labeled “poor”), middle 50th percentile
(“average”), and upper 25th percentile (“good”). Across the 245 nurs-
ing homes, the facility-level score was determined from a range of
two to eight RNs, with a mean of 2.5 RNs per facility. Compared to
CASPER staffing data, this represented a mean of 20% of total
employed RNs per facility.

Nursing home quality measures
We examined three measures of quality, the first two from Nurs-

ing Home Compare, and the third from LTCfocus: (1) percent of high
risk long-stay residents with Stage II-IV pressure ulcers, (2) percent
of long-stay residents who received antipsychotic medication, and
(3) hospitalizations per resident year. The pressure ulcer and antipsy-
chotic measures are both derived from MDS data and reflect the facil-
ity-level unadjusted rate, after excluding cases where the outcome
was either unavoidable or out of the facility’s control.42 The LTCfocus
hospitalization measure is derived from MDS and claims data, and
represents the total number of hospitalizations for short and long-
stay residents from the facility relative to all nursing home days for
all residents in the facility that calendar year. These measures were
chosen because they are widely accepted measures of nursing home
quality that have been previously linked to organizational elements
of nursing such as staffing and turnover.

Nurse outcomes
Nurse outcomes came from the RN survey. Job dissatisfaction was

measured on a four point Likert scale response to the question “How
satisfied are you with your primary job?”, and was dichotomized as

http://ltcfocus.org

https://data.medicare.gov

Table 1
Nursing home and registered nurse characteristics across all nursing homes, and across nursing homes with poor, average, and good work environments.

Nursing home work environment

Nursing home characteristics Total sample (n = 245) Poor (n = 62) Average (n = 122) Good (n = 61)

Ownership, n (%)
For-profit 124 (50.6%) 35 (56.5%) 63 (51.6%) 26 (42.6%)
Nonprofit or government 121 (49.4%) 27 (43.5%) 59 (48.4%) 35 (57.4%)

Chain-owned, n (%) 132 (53.9%) 37 (59.7%) 65 (53.3%) 30 (49.2%)
Payer mix, mean (SD)
% primary payer Medicaid 56.2 (25.1) 61.2 (23.1) 55.8 (25.0) 52.1 (26.8)
% primary payer Medicare 13.7 (12.1) 11.6 (9.7) 15.2 (12.5) 12.7 (13.1)

Staffinga, mean (SD)
RN hours per resident day 0.64 (0.37) 0.57 (0.21) 0.65 (0.34) 0.70 (0.52)
LPN hours per resident day 0.82 (0.40) 0.77 (0.24) 0.84 (0.48) 0.83 (0.37)
CNA hours per resident day 2.46 (0.53) 2.36 (0.51) 2.46 (0.53) 2.57 (0.56)
% total licensed nurse
(RN +LPN) hours per resident
day provided by RNs

43.9 (17.4) 42.5 (14.6) 44.1 (18.7) 44.9 (17.6)

Nursing home work environment

Registered nurse characteristics Total sample (n = 674) Poor (n = 168) Average (n = 356) Good (n = 150)

Age in years, mean (SD) 51.7 (12.1) 52.6 (11.2) 51.0 (12.2) 52.4 (13.0)
Years of experience, mean (SD) 20.6 (14.1) 21.5 (13.2) 19.8 (14.2) 21.5 (14.6)
Sex, female, n (%) 631 (93.6%) 156 (92.9%) 331 (93.0%) 144 (96.0%)
Race, non-white, n (%) 121 (18.0%) 29 (17.3%) 69 (19.4%) 23 (15.3%)
Native language English, n (%) 584 (86.6%) 149 (88.7%) 310 (87.1%) 125 (83.3%)
Position, n (%)
Direct care staff RN 304 (45.1%) 87 (51.8%) 164 (46.1%) 53 (35.3%)*
Nurse manager/administrator 221 (32.8%) 47 (28.0%) 116 (32.6%) 58 (38.7%)*
Other nursing role 149 (22.1%) 34 (20.2%) 76 (21.3%) 39 (26.0%)*

* Differences in characteristics across nursing homes with poor, average, and good work environments significant at p < .05, as tested using Pearson chi-square statistics for cate- gorical variables, and F-tests from ANOVA for continuous variables.

a RN = registered nurse; LPN = licensed practical nurse; CNA = certified nursing assistant.

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“very or somewhat dissatisfied” vs. “very or somewhat satisfied”.
Burnout was measured with the Emotional Exhaustion scale of the
Maslach-Burnout Inventory, a validated measure of occupational
burnout.43 As specified in the instrument’s scoring guidelines, RNs
were classified as having burnout if their score was 27 or higher, the
published average for healthcare workers.44

Analysis
We first generated descriptive statistics to examine nursing home

and RN characteristics, and determine differences in quality meas-
ures and RN outcomes across facilities, using F-tests, t-tests, and chi-
square tests as appropriate. We then estimated the effects of the
overall (composite) work environment, and its different components,
on the nursing home quality measures and the RN outcomes, control-
ling for potentially confounding factors. We used nursing home-level
data and linear regression models for the quality measures (i.e., the
pressure ulcer, antipsychotic, and hospitalization outcomes), and
controlled for nursing home factors including ownership type, chain
affiliation, Medicare census, Medicaid census, RN skill mix, certified
nursing assistant staffing, presence of an Alzheimer’s unit, average
resource utilization group (RUG) score (a measure of case mix), and
an indicator of whether the facility accepts ventilator-dependent
patients. For the RN outcomes (job dissatisfaction and burnout), we
used multilevel data and robust logistic regression models to account
for clustering of RNs in nursing homes. In these models, we con-
trolled for both nursing home characteristics and RN characteristics
(age, sex, race, position, years of experience, native language).

To compensate for the problem of heteroscedasticity due to our
work environment measure being based on a small number of RNs
per nursing home, we used analytic weights to weight the aggregated
facility score in our linear regression models by the number of
respondents per facility, giving greater weight to nursing homes with
more respondents.45,46 We also controlled for the number of

respondents per nursing home in all models. Data were analyzed
using Stata version 15.1 (Stata Corp., College Station, TX). The Univer-
sity of Pennsylvania institutional review board approved this study.

Results

Table 1 shows nursing home and RN sample characteristics. Nursing
homes with poor work environments were more often for-profit, chain-
owned, had a higher Medicaid census, and lower staffing than nursing
homes with average or good environments, but none of these differen-
ces were statistically significant. RNs in nursing homes with good envi-
ronments were significantly more likely to be employed in managerial
and other roles, and less likely to be employed as direct care staff, than
RNs in nursing homes with average or poor environments. No other RN
characteristics differed across nursing home work environments.

Table 2 summarizes variation in quality measures and RN outcomes
across nursing homes with different characteristics. These unadjusted
differences reveal that nursing homes with poor environments had sig-
nificantly higher rates of pressure ulcers and antipsychotic use, and
more RNs who were dissatisfied and exhibited burnout. Other organi-
zational characteristics had less consistent effects across outcomes.

Table 3 shows results of bivariate and adjusted linear regression
models for the nursing home quality measures. The three work envi-
ronment categories are treated as a linear term for both the overall
PES-NWI and its subscales. As such, a one unit change represents the
difference between average vs. poor or good vs. average environments,
while a two unit change represents the difference between good vs.
poor environments. Controlling for other organizational characteristics,
nursing homes with average vs. poor work environments, and good vs.
average environments, had 0.9% fewer long-stay high risk residents
with pressure ulcers (p=.02), and 0.08 fewer hospitalizations per resi-
dent year (p=.05). This implies that nursing homes with good vs. poor
environments had 2 £ 0.9% = 1.8% fewer pressure ulcers and

Table 2
Differences in quality measures and registered nurse (RN) outcomes by nursing home organizational characteristics.

