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Corresponding author: E. Alison Holman, Sue & Bill Gross School of Nursing Room 4517, Nursing and Health Sciences Hall, 854 Health Sciences Road, University of California, Irvine, Irvine, CA 92697.
The COVID-19 pandemic disproportionately impacts racial and ethnic minority nurses.
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Understanding the pandemic's psychological impact on minority nurses in the US is emerging.
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The available studies identify few racial/ethnic differences; significant gaps remain.
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Further understanding of pandemic impacts is needed to retain a diverse nursing workforce.
Abstract
Background
The COVID-19 pandemic has affected the well-being of nursing professionals, especially long-term and acute care nurses, many of whom are nurses of color.
Purpose
We examine the evidence and gaps in the literature addressing psychological well-being of racial/ethnic minority RNs in the United States during COVID-19.
Methods
We searched eight databases during March 2022 and used Joanna Briggs’ Scoping Review Methodology and PRISMA-ScR reporting standards.
Discussion
Seven studies met inclusion criteria. Two exclusively examined nurses; five reported findings from heterogeneous samples of health care workers. No significant racial/ethnic differences in well-being were reported among health care workers. Among nurses, if a difference existed, White nurses reported decreased psychological well-being relative to ethnic and racial minority nurses. Two studies report modest racial/ethnic differences in nurses’ psychological well-being.
Conclusion
Significant gaps in the literature remain; future studies should analyze groups of health care workers separately, clearly identify racial and ethnic groups, and examine the role of respondents’ work setting.
Protecting the front line: A cross-sectional survey analysis of the occupational factors contributing to healthcare workers’ infection and psychological distress during the COVID-19 pandemic in the USA.
Health-care professionals’ perceptions of critical care resource availability and factors associated with mental well-being during coronavirus disease 2019 (COVID-19): Results from a US survey.
) while, on the frontlines, essential HCW's struggled to provide patient care despite inadequate staffing, extended work hours, working in unfamiliar care settings, and lacking necessary equipment and supplies (
Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States.
). These challenges, combined with the stresses of caring for critically ill patients, many of whom did not survive, have contributed to significant stress, anxiety, depression, burnout, and moral injury among HCW's (
Protecting the front line: A cross-sectional survey analysis of the occupational factors contributing to healthcare workers’ infection and psychological distress during the COVID-19 pandemic in the USA.
Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States.
Moral distress in frontline healthcare workers in the initial epicenter of the COVID-19 pandemic in the United States: Relationship to PTSD symptoms, burnout, and psychosocial functioning.
Health-care professionals’ perceptions of critical care resource availability and factors associated with mental well-being during coronavirus disease 2019 (COVID-19): Results from a US survey.
Nurses and nursing assistants are the largest group of HCW's in the US with more than 4 million registered nurses (RN's) and licensed vocational nurses/licensed practical nurses (LVNs/LPNs, hereafter referred to as LVN's) in the workforce (
Bureau of Labor Statistics, U. S. Department of Labor. (2022a, March 31) Occupational employment and wages: 29-1141 registered nurses. Retrieved April 19, 2022, from https://www.bls.gov/oes/current/oes291141.htm.
). Regardless of educational background, nursing staff/personnel are at highest risk of COVID-19 exposure and mortality because they provide extended periods of direct patient care in high-risk settings, while experiencing supply and equipment shortages and inadequate staffing (
). As the frontline HCW's who provide most of the direct, hands-on care to patients and their families, nurses have been directly exposed not just to COVID-19, but extensive suffering and death while simultaneously supporting grief-stricken families who could not visit dying loved ones (
). Nurses (and other HCWs) also lived with the daily fear of taking the deadly virus home, with many choosing to isolate from their families to prevent spreading the disease to loved ones (
, of the RN's who died COVID-related deaths, 54.1% were nurses of color—while only 24.1% of nurses in the US are individuals of color. The pandemic has also significantly affected the psychological well-being of minority nurses: Among nurses of color, 42% report having had “an extremely stressful, disturbing, or traumatic experience due to COVID-19,” 29% described themselves as “not” or “not at all” emotionally healthy (
These findings are particularly disturbing given the need for racial and ethnic diversity within the nursing profession. According to the Sullivan Commission (
), there is a direct link between the lack of minority health care providers and poorer outcomes for minority patients. National nursing organizations and nursing leaders recognize that a diverse nursing workforce is necessary to provide quality, culturally sensitive care that reflects the evolving demographic of the country, and they have made recruiting and retaining racial and ethnic minority nurses a priority (
). Given the critical need to diversify the profession, it is imperative to understand how the COVID-19 pandemic has affected the psychological well-being of racial and ethnic minority nurses and to develop supportive interventions to prevent their exodus from the profession.
