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. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Nurs Outlook. 2024 Jul 10;72(5):102234. doi: 10.1016/j.outlook.2024.102234

BURNOUT AND PSYCHOLOGICAL DISTRESS AMONG HISPANIC NURSES ACROSS ILLINOIS AND NEW YORK HOSPITALS: IMPLICATIONS FOR STRUCTURAL AND PERSON-CENTERED SOLUTIONS

J Margo Brooks Carthon a,b, Heather Brom a,b, Alexandra Maye a,b, Christin Iroegbu a,b, Jennifer Gil a,b, John Rizzo a,b, Kelvin Amenyedor a, Wanda Montalvo c, Antonia M Villarruel a,b
PMCID: PMC11490398  NIHMSID: NIHMS2007023  PMID: 38991236

Abstract

Background:

Despite high levels of burnout and psychological distress among nurses few studies have evaluated these outcomes among Hispanic nurses.

Purpose:

Evaluate differences in job-related and psychological well-being outcomes for Hispanic and non-Hispanic White nurses and the association of nurse work environments.

Method:

Cross-sectional analysis of the 2021 RN4CAST-NY-Ill nurse survey. Muli-level logistic regression models examined the association between nurse ethnicity and jobrelated outcomes and psychological well-being.

Findings:

Our sample included 798 (10.7%) Hispanic and 6,642 (89.3%) non-Hispanic white nurses in 249 hospitals. In unadjusted models, Hispanic ethnicity was associated with higher odds of burnout (OR 1.21; 95% CI: 1.03–1.42), which diminished when considering the work environment (OR 1.16; 95% CI: 1.01–1.35) and nurse characteristics (i.e., age) (OR 1.01; 95% CI: 0.83–1.21).

Conclusion:

Equity-driven solutions to support the well-being of Hispanic nurses should consider a focus on the needs of young Hispanic nurses and include increased support in work environments.

Keywords: equity, psychological wellbeing, burnout, Hispanic nurses (look for other MeSH)

INTRODUCTION

Throughout the COVID-19 pandemic, nurses worked under substantial pressure worsening a burnout crisis that was simmering for over a decade (Galanis, et al., 2021). Surveys conducted during the pandemic found that burnout was present in up to 50% of nurses (Lasater, Aiken, Sloane, French, Martin, et al., 2021). Others noted that nurses experienced higher levels of psychological distress, including anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms, compared to other healthcare providers (Huffman et al., 2021; Mensinger et al., 2022; Shechter et al., 2020). Stressors among healthcare providers were linked to younger age, fear of caring for COVID-19-infected patients and concerns over personal well-being, as well as fears of infecting family members (Galanis, et al, 2021; Huffman et al., 2021; Norful et al., 2021). Limited psychosocial and organizational resources also contributed to notable burnout and psychological distress (Aiken, Lasater, et al., 2023).

Despite the increased attention to the burnout crisis from the U.S. Surgeon General and National Academy of Medicine (Murthy, 2022), little attention has been paid to describing this crisis among racially and ethnically minoritized nurses, particularly Hispanic nurses. Most surveys on burnout during the pandemic included samples that were predominately white and female (Dyrbye et al., 2019; Kelly, Gee, & Butler, 2021; Shah et al., 2020), leaving the voices and experiences of minoritized nurses largely silenced. Hispanic nurses represent 6% of the U.S. nursing workforce, lagging behind the proportion of Hispanics in the U.S., which currently stands at 19% (Funk & Lopez, 2022; Cuellar, 2020). Research conducted before the pandemic documented notable pay disparities and higher reports of intent to leave among Hispanic nurses (Moore & Continelli, 2016). Other studies have documented Hispanic nurses’ experiences of bias and feeling overlooked and undervalued (Moceri, 2012). These job-related disparities were likely exacerbated during the pandemic. For example, in a large study of 788 registered nurses employed in hospitals during the pandemic, minoritized nurses, including Hispanic nurses, experienced higher rates of microaggressions, hostile racial climates, and severe emotional distress (Thomas-Hawkins et al., 2022).