Quality measures RN outcomes

Percent of long-stay
high risk residents with

pressure ulcers
(n = 222)a

Percent of long-stay
residents who received
antipsychotics (n = 230)

Number of
hospitalizations per

resident year (n = 244)

Number of RNs
dissatisfied with their

job (n = 656)

Number of RNs with
burnout (n = 577)

Organizational
characteristics Mean SD Mean SD Mean SD n % n %

All nursing homes 5.1 (3.8) 15.5 (6.8) 1.1 (0.5) 161 (24.5) 196 (34.0)
Work environment

Poor 5.6 (3.6)* 17.5 (7.3)* 1.1 (0.5) 76 (46.6)* 77 (55.4)*
Average 5.2 (4.4) 14.9 (6.6) 1.1 (0.6) 73 (21.1) 100 (32.4)
Good 4.3 (2.7) 14.7 (6.5) 1.0 (0.6) 12 (8.2) 19 (14.7)

Ownership
For-profit 5.5 (4.5) 15.5 (6.8) 1.2 (0.6)* 88 (28.8)* 99 (36.8)
Nonprofit or government 4.6 (3.0) 15.5 (7.0) 0.9 (0.5) 73 (20.9) 97 (31.5)

Chain-owned
Yes 4.6 (3.5)* 14.8 (6.9) 1.2 (0.6)* 87 (26.1) 108 (35.6)
No 5.7 (4.2) 16.3 (6.7) 1.0 (0.5) 74 (23.0) 88 (32.2)

Medicaid census
Highb 5.1 (3.2) 16.7 (7.4)* 1.0 (0.4) 90 (25.5) 102 (32.8)
Low 5.1 (4.5) 14.0 (5.8) 1.1 (0.7) 71 (23.4) 94 (35.3)

Medicare census
Highb 5.0 (4.1) 14.5 (5.6) 1.4 (0.6) 44 (25.0) 66 (40.2)*
Low 5.1 (3.8) 15.9 (7.2) 0.9 (0.5) 117 (24.4) 130 (31.5)

Average Resource
Utilization Group score
Highb 4.9 (4.0) 15.4 (6.4) 1.2 (0.6)* 107 (26.6) 130 (36.3)
Low 5.4 (3.6) 15.7 (7.5) 0.9 (0.4) 54 (21.3) 66 (30.1)

RN hours per resident dayc

Highb 5.2 (4.3) 14.7 (7.1) 1.1 (0.6) 84 (23.3) 115 (35.0)
Low 4.9 (3.3) 16.4 (6.4) 1.0 (0.4) 77 (26.1) 81 (32.7)

LPN hours per resident dayc

Highb 5.1 (3.7) 16.1 (7.3) 1.1 (0.6) 65 (24.5) 75 (34.3)
Low 5.1 (3.9) 15.1 (6.5) 1.1 (0.5) 96 (24.6) 121 (33.8)

CNA hours per resident dayc

Highb 5.0 (4.0) 14.8 (6.1) 1.1 (0.6) 82 (23.4) 94 (30.8)
Low 5.2 (3.7) 16.3 (7.5) 1.1 (0.5) 79 (25.9) 102 (37.5)

% of total licensed nurse (RN+LPN)
hours per resident day
provided by RNs
Highb 5.4 (4.4) 14.7 (7.0)* 1.1 (0.6) 97 (23.5) 126 (33.6)
Low 4.7 (2.8) 16.7 (6.5) 1.0 (0.5) 64 (26.3) 70 (34.7)

* Differences significant at p < .05, as indicated by F-tests or t-tests. a Sample sizes vary across quality measures and nurse outcomes because of missing outcomes data. b “High” and “Low” represent values that are at/above and below the national mean, as determined from LTC Focus data. c RN = registered nurse; LPN = licensed practical nurse; CNA = certified nursing assistant.

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4 E.M. White et al. / Geriatric Nursing 00 (2019) 1�7

2 £ 0.08 = 0.16 fewer hospitalizations per resident year, or 16 fewer
hospitalizations per 100 residents per year. Since these differences rep-
resent about one-half of a standard deviation in the case of pressure
ulcers and one-third of standard deviation with respect to hospitaliza-
tions, the difference between nursing homes with good vs. poor work
environments would equate, all else being equal, to being in the 40th
vs. 60th percentile for pressure ulcers, and in the 43rd vs. 56th percen-
tile for hospitalizations. Nursing homes with good vs. poor work envi-
ronments had fewer residents on antipsychotics, but the difference
was not statistically significant in adjusted models.

Similar effects were found for the different subscales, though only
roughly half of them were statistically significant in the adjusted pres-
sure ulcer and hospitalization models. Strong nursing foundations,
nursing leadership, and collegial nurse-physician relationships were
significantly associated with reduced pressure ulcers. Staffing/resource
adequacy and collegial nurse-physician relationships were significantly
associated with reduced hospitalizations. None of the subscales were
significant in adjusted models for the antipsychotic outcome.

Table 4 summarizes results of bivariate and adjusted logistic regres-
sion models for the RN outcomes. Controlling for nursing home and RN
characteristics, the odds ratios in the table indicate that RNs in nursing
homes with good vs. average work environments, and in nursing

homes with average vs. poor environments, were significantly less
likely to report job dissatisfaction and to exhibit high burnout, by fac-
tors of 0.32 and 0.35, respectively. Since these coefficients are multipli-
cative, the squared odds ratios shown in the table indicate that RNs in
nursing homes with good vs. poor work environments, were one-tenth
as likely to be dissatisfied with their jobs, and one-eighth as likely to
exhibit burnout, as RNs employed in facilities with poor environments.
All subscales were significantly associated with both outcomes.

Discussion

Nursing homes with better RN work environments had fewer
pressure ulcers and hospitalizations. RNs employed in these facilities
were significantly less likely to exhibit job dissatisfaction and burn-
out than RNs employed in facilities with poor environments. Our sub-
scale analysis showed that multiple components of the work
environment were associated with outcomes we examined, not just
staffing and resource adequacy. This suggests that, in addition to hav-
ing adequate staffing and resources, other work environment ele-
ments are necessary to support RNs in providing high quality care in
nursing homes. And while this study specifically examined RNs, it is
likely that these same elements also help to support licensed

Table 3
Effects of the work environment composite scale and subscales on quality measures, adjusting for other nursing home characteristics.

Quality measures

Percent of long-stay residents
with pressure ulcers (n = 222)a

Percent of long-stay residents
on antipsychotics (n = 230)

Number of hospitalizations
per resident year (n = 244)

Work environment measures b 95% CI p b 95% CI p b 95% CI p

PES-NWI composite scale
Bivariate �0.88* (�1.61, �0.14) .02 �1.42* (�2.67, �0.18) .03 �0.05 (�0.15, 0.05) .32
Adjusted �0.90* (�1.64, �0.17) .02 �1.10 (�2.32, 0.12) .08 �0.08* (�0.15,�0.001) .05

PES-NWI subscales
Nurse participation in organizational affairs
Bivariate �0.59 (�1.34, 0.16) .12 �1.39* (�2.65, �0.13) .03 �0.01 (�0.11, �0.10) .92
Adjusted �0.57 (�1.32, 0.19) .14 �0.92 (�2.15, 0.32) .14 �0.03 (�0.11, 0.04) .39

Nursing foundations for quality of care
Bivariate �0.86* (�1.60, �0.13) .02 �1.34* (�2.58, �0.11) .03 �0.06 (�0.16, 0.03) .20
Adjusted �0.86* (�1.61, �0.12) .02 �1.01 (�2.23, 0.21) .11 �0.06 (�0.14, 0.02) .12

Nurse manager ability, leadership, and support
Bivariate �0.78* (�1.51,�0.05) .04 �1.22 (�2.45, 0.01) .05 �0.03 (�0.13, 0.63) .48
Adjusted �0.81* (�1.54,�0.08) .03 �0.96 (�2.16, 0.24) .12 �0.06 (�0.13, 0.02) .12

Staffing/resource adequacy
Bivariate �0.65 (�1.42, 0.11) .10 �1.37* (�2.65, �0.08) .04 �0.12* (�0.23, �0.02) .02
Adjusted �0.72 (�1.50, 0.07) .07 �1.14 (�2.44, 0.16) .09 �0.10* (�0.18,�0.02) .01

Collegial nurse-physician relationships
Bivariate �1.47* (�2.27, �0.66) <.001 �0.32 (�1.70, �1.07) .65 �0.14* (�0.24, �0.03) .01 Adjusted �1.46* (�2.26, �0.66) <.001 �0.28 (�1.63, 1.07) .69 �0.12* (�0.19, �0.04) .005