Studies of the psychological well-being of nurses, and racial/ethnic minority nurses specifically, during the pandemic are just beginning to appear in the literature. However, most of these studies examine nurses outside of the United States. Given the unique organizational structure of US health care systems and the racial disparities in US health and socioeconomic systems, findings from studies of nurses in other countries are not generalizable to nurses in the US. Therefore, this scoping review examines the types of available evidence, findings, and knowledge gaps in the body of available literature on the psychological well-being of racial and ethnic minority nurses in the United States during the COVID-19 pandemic.
Methods
This review follows the Joanna Briggs Institute (JBI) guidelines for a scoping review (
), as this is an appropriate choice to explore the scope of a body of literature on a topic by mapping and summarizing available evidence. Scoping reviews help identify knowledge gaps and areas for further research. Results are reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidance on reporting literature reviews (
). As the purpose of a scoping review is to understand the range of evidence available on a topic, inclusion criteria are quite broad and formal assessment of the quality of individual studies is usually not completed (
Studies were included in this review if: (a) the study population included nurses; (b) at least one aspect of psychological well-being during the COVID-19 pandemic was measured; (c) racial/ethnic breakdown of psychological well-being outcomes were included in the analysis; and (d) the study was conducted in the United States (see Table 1 for complete list of inclusion/exclusion criteria).
Table 1Inclusion and Exclusion Criteria for Article Selection
Inclusion Criteria
Exclusion Criteria
• Study sample includes registered nurses
• Study outside of the United States
• Measures at least one aspect of mental wellbeing
• Does not include or report on racially/ethnically diverse sample characteristics or findings
• Published in English
• Does not address mental health symptoms experienced during the protracted COVID-19 pandemic
• Description of study sample characteristics includes racial/ethnic breakdown
• Does not include RNs or APRNs
• Focus of manuscript is to understand the mental health/well-being of health care workers during the protracted COVID-19 pandemic
The database search strategy was developed in consultation with a medical librarian. Medline Complete, CINAHL Complete, APA PsycInfo, Web of Science Core Collection, PubMed, ProQuest Dissertation, EBSCO Academic Search Complete, and Google Scholar were searched in March 2022. The search strategies combined keywords, keyword phrases, and subject headings/thesauri terms according to the limits of each database. The main topic areas included COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), nurse, racial and ethnic minority. This was matched with mental health terminology focusing on mental health and wellbeing as well as symptoms such as depression, anxiety, post-traumatic stress disorder (PTSD), and related issues (Table 2).