Hispanic nurses were more likely to contract COVID-19 and are known to disproportionately work in high COVID-19 exposure settings (Artiga et al., 2020), including long-term and home care (Nikpour & Brooks Carthon, 2023). Nurses in these settings, especially at the start of the pandemic, had limited access to personal protective equipment and witnessed excessive patient deaths. A number of studies have shown that caregiving during the pandemic took a significant toll on nurses and has been linked to the development of depression and PTSD symptoms (Copel et al., 2023). Despite these findings, less is known about the impact of the pandemic on the psychological wellbeing of Hispanic nurses in hospital settings (Jason et al., 2023; Rivas, 2020). Given the disproportionate impact of the pandemic on minoritized communities, Hispanic nurses were also more likely to experience personal losses in their own families and communities. At least one study described the experiences and coping mechanisms of Hispanic nurses providing direct patient care during the pandemic (Sandoval et al., 2023). In their qualitative study of 20 Hispanic nurses, participants reported coping with caregiving during the pandemic by leveraging family and community connections and involvement in professional organizations including the National Association of Hispanic Nurses. In contrast, others reported more maladaptive coping such as eating more or other unhealthy behaviors. For example, one participant was quoted as saying “I’ve never been an anxious person, but at that point, I think I became an anxious person because I couldn’t sleep. I was nervous all the time. I started eating more instead of eating less. But it was stressful” (Sandoval et al., 2023; p. 30).

Despite notable COVID disparities, equity centered solutions to address job related disparities and the psychological wellbeing of Hispanic nurses are lacking. A recent meta-analysis of burnout suggests that organizational and individual-level interventions can reduce burnout (Galanis, et al., 2021). In recent years a growing number of hospitals have launched initiatives to address burnout among nurses that include strategies such as resiliency training and mindfulness. Professional organizations, such as the American Nurses Association, have launched national initiatives including the “Nurse Burnout Prevention Program” (American Nurses Association, n.d.). This program provides individual nurses resources, tools, and strategies to mitigate burnout and increase self-care. However, more evidence is required to equally support person-centered interventions that prioritize minoritized nurses, while addressing important organizational factors such as resource adequacy, administrative support, and working conditions—factors known to influence burnout (Aiken, Lasater, et al., 2023).

In this study, we examine the relationship between Hispanic nurse burnout, intent to leave, and psychological well-being, and evaluate how organizational factors, specifically the nurse work environment, and individual characteristics of nurses such as age, influence these outcomes. The social and organizational context that permeates the clinical workplace can have an overall impact on worker’s performance and productivity (Kanter, 1976; Litwin & Stringer, 1968). Systems and norms within organizational contexts can also influence the well-being of workers. Hospital settings with healthy and supportive work environments are characterized by sufficient staffing resources, collegial relationships with colleagues, and an organizational structure that advances professional nursing standards (Lake, et al 2019). Our focus on the nurse work environment builds on a substantive literature base, including a recent literature review, linking lower levels of burnout to work environments supportive of nursing (Brooks Carthon et al., 2021; Dall’Ora et al., 2020; Schlak et al., 2021; Shah et al., 2020).

Conceptual Framework

Our study is informed by the Systems Model of Clinical Burnout and Professional Well-being model developed by the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience (National Academies of Sciences, Engineering, & Medicine, 2019). According to the framework, a person’s well-being is determined by the interaction between physical, emotional, mental, social, and spiritual factors as they interact within the ecosystem where a person resides. Many of these factors may also contribute to clinician burnout. Therefore, this model includes three interacting levels that contribute to burnout and wellbeing: 1) frontline care delivery, 2) the health care organization, and 3) the external environment. At each level, decisions are made that influence job demands and what resources are available to clinicians, which ultimately impact their experiences of burnout and well-being. Individual clinician factors, such as personal experiences, are also included in the model as mediating factors between the three system factors and clinician burnout and well-being. As healthcare systems continue to learn about factors affecting clinician burnout and well-being, our study focuses on the health care organization (e.g., work environment) and individual factors (e.g. age, years of experience) and their influence on burnout, other job-related outcomes such as intent to leave, and the psychological wellbeing of Hispanic and non-Hispanic White Nurses.

The COVID-19 pandemic constrained the resources of most acute care settings and studies suggest that ratings of nurse work environments dipped during the pandemic (Aiken, Sloane, et al., 2023; Martin et al., 2023). In this study we evaluate if worsened working conditions during the pandemic disproportionately affected Hispanic nurses. Using data from survey responses of 7,440 nurses, of whom 798 were Hispanic, working in 249 hospitals, we sought to:

  1. describe differences in job outcomes (i.e., burnout and intent to leave) and psychological well-being measures (i.e., depression, and posttraumatic stress symptoms) between Hispanic and non-Hispanic white nurses.

  2. describe differences in the work environment where Hispanic and non-Hispanic white nurse’s work.