* Differences were significant at p < .05, as indicated by z-scores in bivariate and adjusted linear regression models. b coefficients represent the difference in outcomes between nursing homes with average vs. poor, and good vs. average work environments. Adjusted models control for nursing home ownership type, chain affiliation, Medicare census, Med- icaid census, and RN skill mix. Additional covariates vary by outcome, as follows: (1) for pressure ulcers, certified nursing assistant (CNA) staffing was also controlled; (2) for antipsy- chotics, CNA staffing and presence of Alzheimer's unit were controlled; and (3) for hospitalizations per resident year, average Resource Utilization Group (RUG) score, and an indicator for whether the facility accepts ventilator-dependent patients were controlled. All models, including bivariate models, weight the aggregated nursing home work environ- ment score by the number of respondents per facility using analytic weights, and control for the number of respondents per facility. The three categories of the composite Practice Environment Scale of the Nursing Work Index (PES-NWI), and the subscales that comprise it, are treated as a linear term; thus, a one unit change represents the difference between average and poor environments, and a two unit change represents the difference between good and poor environments. CI = confidence interval; p = the probability that the coeffi- cients are zero.

a Sample sizes vary across outcomes because of missing outcomes data.

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E.M. White et al. / Geriatric Nursing 00 (2019) 1�7 5

practical nurses (LPNs) and certified nursing assistants (CNAs), who
provide much of the direct patient care in this setting.

Nursing home leaders often function under tight budgetary con-
straints due to heavy dependence on Medicaid, yet there are still

Table 4
Effects of the work environment composite scale and subscales on nurse job dissatisfaction a

Dissatisfied with job (n =

Work environment measures OR OR2 95% C

PES-NWI composite scale
Bivariate 0.31* 0.10 (0.24, 0.4
Adjusted 0.32* 0.10 (0.24, 0.4

PES-NWI subscales
Nurse participation in organizational affairs
Bivariate 0.39* 0.15 (0.30, 0.5
Adjusted 0.39* 0.15 (0.29, 0.5

Nursing foundations for quality of care
Bivariate 0.37* 0.14 (0.29, 0.4
Adjusted 0.38* 0.15 (0.29, 0.5

Nurse manager ability, leadership, support
Bivariate 0.40* 0.16 (0.31, 0.5
Adjusted 0.41* 0.17 (0.32, 0.5

Staffing/resource adequacy
Bivariate 0.33* 0.11 (0.25, 0.4
Adjusted 0.34* 0.12 (0.25, 0.4

Collegial nurse-physician relationships
Bivariate 0.55* 0.30 (0.40, 0.7
Adjusted 0.56* 0.31 (0.41, 0.7

* Differences significant at p < .05. All estimates are from adjusted robust multivariate lo ment Scale of the Nursing Work Index (PES-NWI), and the subscales that comprise it, are tr reporting the two outcomes in nursing homes with good vs. average and average vs. poor odds of RNs reporting the two outcomes in nursing homes with good vs. poor environments RN respondents per nursing home; nursing home characteristics (ownership type, chain af sex, race, position, years of experience, native language). CI = confidence interval; p = the pro

a Registered nurse (RN) sample sizes for job dissatisfaction and burnout differ due to the n

many evidence-based interventions that can improve work environ-
ments through changes in organizational culture and practi-
ces.6,32,33,47 Strong nursing care foundations were significantly
associated with the pressure ulcer and nurse outcomes in our study.

nd burnout, after adjusting for other facility characteristics.

656)a Burnout (n = 577)

I p OR OR2 95% CI p

1) <.001 0.38* 0.14 (0.29, 0.48) <.001 2) <.001 0.35* 0.12 (0.27, 0.46) <.001

1) <.001 0.49* 0.24 (0.37, 0.63) <.001 1) <.001 0.47* 0.22 (0.36, 0.61) <.001

9) <.001 0.40* 0.16 (0.31, 0.51) <.001 1) <.001 0.38* 0.15 (0.29, 0.50) <.001

2) <.001 0.48* 0.23 (0.38, 0.61) <.001 3) <.001 0.47* 0.22 (0.36, 0.61) <.001

4) <.001 0.40* 0.16 (0.31, 0.52) <.001 7) <.001 0.38* 0.15 (0.29, 0.51) <.001

4) <.001 0.48* 0.23 (0.37, 0.62) <.001 7) <.001 0.48* 0.23 (0.36, 0.62) <.001

gistic regression models, in which the 3 categories of the composite Practice Environ-
eated as a linear term. Thus, odds ratios (OR) indicate the difference in the odds of RNs
work environments, and the odds ratios squared (OR2) represent the difference in the
. All models account for clustering within nursing homes, and control for the number of
filiation, Medicare census, Medicaid census, RN skill mix); and RN characteristics (age,
bability that the odds ratios are 1.0, which indicates no difference.
umber of RNs with missing data on the two outcomes.

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6 E.M. White et al. / Geriatric Nursing 00 (2019) 1�7

Multiple nursing care processes are integral to the prevention and
treatment of pressure ulcers such as risk assessment, skin surveil-
lance, mobility and positioning, nutrition interventions, and inconti-
nence management.48 Interventions to support nursing staff in this
regard include providing regular continuing education opportunities,
organizing formal preceptor programs to train and mentor new hires,
and maintaining active quality assurance programs that engage
nurses in identifying and addressing areas for improvement.6 Nurse
leadership was also associated with both the pressure ulcer and
nurse outcomes. To provide effective leadership, staff nurses must
have support from their supervisors, supervisors must have support
from their director(s) of nursing, and the director(s) of nursing must
have support from other senior level administrative staff. This means
offering mentorship and training for nurses to develop leadership
skills, recognizing employees when work is done well, and creating a
culture where mistakes are used as learning opportunities instead of
for criticism or punishment.6

Collegial nurse-physician relationships were associated with the
pressure ulcer, hospitalization, and nurse outcomes, supporting an
existing literature that has shown effective nurse-physician commu-
nication to be an important factor in maintaining resident safety and
preventing avoidable hospitalizations from the nursing home.49,50

Though the PES-NWI specifically measures communication between
nurses and physicians, these findings likely also apply to advanced
practice clinicians, who are playing an increasingly visible role as
medical providers in nursing homes. Interventions in this domain
include encouraging regular participation of all staff in interdisciplin-
ary gatherings such as morning rounds and careplan meetings, and
offering training on best communication practices between nurses
and medical staff. Finally, nurse participation in organizational affairs
was associated with both job dissatisfaction and burnout. Interven-
tions to improve nurse engagement include offering clinical ladders
and other career development opportunities, involving nurses on
quality improvement committees, leadership working with staff to
find solutions to problems, and having formal processes for respond-
ing to employee concerns.6

Some limitations of our study should be noted. First, the cross-
sectional design prevented examination of causal relationships
between the work environment and outcomes. Second, the facility-
level quality measures did not allow for resident-level adjustment
beyond what was already built into Nursing Home Compare. Third,
our nursing home PES-NWI measures are based on a small number of
RNs per facility, a trade-off of using a state-wide RN sample rather
than surveying RNs through their employers. The former approach
offers a clear advantage of reduced response bias at the employer
level, but also makes it harder to find nursing homes with multiple
respondents, particularly since nursing homes employ far fewer RNs
than hospitals. We used analytic weights in our linear regression
models and controlled for the number of RN respondents per facility
to compensate for heteroscedasticity. Finally, our sample of 245 nurs-
ing homes represents just over 8% of all nursing homes in our four
states, which may limit generalizability of our findings. Still, this was
the first study to use a multistate sample of RNs to study the impact
of work environment in nursing homes.

Conclusions

The work environment is an important area for interventions to
improve nursing staff retention and care quality in nursing homes.
Nursing home RNs exhibit high rates of job dissatisfaction and burn-
out which contribute to turnover, a significant problem in this set-
ting. An extensive body of evidence has already shown that better
nurse work environments are associated with improved patient
safety and reduced staff burnout and job dissatisfaction in hospitals.
This study is one of the first to show similar relationships in nursing

homes and has implications not just for RNs, but also for other nurs-
ing staff. Interventions to improve work environments reflect recom-
mendations in the Institute of Medicine’s 2004 report Keeping
Patients Safe: Transforming the Work Environment of Nurses,5 and hold
potential to bolster systems of care in nursing homes to improve
quality and safety.