Table 2Full Electronic Search Strategy for PubMed
(“COVID-19”[Mesh] OR “SARS-CoV-2”[Mesh] OR “COVID-19 Vaccines”[Mesh] OR “COVID-19 Testing”[Mesh] OR “COVID-19 Serological Testing”[Mesh] OR “COVID-19 Nucleic Acid Testing”[Mesh] OR “novel coronavirus” OR COVID19 OR covid-19 OR SARS-CoV-2 OR 2019-nCoV OR “coronavirus disease 2019” OR “coronavirus disease-19” OR coronavirus[tiab]) AND (“Nursing Staff”[Mesh] OR “Nurses”[Mesh] OR nurse*[tiab]) AND (“black and minority ethnic” OR BME OR “Black, Asian, and minority ethnic” OR BAME OR “Black, Indigenous and People of Color” OR BIPOC OR ethnic* OR minorit* OR “african american” OR black[tiab] OR asian[tiab] OR “African Americans”[Mesh] OR “Minority Groups”[Mesh] OR “Ethnic Groups”[Mesh]) AND (“Stress, Psychological”[Mesh] OR burnout OR burn-out OR “compassion fatigue” OR “Bullying”[Mesh] OR bully* OR “Social Segregation”[Mesh] OR “Race Relations”[Mesh] OR “Racism”[Mesh] OR racism OR targeted OR targeting OR “Incivility”[Mesh] OR “Prejudice”[Mesh] OR “Scapegoating”[Mesh] OR “Social Discrimination”[Mesh] OR “Social Isolation”[Mesh] OR “Social Marginalization”[Mesh] OR disproportiona* OR “Suicide”[Mesh:NoExp] OR “Suicidal Ideation”[Mesh] OR “Suicide, Attempted”[Mesh] OR “Suicide, Completed”[Mesh] OR “Self-Injurious Behavior”[Mesh] OR “Mental Fatigue”[Mesh] OR suicide OR (mental N3 fatigue) OR “Death”[Mesh] OR “Morbidity”[Mesh:NoExp] OR “Mortality”[Mesh:NoExp] OR death[tiab] OR mortality OR “Depression”[Mesh] OR “Anxiety”[Mesh] OR “Catastrophization”[Mesh] OR PTSD OR depression OR anxiety OR catastrophiz* OR distress*) Filters: English, from 2020 – March 2022
Where database search limits allowed, the following parameters were used for each search: publication date 2020-present and English language. Hand searches were also performed including a grey literature search of the reference lists of included articles, articles that cited the included documents, as well as those of the reviews of literature identified in our database search results.
Study Selection and Data Extraction
The search strategy yielded 347 publications. Duplicates (n = 94) were removed leaving 253 articles. Title and abstract screening identified 227 articles that did not meet inclusion criteria. The full texts of the remaining 26 articles were reviewed and 19 articles were excluded with reasons noted in Figure 1. The remaining seven articles are included in this scoping review (Figure 1). Publications included one dissertation and six journal articles.
Emotional distress experiences: modified Gallup negative experiences index- 6 yes/no questions asking participants if they experienced a feeling a lot of the day yesterday, 1 yes/no question if they had trouble sleeping last night.
Job burnout: 41% of health care workers reported experiencing job burnout. Job burnout was not associated with race/ethnicity.
Emotional distress experiences: No racial/ethnic difference in risk of reporting distress experiences.
Emotional distress experiences: modified Gallup negative experiences index- 6 yes/no questions asking participants if they experienced a feeling a lot of the day yesterday, 1 yes/no question if they had trouble sleeping last night.
Job burnout: 27.8% of HCW's responded, White participants most likely to respond. 42.4% of HCW's reported job burnout. Job burnout was not significantly associated with race/ethnicity.
Emotional distress experiences: 52.4% of HCW workers responded, White participants most likely to respond. Hispanic respondents most likely/Asian and Black participants least likely to report at least 3 daily impacts. * Findings not broken down by profession/role
Total sample: 288 Nurses in sample: RN = 61 (23%) NP/CNM = 82 (30%) Other nurse = 7 (3%)
Reproductive health providers engaged in clinical care or counseling about contraception. Racial/ethnic breakdown: (Total sample) Asian/Pacific Islander: 26 (10%) Black: 29 (11%) Hispanic/Latinx: 40 (15%) Native American: 4 (2%) White: 165 (62%) Other: 3 (1%)
*Total sample size may be different from racial/ethnic breakdown data due to missing or inconsistent data
Symptoms of stress, anxiety, or depression
Participants were asked in what ways they have been affected by COVID-19.