  3. determine if there is an association between ethnicity and job outcomes and psychological well-being measures and if the work environment mitigates any of these differences after accounting for individual nurse characteristics.

METHODS

Design

We conducted a cross-sectional analysis of 2021 RN4CAST-New York/Illinois survey data (Lasater, Aiken, Sloane, French, Martin, et al., 2021). Email surveys were sent via the National Council of State Boards of Nursing to a 100% sample of registered nurses licensed in New York and Illinois between April and June 2021 (approximately half a million RNs) (French et al., 2022; Lasater, Aiken, Sloane, French, Anusiewicz, et al., 2021). The data collection procedure used a modified Dillman approach that included scheduled follow up email reminders to non-responders over a one-month period and yielded an overall response rate of 14% (Aiken, Sloane, et al., 2023), which is typical of online surveys. There were on average 65 nurse respondents per hospital to the survey. Additionally, our sample includes 93% of general acute care hospitals in NY and IL; with 100% representation among the larger hospitals (>250 beds) which care for the greatest share of patients. In the survey, nurses were asked demographic questions, about their working conditions, and to provide their employer’s name, which allows us to aggregate nurse data to the hospital level. Additional details of survey methodology are published elsewhere (Aiken, Sloane, et al., 2023; Lasater, Aiken, Sloane, French, Anusiewicz, et al., 2021). This study was approved by the University of Pennsylvania Institutional Review Board.

Setting & Sample

Our sample included Hispanic and non-Hispanic White nurses working in non-federal acute care hospitals in New York and Illinois. Based on prior work, we included hospitals where there were at least four nurse respondents to our survey (Clark, Peele, & Lake, 2022; Lake et al., 2020). Our sample included 7,440 nurses working in 249 hospitals.

Variables and Measures

Dependent variables (measured at the nurse-level).

We included two job-related outcomes (burnout and intent to stay) and two measures of psychological well-being (depression, and COVID-related post-traumatic stress disorder (PTSD), in our analysis.

Job outcomes.

Like others, the 9-item Emotional Exhaustion subscale of the Maslach Burnout Inventory was used to measure nurse burnout (Maslach, Jackson, Leiter, Schaufeli et al., 1986; Schlak et al., 2021; Aiken et al, 2023; Welp, Meier, & Manser, 2015). Nurses were categorized as experiencing high burnout if their score was 27 or higher (Maslach, Jackson, & Leiter, 1997). Intent to leave was assessed using a single item asking whether the nurse planned to be with their current employer one year from now, those who indicated “no” were coded as “intending to leave” (McHugh & Ma, 2014).

Measures of psychological well-being.

Depression was measured using the Patient Health Questionnaire-2-item scale (PHQ-2) (Arroll et al., 2010). Nurses were categorized as screening positive for depression with a score of 3 or greater (Kroenke et al., 2007). COVID-related PTSD was measured using the Primary Care PTSD Screen for DSM-5 (Prins et al., 2016). If the nurse responded “yes” to four or more of the five questions about whether traumatic events associated with COVID-19 impacted them during the past month, that resulted in a positive screen for PTSD symptoms.

Independent variables.

Ethnicity.

On the survey nurses were asked two questions about race and ethnicity, which align with current federal data collection standards and the Office of Management & Budget (United States Department of Health and Human Services, 2014). We categorized nurses as Hispanic regardless of their answer to the race question if they answered “yes” to the question “Are you Hispanic/Latinx?”. Nurses were categorized as non-Hispanic White if they selected only “White” on the race question and “no” on the Hispanic question.

Organizational factors.

The primary explanatory variable of interest was the nurse work environment, which was measured by the 5-item abbreviated version of the Practice Environment Scale of the Nursing Work Index (PES-5) (Lake, 2002). This 5-item measure was derived from the original 31-item PES and its 5-subscales that assessed nurses’ level of agreement about organizational features present in their work settings: 1) nurse participation in hospital affairs; 2) nursing foundations for quality care; 3) nurse management ability; 4) staffing and resource adequacy; and 5) interprofessional collaboration. The Cronbach’s alpha for the PES-5 is 0.81 and its validity has been previously published (Lake, et al, 2024). Nurse responses for the scale were averaged and then aggregated to the hospital-level. Like others, we then divided the hospital-level work environment into quartiles where the bottom 25th percentile was labeled as “poor,” the middle 50th percentile labeled as “mixed” and the top 25th percentile labeled as “good” (Lasater & McHugh, 2016; Muir, McHugh, et al., 2023). A measure of medical-surgical nurse staffing was created by averaging the number of patients they reported caring for in their last shift within each hospital.