Funding

This research was supported by the National Institute of Nursing
Research, T32 NR-007104 (Aiken, PI) and R01 NR-014855 (Aiken, PI).

Supplementary materials

Supplementary material associated with this article can be found
in the online version at doi:10.1016/j.gerinurse.2019.08.007.

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Nursing home work environment, care quality, registered nurse burnout and job dissatisfaction

Introduction
Methods
Design and data sources
RN4CAST-US
LTCfocus
Nursing Home Compare
Study population
Variables and measures
Work environment
Nursing home quality measures
Nurse outcomes
Analysis

Results
Discussion
Conclusions
Funding
Supplementary materials
References

ORIGINAL PAPER

‘‘They Treat you a Different Way:’’ Public Insurance,
Stigma, and the Challenge to Quality Health Care

Anna C. Martinez-Hume1 • Allison M. Baker2

•

Hannah S. Bell
1

• Isabel Montemayor
3

•

Kristan Elwell4 • Linda M. Hunt1

Published online: 26 December 2016

� Springer Science+Business Media New York 2016

Abstract Under the Affordable Care Act, Medicaid Expansion programs are
extending Medicaid eligibility and increasing access to care. However, stigma

associated with public insurance coverage may importantly affect the nature and

content of the health care beneficiaries receive. In this paper, we examine the health

care stigma experiences described by a group of low-income public insurance

beneficiaries. They perceive stigma as manifest in poor quality care and negative

interpersonal interactions in the health care setting. Using an intersectional

approach, we found that the stigma of public insurance was compounded with other

sources of stigma including socioeconomic status, race, gender, and illness status.

Experiences of stigma had important implications for how subjects evaluated the

quality of care, their decisions impacting continuity of care, and their reported

ability to access health care. We argue that stigma challenges the quality of care

provided under public insurance and is thus a public health issue that should be

addressed in Medicaid policy.

Keywords Stigma � Insurance � Poverty � Healthcare � Medicaid �
Intersectionality

& Linda M. Hunt
huntli@msu.edu

1
Department of Anthropology, Michigan State University, 355 Baker Hall, 655 Auditorium

Drive, East Lansing, MI 48824, USA

2
Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue,

Boston, MA 02115, USA

3
Department of Sociology and Anthropology, University of Texas at Arlington, 430 University

Hall, 601 S. Nedderman Drive, Arlington, TX 76019, USA

4
Center for Health Equity Research, Northern Arizona University, 1100 S. Beaver St., Flagstaff,

AZ 86011, USA

123

Cult Med Psychiatry (2017) 41:161–180

DOI 10.1007/s11013-016-9513-8

http://orcid.org/0000-0002-1214-8569

http://crossmark.crossref.org/dialog/?doi=10.1007/s11013-016-9513-8&domain=pdf

Introduction

A key feature of the Affordable Care Act is Medicaid Expansion, which extends

Medicaid eligibility to many low-income adults with the goal of improving health

equity through increased access to care. While addressing an urgent public health

need, issues within the social context of public insurance may diminish the success

of such programs in effectively addressing health disparities. One such concern is

stigma associated with public insurance coverage, including Medicaid and other

state-sponsored programs for the low-income, which may meaningfully affect the

nature and content of health care.

Stigma—the negative experience of stereotyping, labeling, exclusion and

discrimination due to some personal attribute—is commonly reported by individuals

using Medicaid and other state-sponsored health plans (Allen et al. 2014; Horton

et al. 2014; Stuber and Kronebusch 2004; Wagenfeld-Heintz, Ross, and Lee 2007).

Being stigmatized in the health care setting, specifically, due to public insurance

status may have important impacts extending beyond just bad feelings; it may result

in increased disparities in health care. In this paper, we examine the experiences of

stigma in health care described by a group of low-income individuals eligible for

Medicaid in Michigan. We discuss the types of stigma experienced by these

individuals when using public insurance,
1
and the influence of such stigma on their

health-seeking behaviors. Based on these case examples, we consider how stigma

associated with public insurance may combine with other types of stigma to impact

the quality and continuity of care for those using Medicaid and other public

insurance programs. Finally, we argue that to promote the health equity goals of the

Affordable Care Act, health policy should be developed to address the multiple

interactive factors that induce stigma and its impacts on health care.

Public Health Insurance in Michigan

Medicaid has been the main form of health insurance for low-income Americans

since its inception in 1965; providing coverage to pregnant women, children, the

blind and disabled, and the elderly, depending on income. Federal laws have long

excluded most adults without dependent children from Medicaid coverage, leaving

large numbers of adults uninsured. (Kaeser Family Foundation 2013).

Beginning in the late 1990s, Michigan, like many other states, instituted

community health plans managed by county governments, to help provide access to

health care for those not eligible for Medicaid. The Ingham Health Plan (IHP)

provides an example of one such plan. Michigan regulations require health

insurance plans to provide a minimum set of benefits. In order to maximize the

number of people to be covered, the IHP was expressly designed not as a health

insurance plan, but rather as a program with a limited set of ‘‘medical benefits,’’

1
We define ‘‘Public insurance’’ as Medicaid and other government funded healthcare plans, such as

county funded health plans available to low-income individuals. Medicare, which is not means-tested, is

not included in this definition.

162 Cult Med Psychiatry (2017) 41:161–180

123

providing access to primary care services and some medications. (Rovin et al. 2012;

Silow-Carroll et al. 2001).

Despite the large numbers of Michigan residents being left uninsured and

underinsured by these programs, the state legislature, dominated by conservative

politicians, was reluctant to pursue Medicaid expansion as called for by the

ACA.

After much contentious debate, the Michigan legislature passed a bill expanding

Medicaid under a Section 1115 Waiver, amending the usual Medicaid regulations to

add personal responsibility requirements in the form of cost-sharing and financial

incentives for healthy behaviors. These added features of the Healthy Michigan Plan

(HMP) are designed to assure that recipients have ‘‘skin-in-the-game,’’ and take

responsibility for their lifestyle choices (Baker and Hunt 2016).

While at its inception, it had been anticipated that about 400,000 people would be

covered under HMP (Ayanian et al. 1993), more than 600,000 people had enrolled

in the plan in the first year (MDHHS 2016). The study we report here draws on data

collected just as HMP was beginning to enroll beneficiaries. The experiences of

stigma they report in using public insurance, therefore, refer to standard Medicaid,

IHP, and similar plans that pre-dated Michigan’s Medicaid expansion under the

ACA.

Stigma and Its Implications for Health Disparities

How experiences of stigma may impact those subject to its influence has long been

of concern to social scientists and health researchers. Stigma is manifest through

processes of exclusion, rejection, or blame. Goffman (1963) notes that stigma is a

product of power differentials in an interpersonal relationship that is ‘‘deeply

discrediting’’ to an individual’s social identity. In the health care setting,

interpersonal stigma originates from the in-group (i.e., health care providers),

who have the power to stigmatize and exclude others (i.e., patients) (Mason-

Whitehead and Mason 2007) and can stem from the provider’s assumptions about

the patient’s personal attributes (Weiss and Ramakrishna 2006).

It has been widely demonstrated that sources of stigma affecting health care

experiences may include race, class, gender, and illness-status (Bird and Bogart

2000; Drury, Aramburu, and Louis 2002; Earnshaw and Quinn 2011; Franks,

Fiscella, and Meldrum 2005; Henderson, Stacey, and Dohan 2008; Kinsler et al.

2007; Reutter et al. 2009; Stuber and Schlesinger 2006). Stigma associated with

such personal attributes has been shown to have real and serious consequences for

health status. For example, studies show that health care stigma is associated with

underutilized care, infrequent routine check-ups, delaying care, forgoing needed

tests, illness progression, and lower quality of life (Becker and Newsom 2003;

Drury, Aramburu, and Louis 2002; Earnshaw and Quinn 2011; Nadeem et al. 2007;

Sayles et al. 2009; Young and Bendavid 2010).