Individual nurse characteristics.

In our analyses we also account for nurse demographics (e.g., age, years as a RN, gender, race, education) (Gómez‐Urquiza et al., 2017; Shah et al., 2020).

Covariates.

In our analyses we also account for clinical setting (e.g., hospital unit, state). We also account for whether the nurse ever tested positive for COVID and how many patients they cared for in the past month that had COVID.

Data Analysis

We first described our sample by using means and standard deviation for continuous variables and frequencies and percentages for categorical variables. We compared Hispanic and non-Hispanic White nurses on their demographics, work characteristics, work environments, staffing, job outcomes, and measures of psychological well-being using chi-square for categorical and t-test for continuous variables. We also described job outcomes and psychological well-being measures of the whole sample by type of work environment (i.e., poor, mixed, best) using chi-square. Finally, to estimate the association between Hispanic ethnicity and our outcomes of interest we fit a series of multi-level logistic regression models. The first series were the unadjusted association between Hispanic and each outcome. The next series added in the work environment, the third series added in nurse characteristics and the fourth and final series also accounted for COVID-related factors. All models accounted for clustering of nurses in hospitals (Rogers, 1994). STATA 17 was used for all analyses.

RESULTS

Nurse Characteristics

Our sample consisted of 7,440 nurses working in 249 hospitals, of whom 10.7% were Hispanic and 89.3% were non-Hispanic White. On average, Hispanic nurses were younger compared to non-Hispanic White nurses (37.6 years vs. 43.0 years, respectively; p < .001), had less years of nursing experience (8.7 years vs. 14.9 years, respectively; p < .001), and more frequently held a BSN or higher (82.0% vs. 72.7%, respectively p < .001). Hispanic nurses more frequently worked on medical/surgical units compared to non-Hispanic White nurses (27.4% vs. 22.2%, respectively, p < .001) and less frequently worked on critical care units (17.7 vs. 19.9%, respectively, p <.001). A higher proportion of Hispanic nurses ever tested positive for COVID compared to non-Hispanic White nurses (32.3 vs. 20.7%, respectively; p < .001) and cared for COVID patients more frequently in the past month (15.2% vs. 11.1%, respectively; p < .05). Additional sample characteristics can be found in Table 1.

Table 1.

Sample characteristics comparing Hispanic and non-Hispanic white nurses.

Nurse Characteristics Total Sample (n=7,440) Hispanic Nurses (n= 798; 10.7%) Non-Hispanic White Nurses (n= 6,642; 89.3%) p-value
Age, years, mean (SD) 42.5 (13.2) 37.6 (10.8) 43.0 (13.4) <.001
Years RN, mean (SD) 14.2 (12.6) 8.7 (8.8) 14.9 (12.8) <.001
Female, n (%) 6,713 (90.4) 696 (87.2) 6,017 (90.8) .004
Race, n (%)
 White 7,028 (95.2) 386 (48.4) 6,642 (100.0)
 Multiple/Other 283 (3.9) 275 (34.7) 0
 Black/African American 73 (1.0) 73 (9.8) 0
BSN and higher, n (%) 5,472 (73.7) 653 (82.0) 4,819 (72.7) <.001
Hospital unit, n (%) <.001
 Med/surg 1,693 (22.8) 219 (27.4) 1,474 (22.2)
 Other 1,504 (20.2) 128 (16.0) 1,376 (20.7)
 Critical care 1,459 (19.6) 141 (17.7) 1,318 (19.9)
 Peds/PPM/L&D 865 (11.6) 97 (12.2) 768 (11.6)
 ED 778 (10.5) 78 (9.8) 700 (10.5)
 OR 640 (8.6) 53 (6.6) 587 (8.9)
 Stepdown 494 (6.6) 82 (10.3) 412 (6.2)
State, n (%) .633
 New York 4,632 (62.3) 503 (63.0) 4,129 (62.2)
 Illinois 2,808 (37.7) 295 (37.0) 2,513 (37.8)
Ever tested positive for COVID, n (%) 1,282 (21.9) 185 (32.3) 1,097 (20.7) <.001
Cared for COVID patients the most in the past month, n (%) 683 (11.5) 90 (15.2) 593 (11.1) .003
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Differences in Job Outcomes and Psychological Well-being Measures by Hispanic Ethnicity

Hispanic nurses more frequently experienced burnout, intent to leave, depression, and COVID-related PTSD (Figure 1). For example, 55.2% of Hispanic nurses experienced burnout compared to 50.5% of non-Hispanic White nurses (p < .05) and 17.9% of Hispanic nurses experienced COVID-related PTSD compared to 12.7% of non-Hispanic White nurses (p < .001). See Figure 1 for additional differences in outcomes.

Figure 1.

Figure 1.

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Differences in job outcomes and psychological well-being measures between Hispanic and non-Hispanic white nurses.

Note. * p < .05 ** p < .01 *** p <.001

Differences in the Work Environment by Ethnicity and Outcomes

Hispanic nurses (28.8%) were more likely to work in poor work environments compared to non-Hispanic White nurses (23.5%) and less likely (16.7%) to work in good work environments compared to non-Hispanic White nurses (20.3%; p<.001; Table 2).

Table 2.

Differences in hospital-level work environment and nurse staffing between Hispanic and non-Hispanic nurses.

Hospital Characteristics Total hospitals (n=249) Hispanic Nurses (n= 798; 10.7%) Non-Hispanic White Nurses (n= 6,642; 89.3%) p-value
Work environment, n (%) <.001
 Poor 57 (22.9) 230 (28.8) 1,558 (23.5)
 Mixed 117 (47.0) 435 (54.5) 3,735 (56.2)
 Good 75 (30.1) 133 (16.7) 1,349 (20.3)
Nurse staffing, mean (SD)
 Medical-surgical 5.5 (1.1) 5.3 (0.9) 5.4 (0.9) .090
 ICU 2.4 (0.8) 2.3 (0.5) 2.3 (0.5) .219
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Note. Work environment is derived from the ANWI-5 aggregated to the hospital level. Poor environments are those in the bottom 25%, mixed in the middle 50% and good in the top 25%. Nurse staffing is the hospital level average of patients cared for on the last shift across medical surgical nurses and ICU nurses in the hospital.

All job and psychological wellbeing outcomes differed significantly by work environment such that worse outcomes occurred more frequently in poor work environments. For example, 63% of nurses working in poor environments experienced burnout compared to 35.6% of nurses in good work environments (p < .001). See Table 3 for a complete description of outcomes by work environment.

Table 3.

Job outcomes and psychological well-being measures among all nurses and differences in outcomes by the work environment.

Work environment
Outcome All nurses (n=7,440) Poor (n=1,788; 24.0%) Mixed (n=4,170; 56.1%) Good (n=1,482; 19.9%) p-value
Job outcomes, n (%)
 Burnout 3,446 (51.0) 1,019 (63.4) 1,946 (51.1) 481 (35.9) <.001
 Intent to leave 1,708 (24.0) 520 (30.2) 953 (23.9) 235 (16.6) <.001
Psychological well-being, n (%)
 Depression 1,100 (16.1) 307 (18.7) 624 (16.3) 169 (12.4) <.001
 Covid-related PTSD 778 (13.2) 229 (16.0) 443 (13.4) 106 (9.1) <.001
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Note. Work environment is derived from the ANWI-5 aggregated to the hospital level. Poor environments are those in the bottom 25%, mixed in the middle 50% and good in the top 25%.

The Association of Job Outcomes and Psychological-Well Being with Ethnicity and the Nurse Work Environment

Tables 4 displays a series of multi-level logistic regression models estimating the association between each outcome and Hispanic ethnicity (Model 1) while additionally accounting for the nurse work environment (Model 2), nurse characteristics including age, education, and gender (Model 3), and COVID factors including ever tested positive for COVID and caring for COVID patient the most in the last month (Model 4). For the outcome of burnout there was a significant relationship between burnout and Hispanic ethnicity in the unadjusted model (OR = 1.21, 95% CI: 1.03–1.42; p < .05). This association remains significant but was reduced after adjusting for the work environment in Model 2 (OR = 1.16, 95% CI: 1.01–1.35; p < .05). The disparity between Hispanic ethnicity and burnout was diminished and no longer statistically significant after accounting for nurse characteristics in Model 3 (OR = 1.03, 95% CI: 0.89–1.19). There was a significant association between age and burnout 0.97 (0.97–0.98), though not for sex 0.98 (0.83–1.15) or level of education 0.89 (0.79–1.01). The Hispanic-ethnicity burnout relationship did not change after accounting for the COVID-related factors in Model 4 (OR = 1.04, 95% CI: 0.83–1.21). Depression and COVID-related PTSD followed a similar trend as burnout. Figure 2 displays burnout and ethnicity, by age and shows higher rates of burnout among younger nurses, with the highest rates among young Hispanic nurses.