Additionally, studies have documented that stigmatization may be based on

having public insurance or being uninsured. Patients with public insurance report

feeling ignored, disrespected, or rushed, have difficulty scheduling appointments,

and often face long wait times; which may lead them to have low satisfaction with

Cult Med Psychiatry (2017) 41:161–180 163

123

healthcare providers and staff, and to perceive public insurance as providing

substandard care. As a result of these experiences some patients with public

insurance miss follow up appointments, change health care providers, and become

reluctant to access essential services (Allen et al. 2014; Becker 2004; Becker and

Newsom 2003; Piña 1998; Wagenfeld-Heintz, Ross, and Lee 2007).

Because racial and ethnic minorities are often over-represented among the poor,

these groups are also over-represented among public insurance beneficiaries (Kaeser

Family Foundation 2013). Ablon (1981) notes, groups who experience stigma in

health care are likely to be individuals who enter into the health care system as

already stigmatized patients. Becker and Newsom (2003) reported that a majority of

the low-income African American participants in their study felt racism impacted

the care they received, and Sayles et al. (2009) found that stigma associated with an

HIV diagnosis negatively impacted patients’ treatment experiences. In a large

survey, Weech-Maldonado et al. (2012) found that Medicaid beneficiaries reported

experiencing racial and ethnic discrimination when receiving care.

Stigma in healthcare for Medicaid and other public insurance beneficiaries may

occur for a variety of reasons. DelVecchio Good et al. (2003) write that the

‘‘medical gaze,’’ or the culture of medicine, may lead providers to unknowingly

treat some patients differently than others. Medical providers generally follow

regimented consultation protocols, often including structured patient interviews

under strict time constraints. Low-income patients with complex social problems

may disrupt the context of the provider’s expected clinical encounters, and may be

interpreted as troublesome or non-compliant patients, (see also Horton 2006).

Furthermore, providers are encouraged to treat minority patients differently by

contemporary epidemiological and medical research which often presumes racial

and ethnic groups share genetic, socio-economic and cultural characteristics

(Acquaviva and Mintz 2010; Gaines 2005; Gravlee 2009; Nawaz and Brett 2009;

Witzig 1996). Through their medical training, published articles, and clinical

guidelines, clinicians are regularly instructed that race and ethnicity are clinically

relevant, and they routinely embrace and act upon these notions (Hunt and Kreiner

2013; Hunt and de Voogd 2005; Hunt, Truesdell, and Kreiner 2013). Thus,

differential treatment in healthcare is clearly the result of multidimensional

processes, many of which are structural in nature.

Stigma in health care is associated with a variety of factors, and it is well-known

to importantly affect the quality and content of care patients receive. However, it is

essential to further recognize that, in the course of health seeking, patients may be

impacted by not just one type of stigma, but by the combined effect of the various

sources of stigma they face. This understanding of stigma is grounded in

intersectionality theory, which recognizes that each individual’s unique experience

of stigma and discrimination is the result of their social positioning within a range of

attributes which may be sources of power and oppression (Crenshaw 1989;

Crenshaw 1991; Davis 2008). In public health discourse, it is increasingly

recognized that in order to understand health disparities, we must consider how

various social conditions may interact to affect health care access (Bowleg 2012;

Jackson and Williams 2006; Phelan, Link, and Tehranifar 2010).

164 Cult Med Psychiatry (2017) 41:161–180

123

Clearly, stigma may have important implications for the health of public

insurance beneficiaries, affecting their ability and likelihood to access high-quality

health care. Hatzenbuehler, Phelan, and Link (2013) argue that stigma is a critical

influence on population health because of its persistent association with health

inequities. Thus the issue of stigma merits closer scrutiny in light of Medicaid

expansion. States that expanded Medicaid prior to the Affordable Care Act saw an

increase in utilization of health care services and a general improvement in

beneficiaries’ self-reported health status and access to health care (Baicker et al.

2013; Van Der Wees, Zaslavsky, and Ayanian 2013). Understanding how stigma

may contribute to historical patterns of late diagnoses, higher mortality, and poorer

health outcomes for public insurance recipients, (Ayanian et al. 1993; Burstin et al.

1992; Kwok et al. 2010; Sorlie et al. 1994) may point to strategies to address those

issues, and thereby maximize the positive effects of Medicaid expansion. In this

paper we examine specific ways insurance status may impact health care

experiences, how other stigmatized patient characteristics may amplify those

experiences, and how the combined effects of these sources of stigma may impact

the quality of health care. We present a series of case examples illustrating how

stigma has impacted health-seeking experiences and perceived quality of care

among a group of Medicaid-eligible adults.

The Study

As part of a study examining the experiences and concerns of people targeted by

Michigan’s Medicaid expansion program, the HMP, we conducted interviews with a

group of low-income individuals in Mid-Michigan. We recruited participants

through community organizations and gathering places, such as farmers markets,

health fairs and food banks, and through snowball sampling. Individuals were

eligible to participate if they met the main criteria for HMP: being between 19 and

64 years of age with income less than or equal to 138% of the federal poverty level,

and not covered by private health insurance or Medicare. If individuals expressed

interest we assessed their eligibility, obtained informed consent and scheduled

interviews at participants’ homes or in public spaces. In-depth, semi-structured

interviews lasted approximately 1 hour, were conducted in English, and were audio

recorded and transcribed. Participants each received a $25 gift card to a local

grocery store in appreciation for their time.

The study protocol was approved by the Institutional Review Board of Michigan

State University. Interview questions explored participants’ general health concerns,

previous health care experiences, experiences with health insurance and being

uninsured, and understandings and expectations about Medicaid expansion. It

should be noted that our recruitment strategy allowed us to sample a cross-section of

Medicaid-qualified individuals who had received care from a wide variety of health

care providers and institutions, about which we did not collect any specific

information.

Interview transcripts were checked for accuracy and then coded using NVivo 10,

a qualitative data analysis program. Using a general inductive approach, codes were

Cult Med Psychiatry (2017) 41:161–180 165

123

designed to capture overarching thematic responses including health-seeking

experiences, behavioral strategies, and emotional responses, such as frustration or

dissatisfaction. The research team met regularly to compare and review coding

themes before finalizing a code book. Although not a central focus of the project,

stigma emerged as a common theme in participant responses. Comments coded for

‘‘stigma’’ included all references to perceptions of and experiences with stigma or

discrimination when accessing or receiving any health service, treatment, or health

coverage. At later stages of analysis, we refined the stigma code to include

descriptive subcodes, such as ‘‘experiential stigma’’ and ‘‘outcomes of experiential

stigma.’’ We conducted NVivo queries examining various factors associated with

the stigma code.

Of 31 total participants, 21 were women and 10 were men. About half were self-

identified white, a third African American, and the remainder Hispanic. Their ages

ranged from 20 to 63 years, with most (65%) being under 40 years old. Most had

incomes that fell well below the federal poverty level, and almost half (48%)

reported no income at all. Nearly all (81%) had health insurance through some form

of Medicaid, and only a handful (13%) were uninsured at the time of the interview.

Detailed demographic information for our sample is presented in Table 1.

Those enrolled in Medicaid had the standard state plan which pre-dated the ACA,

which used private insurers contracted by the state to provide Medicaid coverage.

Our participants were enrolled in a variety of different plans managed by these

private companies. At the time of the interviews, Michigan had just begun enrolling

individuals into HMP: while 11 of our participants reported having enrolled in HMP

none had yet begun using the plan.

Experiences of Stigma with Public Insurance

Participants reported encountering a range of experiences with stigma as they

navigated the health care system, much of it related to insurance status. When asked

if they felt public insurance status affects how health care providers treat people,

three quarters (77%) said they thought it did, and more than half (65%) said they

had either personally experienced such treatment or observed others being treated

differently. As Lauren,
2
a 24-year-old white part-time nurse covered by Medicaid,

expressed:

I see it every day. I see different physicians treating Medicaid people different

than if you came in with…something that’s actually paid for out of your
pocket…Yeah, I feel strongly that Medicaid holders are treated way
differently than if you came in with a paid insurance.