Table 4.

Association between nurse job outcomes and psychological well-being, ethnicity, and work environments.

Outcome Model 1 Unadjusted Model 2 Adjusted for work environment Model 3 Adjusted for work environment and nurse characteristics Model 4 Adjusted for work environment, nurse characteristics and COVID factors
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Burnout
Hispanic 1.21 (1.03–1.42)* 1.16 (1.01–1.35)* 1.03 (0.89–1.19) 1.01 (0.83–1.21)
Work environment
 Mixed -- 0.61 (0.52–0.70)*** 0.58 (0.50–0.68)*** 0.58 (0.49–0.68)***
 Good -- 0.32 (0.27–0.39)*** 0.32 (0.27–0.39)*** 0.32 (0.27–0.39)***
Age -- -- 0.97 (0.97–0.98)*** 0.98 (0.97–0.98)***
BSN or higher -- -- 0.89 (0.79–1.01) 0.93 (0.81–1.06)
Female -- -- 0.98 (0.83–1.15) 1.05 (0.88–1.25)
Ever tested positive for COVID -- -- -- 1.16 (1.02–1.31)*
Cared for COVID patients the most -- -- -- 1.88 (1.57–2.23)***
Intent to leave
Hispanic 1.54 (1.29–1.84)*** 1.50 (1.25–1.80)*** 1.42 (1.18–1.69)*** 1.42 (1.17–1.71)***
Work environment
 Mixed -- 0.73 (0.61–0.88)** 0.72 (0.60–0.87)** 0.70 (0.57–0.86)**
 Good -- 0.47 (0.38–0.58)*** 0.46 (0.37–0.57)*** 0.46 (0.36–0.58)***
Age -- -- 0.99 (0.98–0.99)*** 0.99 (0.98–0.99)***
BSN or higher -- -- 0.96 (0.83–1.11) 0.98 (0.83–1.15)
Female -- -- 0.89 (0.74–1.06) 0.93 (0.96–1.29)
Ever tested positive for COVID -- -- -- 1.11 (0.96–1.29)
Cared for COVID patients the most -- -- -- 1.51 (1.24–1.83)***
Depression
Hispanic 1.29 (1.03–1.60)* 1.26 (1.02–1.57)* 1.17 (0.93–1.47) 1.15 (0.89–1.47)
Work environment
 Mixed -- 0.85 (0.73–0.99)* 0.84 (0.71–0.98)* 0.87 (0.73–1.02)
 Good -- 0.62 (0.49–0.79)*** 0.64 (0.50–0.81)** 0.65 (0.51–0.81)***
Age -- -- 0.98 (0.97–0.98)*** 0.98 (0.97–0.99)***
BSN or higher -- -- 0.68 (0.59–0.79)*** 0.72 (0.61–0.84)***
Female -- -- 0.83 (0.66–1.03) 0.89 (0.70–1.13)
Ever tested positive for COVID -- -- -- 1.12 (0.96–1.32)
Cared for COVID patients the most -- -- -- 2.13 (1.78–2.55)***
COVID-Related PTSD
Hispanic 1.49 (1.19–1.88)** 1.46 (1.16–1.83)** 1.22 (0.96–1.56) 1.11 (0.86–1.44)
Work environment
 Mixed -- 0.82 (0.68–0.99)* 0.78 (0.64–0.96)* 0.82 (0.68–1.00)
 Good -- 0.53 (0.41–0.69)*** 0.53 (0.40–0.69)*** 0.55 (0.42–0.72)***
Age -- -- 0.96 (0.96–0.97)*** 0.96 (0.96–0.97)***
BSN or higher -- -- 1.09 (0.89–1.26) 1.15 (0.94–1.39)
Female -- -- 1.00 (0.80–1.26) 1.07 (0.83–1.38)
Ever tested positive for COVID -- -- -- 1.18 (0.99–1.41)
Cared for COVID patients the most -- -- -- 4.32 (3.63–5.14)***
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Note. Hispanic comparison group is non-Hispanic White; work environment comparison group is poor; BSN or higher comparison group is less than a BSN; female comparison group is male; ever tested positive for COVID comparison group is never tested positive; cared for COVID patients the most comparison group is those who cared for fewer COVID patients.

*

p <.05

**

p<.01

***

p<.001

Figure 2.

Figure 2.