Participants’ stories about being treated differently focused on two central stigma

themes: receiving poor quality care and experiencing negative interpersonal

interactions.

2
To protect anonymity, all proper names in this paper are pseudonyms.

166 Cult Med Psychiatry (2017) 41:161–180

123

Perceptions of Poor Quality Care

Participants described a variety of ways in which they felt they had received lower

quality of care when using public insurance, as compared to private insurance

holders. They told of being offered different prescriptions and treatment options,

and of providers being rushed or reluctant to provide them treatment at all. Jennifer,

a 50-year-old white woman who had been unemployed since losing her job at a dry-

cleaners, shared this story about seeing a specialist at a university based private

hospital for a back condition while she was unemployed and covered by Medicaid:

I was sent to see if I was a candidate for back surgery…It was a long drive,
and I get there and I’m expecting to see this specialist come in, and he takes—

I don’t even know what kind of instrument it was—but he ran it down the side

of my thigh and down my leg and turned around and walked out of the room.

He didn’t say anything to me. And I’m sitting there like, ‘‘What the hell?’’ I

really felt that if I had walked in there with Blue Cross Blue Shield, I would

have had surgery.

Table 1 Interview participant demographics

N %

Participants 31

Sex

Female 21 68

Male 10 32

Age

18–29 12 39

30–39 8 26

40–49 3 10

50–59 6 19

60–64 2 6

Race/ethnicity

White 16 52

African American 10 32

Hispanic 5 16

Household income as % FPL

0 15 48

1–49 4 13

5–99 7 23

100–138 5 16

Current health coverage

Uninsured 4 13

County plan 2 6

Medicaid 25 81

Cult Med Psychiatry (2017) 41:161–180 167

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While Jennifer’s encounter occurred in a private hospital, a setting that may see

relatively fewer patients with public insurance, others reported similar experiences

in health care settings like emergency rooms or health centers, where public

insurance is common. Carrie, a 38-year-old white, unemployed paralegal, described

the receptionists at a public hospital clinic she normally visits for gynecological

appointments as quick and ‘‘rude.’’ She said, ‘‘I hate going to the obstetrician there

or gynecologist…It’s like an assembly line…. there’s like 100 pregnant ladies. I
think oh, because we have Medicaid…’’’ Similarly, Destiny, a 25-year-old white
woman, recounted her experience taking her young son to a clinic she called ‘‘the

welfare clinic.’’ Destiny attributed the rushed and poor quality care her children

received to their having public insurance. She explained:

The wait was an hour long…and then they were very quick with us, they
didn’t take their time to ask questions…It’s like they weren’t patients, they
were just another number, you know, to get them out the door, and the next

one in… [The doctor] just sent us on our way without even fully
understanding what the problem was… [My son] had a really bad cold or
bronchitis and I told the doctor before he’s allergic to amoxicillin, penicillin,

and he actually wrote him an amoxicillin script. It was in his file. He didn’t

even read through his file.

Like Destiny, other participants felt that public insurance beneficiaries are often

given little attention by health care personnel and not allotted long enough

appointment times. Many participants also said they had experienced very long wait

times in both public and private health care settings, which they attributed to having

public insurance. Oftentimes the situation was made doubly frustrating because the

long wait was followed by a rushed appointment. Ella, an unemployed 48-year-old

African American woman who had just recently enrolled in Medicaid after being

uninsured for three years, discussed her experience:

It was like, you may have an appointment, you could be the first one to sign

up…but if somebody’s insurance might be better than yours, they get better
service…Since they know that’s the type of insurance you get, your
background like, you’re working [or] not, it has an effect on how people act

towards you…It’s like, gosh, I’ll be the first one here, be the last one coming
on out of here.

For Ella, public insurance represented more than just insurance coverage. It

denoted other presumed social attributes, including her ‘‘background’’ and

employment status, which influenced the way health care personnel treated her.

Teresa, a 57-year-old African American mother of five, was an unemployed

computer repair specialist and uninsured at the time of the interview. She recounted

having similar experiences when she was covered by public insurance in the past:

[Health care providers] just think people that are on assistance have all the

time in the world…I can remember having to wait for hours at the doctor’s
office, where someone that came in and pulled out their Blue Cross Blue

Shield card they got right in. I would have an appointment also…and then they

168 Cult Med Psychiatry (2017) 41:161–180

123

would tell me, ‘Well she had to get back to work,’ and it was like, ‘What

difference does it make? I was on time.’

Like Ella, Teresa felt her public insurance status is taken to be a reflection of her

employment status—that she has time to wait and no job to get back to. In their

experience, their public insurance status was conflated with other socially

disempowering characteristics, intensifying the stigma they encountered.

Thus far we have seen a variety of ways in which public insurance beneficiaries

felt their insurance status caused them to receive poor quality care. Participants

described long wait times, rude behavior, or rushed and inattentive care in the health

care setting, which they attributed to their insurance status. Some also felt that this

intensified the impact of other perceived and stigmatized social attributes such as

being unemployed. In what follows, participants describe a related concern: their

experiences with negative interpersonal interactions in the health care setting.

Negative Interpersonal Interactions

Participants described a variety of negative interpersonal interactions with health

care personnel or staff many of which they attributed to their public insurance

status. These included shaming, mistreatment, being disrespected or ignored, not

being believed, and being treated like they were unintelligent. Kimberly, a 39-year-

old white woman who works in retail, remembered having such encounters when

being treated for pain at an out-of-state hospital while covered by Medicaid:

I couldn’t even move, and first of all they didn’t even want to treat me. I was

in pain, crying, bent over, couldn’t move. He [the health care provider] was

like, ‘just get up’ and just treated me like dirt…They didn’t run no tests or
nothing, they just gave me some meds.

Kimberly’s treatment at the hospital exemplifies how patients may interpret

negative interpersonal interactions with providers as inadequate care. Similarly,

Shannon, a 31-year-old unemployed white woman covered by Medicaid, described

negative interpersonal interactions she had experienced, comparing her experiences

when using private insurance versus Medicaid:

When we had Blue Cross and Blue Shield, we were treated much differently

even by the receptionist. People treat you differently. They look at you

differently…It’s a stigma almost. I sometimes don’t want to pull out my green
[Medicaid] card when I’m in the line at the pharmacy…the lady in front of me
has a Blue Cross Blue Shield card and the way they talked to her or interact

with her…is much different than when I roll up with my green card and my
cardboard [Medicaid health plan] card. It’s ‘here, sign this, birth date, co-pay,

have a great day.’

Shannon also told us that health care staff engaged in less conversation with her

and treated her more curtly when she used Medicaid compared to Blue Cross Blue

Shield, further reinforcing her sense of stigmatization when using public insurance.

Cult Med Psychiatry (2017) 41:161–180 169

123

Other negative interpersonal interactions commonly described by our participants

include being ignored, not being believed by health care personnel, and being

treated like they were ‘‘dumb’’ or ‘‘stupid.’’ Melina, a 28-year-old Hispanic

unemployed waitress, told us that she was ignored after going to the hospital for an

emergency while covered by Medicaid. She said, ‘‘They don’t pay attention to you

because they know you got this card, you know, sometimes…they discriminate—
They treat you different than other persons that pay at the hospital.’’ Jacquie, a

28-year-old African American who works as a home health aide, expressed a similar

sentiment. Jacquie felt that due to her Medicaid coverage, health care providers

treated her as if she were unintelligent:

Sometimes, maybe nurses or whatever will go out of their way to explain

something that, to me, might be common sense. They’ll go through your charts

and say, ‘Okay, this. Oh okay, Medicaid,’ and they’ll start talking to you about

something stupid…I assume that they assume…if you have regular insurance
or whatever, that you must have a job or something like that and then they

don’t talk to you like you’re all dumb.

In these examples, we have seen that patients may feel medical staff make

negative assumptions about them based on their public insurance, and treat them

differently than they would be if they had private insurance.

Some study participants expressly noted feeling victim to multiple sources of

stigma. They described providers’ negative assumptions associated with insurance

status being amplified by other personal characteristics like physical appearance,

race, class, and illness status. Crystal, for example, a 35-year-old unemployed social

worker covered by IHP (the county health benefits plan), described feeling

mistreated at a private, suburban clinic due to being a low-income ‘‘young black

woman.’’ She said, ‘‘Most of the clientele there, they appeared to be well-to-do.

They were white. And I noticed that the way the receptionist would talk to me, you

know, she was kind of standoffish, didn’t even give me eye contact.’’ This

participant, who has a master’s degree in sociology, described the negative

assumptions the specialist seemed to make about her:

The way the doctor would ask questions to me—kind of like I was dumb. You

know, the way he would talk to me? But when he heard the way I talk and my

lingo, I shut that down. But the point was, his initial impression of me

was…that maybe I wasn’t as intelligent or probably wasn’t responsible. And
so, his conversation with me reflected that. But I noticed that interactions with

other clients that came in were quite different.

Crystal compared this with her experiences at low-income health care facilities,

saying she did not notice the same treatment in those settings. She attributed this

particular discriminatory experience largely to her race and low-income status,

highlighting that stigma can be compounded and exacerbated by other sources of

disempowerment, discrimination and prejudice.

170 Cult Med Psychiatry (2017) 41:161–180

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Health Implications of Stigma

As participants described their experiences with stigma, several also discussed how

those experiences impacted their health-seeking behaviors, causing them to

interrupt care, forgo treatment and doctor visits, or change primary care providers.

Kelly’s story illustrates how experiencing stigma can interfere with continuity of

care. Kelly is a 32-year-old white bartender who suffers from Graves’ disease, a

chronic autoimmune condition of the thyroid. She was uninsured for two years

before enrolling in Medicaid and was unemployed at the time of the interview.

When asked if she thought people with public insurance were treated differently

than others, Kelly told us ‘‘[it] depends on where you go’’, noting that she never felt

mistreated at university based facilities. However, Kelly strongly felt she was

treated poorly by health care providers at a public hospital clinic because of her

Medicaid insurance, saying, ‘‘They didn’t listen! They just didn’t listen, didn’t

care.’’ She felt that because providers wouldn’t listen to her, she was given an

incorrect prescription, one that she already knew would negatively affect her thyroid

condition. After receiving that prescription, she requested to be seen by a different

doctor at the clinic. Instead, she was only permitted to see a nurse practitioner. Kelly

said she got angry at being treated this way, and told us ‘‘I don’t want to come back,

I don’t. I don’t ever want to come back again.’’

Similarly, Kimberly, the 39-year-old white retail worker we met earlier,

experienced poor treatment which she felt was due to her being covered by

Medicaid, resulting in her leaving her provider. She told us that when she had a

miscarriage, her doctor declined to perform a dilation and curettage procedure when

she requested it. She had to wait a long time before he finally performed the

procedure, a period she described as ‘‘awful.’’ Kimberly strongly felt the delay was

due to her Medicaid coverage status. After this experience, she decided to no longer

use that doctor’s health system. Experiences like Kelly and Kimberly’s were

commonly described by those we interviewed, and often resulted in patients opting

to discontinue seeing their providers, disrupting their continuity of care.

Perhaps the most disquieting account of disruption to care due to stigma came

from Carrie, the 38-year-old unemployed paralegal. Carrie’s HIV-positive status

and Medicaid coverage combine as sources for stigmatization in her health care

encounters, negatively affecting her care. When asked if she thought Medicaid

affects how she gets treated, she said that she has been treated very rudely by

receptionists and clinical staff alike. She told us that she used to have private, ‘‘good

insurance’’ and visited a specialist hospital clinic, noting that ‘‘it’s just a different

experience’’ compared to using Medicaid. When using her current Medicaid

insurance, Carrie stated, ‘‘They just treat you differently, and especially when you

have HIV, you get treated a whole bit differently.’’

Carrie described how one of her doctors put on two pairs of gloves before

examining her, and she told us her medical records folder was ‘‘flagged’’ at the

dentist. Although such actions may be appropriate medical precautions given her

health status, Carrie experienced this behavior as demeaning. She further reiterated,

‘‘You get a lot of stigma in health care, especially if you have [HIV],’’ adding that

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this stigma makes her reluctant to go to the gynecologist. In addition to feeling

mistreated by her doctors, Carrie also talked about enduring long wait times due to

her insurance status. When asked if these experiences affected her desire to go to the

doctor, she said, ‘‘Absolutely. I’m out of care—I’ve missed three appointments for

my HIV doctor because I cannot stand sitting two hours in the lobby…I have to go
to work.’’ Carrie’s care was further interrupted when a particularly disturbing

incident prompted her to change her doctor:

My doctor asked me to swab myself one time when I was being tested for

STDs… How the hell can you work in infectious disease and you don’t want
to swab me? Like okay, I can do that. But how humiliating is that? I’m

switching doctors…I just don’t want to go. I want to be able to sit down and
talk to somebody about what’s going on with me because I’ve been missing

medicine, and that’s serious. It’s a serious thing, and they’re so callous to it.

As Carrie’s story so clearly illustrates, stigmatization can have significant health

consequences for public insurance beneficiaries, particularly those for whom other

personal attributes, such as illness-status or race, compound the stigma experience.

An intersectionality approach suggests that health care stigma experienced by

participants like Carrie emerges from multiple, interacting and discredited social

positions beyond just a stigmatized insurance status.

For our participants, health care stigma towards their public insurance status

combined with other sources of stigma to impact the quality of health care they

received and their interpersonal interactions with providers, which in turn had

significant implications for their health seeking. For some, such experiences led

them to forgo much needed care or discontinue seeing their health care providers,

which may have serious consequences for their health.

Discussion

In this paper we have examined the stigma experiences described by a group of

public insurance beneficiaries in their efforts to access health care. Participants quite

commonly felt stigmatized in being ignored, disrespected, and not believed, being

given rushed and insufficient care, and being forced to wait well past their

appointment times. We have also seen that the stigma associated with public

insurance was compounded for many by stigma due to other personal characteristics

such as class and race, resulting in intersectional stigma. This sometimes had

important consequences for the health and health care of these public insurance

beneficiaries.

Past research has found that stigma due to various personal attributes, including

race/ethnicity, illness-status, socioeconomic status, and gender, is a common

experience in the health care setting (Bird and Bogart 2000; Drury, Aramburu, and

Louis 2002; Earnshaw and Quinn 2011; Kinsler et al. 2007; Reutter et al. 2009;

Sayles et al. 2009; Stuber and Schlesinger 2006). Our findings illustrate some

specific examples of how stigma based on public insurance status may manifest in

clinical encounters and combine with other stigmatized attributes, having an

172 Cult Med Psychiatry (2017) 41:161–180

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important impact on health care. For example, Crystal’s description of being spoken

to condescendingly as a woman who is low income, young, and African American

reflects her experience of multiple sources of stigma including her gender,

socioeconomic status, age, and race. Similarly, Carrie’s story illustrates dual

stigmatization related to both her Medicaid coverage and her HIV-positive status.

Others, like Ella and Teresa, felt their public insurance status prompted negative

assumptions about their employment status, which presented additional sources of

stigma.

Our findings build on previous studies that have found stigma can have

significant implications for access to care, disease management and progression, and

quality of life (Drury, Aramburu, and Louis 2002; Earnshaw and Quinn 2011;

Sayles et al. 2009; Young and Bendavid 2010). We found that in addition to

perceptions of suboptimal care, stigma resulted in some of our participants changing

providers, forgoing care, or becoming reluctant to continue seeking care. For

individuals who require ongoing medical care for serious illnesses, this can be both

distressing and dangerous.

Some participants, like Carrie, Kelly, and Crystal, reported they had noticed a

difference in how they were treated at certain healthcare facilities over others.