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Distribution of Burned Out Nurses’ Age by Ethnicity

There was a significant association between Hispanic ethnicity and intent to leave across all four models. The association between Hispanic ethnicity and intent to leave was reduced by 7% when accounting for the work environment in Model 2 and a 16% reduction when also accounting for nurse characteristics (Model 3) and remained stable when accounting for COVID factors (Model 4). Across all outcomes, there was a significant association between the work environment and each outcome such that in better work environments the odds of each outcome were lower across Models 2–4.

DISCUSSION

Our study reveals that among the nearly 800 Hispanic nurses who responded to the survey, over 55% reported burnout and one in three reported an intention to leave their current employers within the next year. Psychological distress, including higher rates of depression and COVID-related PTSD among Hispanic nurses, suggests that the toll of the pandemic was not born equally. Individual nurse characteristics of Hispanic nurses, such as age, appeared to account for most of the differences in job-related burnout and psychological wellbeing outcomes. Additionally, working in supportive work environments was associated with lower adverse job-related and well-being outcomes for all nurses and partially explained disparities in job and wellbeing outcomes between Hispanic and non-Hispanic White nurses. Hispanic nurses are more likely to work in underserved communities, hence high levels of burnout among Hispanic nurses have clinical implications and may hinder efforts to address health inequity.

Our findings of higher rates of burnout and poorer psychological wellbeing among Hispanic nurses are notable though stand in contrast to several studies of minoritized nurses conducted during the pandemic including a scoping review by Abrahim & Holman (2022) which found no significant racial/ethnic differences in well-being. Studies by Kovner, et al (2021) and Montoya, et al (2021) also examined symptoms of depression and anxiety using validated measures and found that White nurses were more likely to report anxiety then Hispanic, Black, or Asian nurses. Similarly, Kovner (2021) found no significant differences in depression scores based on ethnicity, and Montoya found that White nurses were more likely to report a depressive episode. In contrast, we find higher odds of both depression (OR 1.29) and COVID-related PTSD (OR 1.49) among Hispanic nurses during the pandemic. We suspect that there are several reasons why our findings differ from those of others. Both the Kovner, et al. (2021) and Montaya et al. (2021) studies were conducted between May and August 2020. Our survey, in contrast was collected in the spring of 2021, a full year into the pandemic, when the weight of the pandemic may have accumulated and produced more psychological sequalae. Finally, Kovner, et al.’s (2021) sample was drawn from a single health system while Montoya et al, was drawn from a relatively small (n=393) sample of nurses belonging to a professional nursing association, of which only 18 were Hispanic and 310 were White.

A Case for Structural Solutions

Our study of nurses working across nearly 250 hospitals allowed us to examine a large sample of nurses, and the characteristics of the settings where they provided care. Our focus on New York and Illinois also allowed us to examine outcomes among nurses working in two relatively large states, that were particularly hard hit. Throughout the pandemic, Hispanic community members in NYC were 2 times more likely to be hospitalized for COVID-19 and experienced much higher death rates (The COVID Tracking Project, 2021). This risk of contracting COVID-19 also extended to Hispanic nurses, with nearly a third in our sample reported having contracted COVID-19, compared to 21% of White nurses. This experience of personally contracting COVID, while living in hard hit communities and working in settings where patients who looked like them died in high proportions, likely contributed to a heightened sense of overwhelm or psychological distress. Our findings suggest that the hospital settings where Hispanic nurses were employed also contributed to higher ratings of burnout and intent to leave and lower ratings of psychological well-being. Across our sample, nearly 30% of Hispanic nurses reported employment in a poor work environment (compared to 24% of White nurses) suggesting that they were more often employed in settings that lack adequate staffing or other vital resources. Our findings suggest that nurses working in the best work environments are 68% less likely to experience burnout. Fostering improvements in the work environments in settings where Hispanic nurses are employed may subsequently reduce disparate job and well-being outcomes.

Our study is not the first to link the work environment of nurses to ratings of burnout and psychological wellbeing. Throughout the pandemic all nurses worked in settings where they faced an increased risk of occupational exposure and threat of personal illness (Lusk et al., 2022). Other studies conducted during the pandemic, including those by Lasater, Aiken, Sloane, French, Anusiewicz , et al. (2021) and Aiken, Lasater, et al. (2023), found that nurses employed in settings with better work environments reported lower rates of burnout and lower reports of psychological distress. Our finding that burnout disparities between Hispanic and White nurses were reduced by 3–5% once accounting for the work environment, suggests that the organizational context where Hispanic nurses work play at least a partial role in their personal and professional experiences.