While some mentioned that their treatment might be worse in places who served

few people with public insurance, it was not always clear from their stories whether

they felt the type of healthcare environment (i.e. private versus public) determined

whether or not stigma might occur. While we did not ask our participants to indicate

where their care experiences had occurred, we were able to garner from their

accounts, that they had experienced stigma in both public and private facilities. This

included federally qualified health centers and other clinics targeting the

underserved, which is somewhat surprising since they may be less impacted by

low reimbursement rates than are other kinds of clinics. Previous research has

shown, however, that healthcare facilities treating a high percentage of Medicaid

patients may not provide high quality care, as indicated by their failure to meet

quality measurements (Goldman, Vittinghoff, and Dudley 2007). Thus, while such

clinics may be designed for serving patients with public insurance, the quality of

care they receive may still be compromised. We also found that our participants

experienced stigma not just from doctors and other clinicians, but from support staff

as well, including receptionists and clerks. For example, many participants

described long wait times which they felt were attributable to support staff acting

as discriminatory gate-keepers. Others, like Crystal and Carrie, experienced

‘‘standoffish’’ and ‘‘rude’’ behaviors from receptionists. Our findings are consistent

with other studies that have found discrimination in healthcare does not just

originate within the doctor-patient relationship, but also between patients and

clinical support staff (Tajeu et al. 2015; Wen, Hudak, and Hwang 2007). Thus,

discrimination and stigmatization may be experienced at many levels of the

healthcare encounter, including outside of the consultation room.

While, as our data shows, stigmatizing attitudes may be held by various actors in

the clinical encounter including the doctors, nurses, receptionists and other medical

staff, it is in its essence embedded in interpersonal power differentials (cf: Goffman

1963). Power differentials in interpersonal relationships, while experienced on an

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individual level, are rooted in structural inequalities. These inequalities constitute

the upstream causes of stigma in the health care setting. Link and Phelan (2001)

write that ‘‘by itself the standard model that asks ‘what-makes-person-A-discrim-

inate-against-person-B’ is inadequate for explaining the full consequences of stigma

processes’’ because it obscures the hand of power that structurally discriminates and

stigmatizes groups of people (Link and Phelan 2001:372). While discussion of the

full range of structural causes of health care stigma is beyond the scope of this

paper, we wish to focus on one important concern: that public insurance status itself

may amplify interpersonal stigma in the health care setting.

Medicaid has long carried a burden of stigma in the United States as a ‘‘symbol

of the waste and excess of the welfare state,’’ (Horton et al. 2014:7) carrying with it

sets of assumptions about the people who utilize these resources. Medicaid

recipients are often socially characterized as lazy, willingly unemployed, and less

educated (Barr 2000; Han et al. 2015; Hansen, Bourgois, and Drucker 2014;

Levinson and Sjamsu 2004). The social construction that low-income individuals

who enroll in Medicaid are ‘‘undeserving,’’ needy, and dependent, in contrast to

‘‘deserving’’ Medicare beneficiaries, emerged during the inception of the two

programs (Piatak 2015), and continues to be a dominant political perspective today

(Baker and Hunt 2016). Indeed, the personal responsibility requirements built-into

Medicaid expansion Waivers, like Michigan’s, reflect this notion.

Health care providers have been shown to draw on a variety of domains in

constructing their judgements about who is deserving and who is not, for example,

some groups may be perceived as more of a financial burden than others, or as

failing to meet entitlement norms (Marrow 2012; Skinner et al. 2007). Furthermore,

public insurance stigma has been shown to be exacerbated by low reimbursement

rates, treatment constraints, and high administrative costs (Boehm 2005; Horton

et al. 2001; Willging 2005). In states with higher reimbursements rates for

Medicaid, quality and access of care has been found to be better than those with

lower rates (Cunningham and Nichols 2005; Cunningham and O’Malley 2009;

Druss et al. 2012). Providers struggling to navigate such financial constraints may

be more inclined—whether consciously or not—to hold stigmatizing opinions of

public insurance and its beneficiaries and not accept them as patients, which may

amplify the institutional limitations patients encounter when receiving care in

poorly funded clinics where long wait times and rushed appointments are endemic.

For example, Backus et al. (2001) found that primary care physicians and specialists

described Medicaid patients as posing many challenges, such as being noncompli-

ant, needing extra time for medical explanations during consultations, and having

complex clinical and psychosocial problems.

It should be noted that this study draws on a small convenience sample of

respondents who are qualified for public insurance, and as such was not designed to

produce generalizable findings nor draw comparisons to people with private

insurance. Still, our findings provide useful insight into the complex and concerning

ways Medicaid recipients may experience stigma in their health seeking while using

public insurance. Because we interviewed only Medicaid qualified individuals, we

had no access to how their clinicians actually viewed them, or knowledge of the

characteristics of the specific clinics they described. We can merely surmise how

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clinicians’ attitudes and institutional factors might impact patient’s experiences of

stigma. Future research may add important insights to the understanding of how

stigma impacts such patients, exploring, for example, whether clinicians’ knowl-

edge of public insurance status affects their views of patients, or how specific

institutional factors may act to promote or discourage stigma. Future research might

also explore how funding limitations affect quality of care at public and private

healthcare facilities, and how the experience of stigma may be related to the actual

quality of care.

Conclusion

Stigma merits careful consideration in public insurance policy planning because, as

we have demonstrated, it ultimately challenges health care equity for certain groups.

Stigma can importantly affect the accessibility, continuity, and quality of health care

received by low-income individuals. The Affordable Care Act’s expansion of the

Medicaid program is an important step toward ensuring health equity among low-

income Americans. New state Medicaid expansion plans challenge typical

assumptions about who Medicaid beneficiaries are by extending eligibility and

entitlement to middle class and working individuals (Quadagno 2015), however, it

remains to be seen whether those of middle class status experience similar levels of

stigma when using public insurance.

The experiences of stigma described by the participants in this study are inherent

to the ways public insurance is viewed not just in health care, but in our society in

general. Simply expanding coverage will not in itself necessarily dispel the

historical legacy of stigma associated with the Medicaid program. The positive

impact of Medicaid expansion may be enhanced through interventions focused on

reducing the stigma encountered by those using public health coverage. To that end,

we join others (Allen et al. 2014; Barr 2000; Mason-Whitehead and Mason 2007;

Reutter et al. 2009) in arguing that policy should attend unambiguously to the issue

of stigma and its institutionalization within government programs.

In the context of the recent presidential election, the future of expanded Medicaid

programs may be in question. Still, Medicaid expansion remains the only way many

uninsured Americans can obtain health insurance and access the care they need. It is

our hope that states continue to expand Medicaid programs, and that they will

simultaneously endeavor to identify, revise and remove symbols of Medicaid as a

stigmatized status. For example, removing the ‘‘Medicaid’’ label as the main

signifier of beneficiaries’ health plan coverage and replacing it with a neutral state-

specific plan name, such as Michigan’s ‘‘Healthy Michigan Plan,’’ may be a starting

point in mitigating Medicaid’s stigmatized status. Policy-makers might also

consider improving provider reimbursement rates for Medicaid and further

incentivizing providers to accept more Medicaid patients, in the form of financial

bonuses, perhaps. Including assessment of beneficiaries’ experiences of health care

stigma and discrimination in patient satisfaction surveys might help identify

particularly problematic locations or providers.

Cult Med Psychiatry (2017) 41:161–180 175

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Such attention to the realities of beneficiaries’ lives and experiences may help

alleviate the problem of intersectional stigma in health care and illuminate the ways

in which social attributes such as class, race, and gender may combine with public

insurance stigma to impact health. Training programs might raise awareness among

health care personnel of the importance of insurance status as a source of stigma, the

compounding effect of intersectional stigma, and the impact of these on the health

care they provide.

Inequitable health care received under the stigma of public insurance is a public

health issue as it disadvantages and compromises the health of low-income health

seekers. Toward maximizing our ability to reach the goal of health equity, stigma

should be addressed directly in Medicaid policy planning and development.

Funding The Michigan Department of Community Health (MDCH) provided funding for this research
project (Grant # 134355). The views in this paper are those of the authors, and should not be assumed to
reflect those of MDCH.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee and with the 1964

Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from all individual participants included in this
study. All names have been changed to pseudonyms and identifying information has been removed.

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123

‘‘They Treat you a Different Way:’’ Public Insurance, Stigma, and the Challenge to Quality Health Care

Abstract
Introduction
Public Health Insurance in Michigan
Stigma and Its Implications for Health Disparities
The Study
Experiences of Stigma with Public Insurance
Perceptions of Poor Quality Care
Negative Interpersonal Interactions
Health Implications of Stigma
Discussion
Conclusion
Funding
References

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