Equity Centered & Person-Centered Solutions

In addition to the work environment , the factors that appeared to have the most influence on job-related disparities and psychological well-being of Hispanic nurses were characteristics of Hispanic nurses themselves. Notably, disparities in burnout, depression, and COVID-related PTSD all decreased marginally after accounting for the clinical work environment but were fully eliminated once accounting for individual nurse characteristics. The age of Hispanic nurses Hispanic nurses who were on average 7 years younger appears to have the most influence on reports of burnout or psychological wellbeing. This finding supports the Systems Model of Clinical Burnout and Professional Well-being framework which contends that clinical work environments and individual characteristics of nurses influence burnout and wellbeing (National Academies of Sciences, Engineering, and Medicine, 2019).

Our study is not the first to find that individual nursing factors predict burnout. In their survey of nurses conducted prior to the pandemic, Shapiro, et al. (2022) found that younger nurses (age 21–29) were more likely to report burnout. Factors contributing to burnout included greater exposure to physical violence, working night shifts, and perceiving lower staffing levels. Similarly, in our sample rates of burnout where highest among Hispanic nurses, though decreased significantly as they age. Our findings of a relationship between age, Hispanic ethnicity, and job-related and well-being disparities, suggest concerns for young Hispanic nurses who may have limited clinical experience and lacked proper onboarding and orientation during the wake of the pandemic.

Limitations.

Our important findings should be taken with a few limitations in mind. Our study is cross-sectional in nature, and we are unable to determine causality. Nonetheless, our sample includes 93% of general acute care hospitals in NY and IL; with 100% representation among the larger hospitals (>250 beds) which care for the greatest share of patients. In addition, Hispanic nurses include 11% of our sample, which is larger than the national Hispanic nurse average of 6% (Funk & Lopez, 2022; Cuellar, 2020). We did not account for Hispanic subgroup differences, which should be examined in future studies. Also, our study was limited to two states and a larger study with greater geographical variation would allow us to examine regional differences.

High levels of burnout and psychological distress among Hispanic nurses underscore a call to action and the need for solutions that are person-centered while also addressing organizational and workplace concerns. Several recent research funding opportunities highlight this commitment (Campaign for Action, 2024; National Institutes of Health, 2023). For example, the recent Notice of Special Interest from the National Institute of Nursing Research recognizes the disproportionate impact of burnout on nurses from racially and ethnically minoritized background and is an important step towards identifying interventions towards reducing disparities in clinician wellbeing (National Institutes of Health, 2023). Similarly, the National Academy of Medicine’s Action Collaborative on Clinician Wellbeing and Resilience will host a kickoff event in March 2024 for the National Health Workforce Well-being Day elevating this important issue (National Academy of Medicine, n.d.). These are important steps forward, yet the development of equity-based solutions requires more data on the experiences of Hispanic nurses, which to date has been limited. Our findings revealed little explanation for why intent to leave remained higher among Hispanic nurses, which warrants further research. Finally, structural and person-centered solutions must also be informed by a health equity lens that considers systemic and social drivers, intersectionality, diversity, equity, inclusion, and belonging, and community engagement (Cunningham & Gonzalez-Guarda, 2023). Efforts to reduce burnout and improve job outcomes among Hispanic and other minoritized nurses should include a better understanding of the contextual factors that lead to burnout and intent to leave, and solutions must be developed with the collaboration and leadership of minoritized nurses whose expertise are often excluded.

CONCLUSION

A diverse workforce is regarded as a promising strategy to reduce health inequities, however high levels of burnout and psychosocial distress threaten the retention of these highly valued nursing professionals. Strategies to improve the working conditions and person-centered solutions that promote the needs of Hispanic nurses, especially those who are newer to practice, are warranted.

Highlights.

  • Among nearly 800 Hispanic nurses survey respondents, over 55% reported burnout.

  • Hispanic nurses also experienced high rates of depression and COVID-related PTSD.

  • Hispanic nurses more frequently worked in hospitals with poor work environments.

  • Burnout and psychological distress were reduced in better work environments.

  • Solutions that are person-centered and address organizational concerns are needed.

Acknowledgements:

Research reported in this publication was supported by the National Institute Of Nursing Research of the National Institutes of Health under Award Number T32NR007104. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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Declaration of Competing Interest

The authors whose names are listed immediately below certify that they have NO conflict of interest to declare.

Declarations of interest: none

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