Number (%) of participants who reported feelings of stress, anxiety and/or depression: Total sample: 187 (65%) Nurses: RN = 34 (55.7%) NP/CNM = 53 (64.6%) Other nurse = 6 (85.7%)
In total sample there were no differences by race/ethnicity between those who reported “Stress” or “Anxiety or depression” and those who did not.
*Nurses’ findings not broken down by race/ethnicity
Thematic analysis identified (1) a surge in racial microaggressions associated with the COVID-19 pandemic, and (2) a lack of institutional and public acknowledgement of the hardships faced by Asian health care workers experiencing microaggressions related to COVID-19.
* Findings not broken down by country of residence or profession/role
*Total sample size may be different from racial/ethnic breakdown data due to missing or inconsistent data
Emotional and mental health and well-being as defined by the emotional health and well-being subscales of the Epidemic-Pandemic Impacts Inventory
Epidemic-Pandemic Impacts Inventory: Emotional Health & Well-Being and Mental Health & Well-being subscales
Emotional Health and Well-being: White participants reported more concerns than did participants of color. Mental Health and Well-being: White participants reported more issues compared to Asian participants.
Of the seven included papers, five investigated multiple types of health care workers including nurses, and two focused on only nurses. The studies categorized “nurse” differently: three studies included RN's and LVN's; one study included only RN's; one included RN's, Nurse Practitioners (NP's), Certified Nurse Midwives (CNM's), and “other nurse;” and two did not categorize beyond the label “nurse.”
Five of the studies analyzed a nationwide sample and two included samples from within much smaller geographic areas: New York City area of New York, and Southern Colorado. All but two of the studies included HCW's from a variety of settings (inpatient, outpatient, hospital, skilled nursing facility, education, etc.). The study set in Southern Colorado only recruited HCW's from long-term care facilities and one of the nationwide studies specifically recruited outpatient reproductive health care providers.
All studies were descriptive, with the majority published in 2021, one published in 2020 and one in 2022. In all but one study, data were collected between April and September of 2020 over an average of 3 months. One study analyzed data collected from April 2020 through June 2021. Five studies used a cross-sectional survey design, one study used qualitative methods, and one was a mixed-methods study. The qualitative study collected data through semi-structured interviews; the mixed-methods study used a survey that included open-ended response items. Instruments used for data collection varied from validated measures (e.g., Generalized Anxiety Disorder-7 [GAD-7], Patient Health Questionnaire-2 [PHQ-2]) to researcher-created questionnaires and semi-structured interview guides.
) included a variety of health professions. Each study provided a racial/ethnic breakdown of the overall sample in their analysis, but none provided further breakdown by profession, so we are unable to draw conclusions about racial/ethnic minority nurses specifically.
qualitative study of Asian HCW's in the US and Canada participants reported (1) a surge in racial microaggressions associated with the COVID-19 pandemic and (2) a lack of institutional and public acknowledgement of the hardships faced by Asian HCW's experiencing microaggressions related to COVID-19. This increase in racial discrimination and microaggressions experienced by Asian HCW's is likely to have a detrimental effect on their psychological well-being (
). It is important to note that the articles by these authors analyzed data from the Healthcare Worker Exposure Response & Outcomes (HERO) Registry. The
paper reported analysis of survey responses from April 10, 2020 to June 30, 2021 (N=24,769), suggesting some overlap in the findings reported. Other measures of psychological symptoms used by researchers provided inconsistent results. No racial/ethnic differences were described in one study (Forrest et al., 2020) which used report of emotional distress experiences to measure psychological outcomes, however a second study which used the same measure (
) reported Hispanic respondents most likely and Asian and Black respondents least likely to report three or more negative emotional impacts. No racial/ethnic differences were found in one study (
reported that White participants endorsed worse emotional health and well-being (e.g., anxiety, depression, stress, insomnia) than participants of color according to the Epidemic-Pandemic Impacts Inventory (EPII).
Studies Specifically of Nurses
Only two studies looked at the psychological well-being of nurses specifically (
). Both studies examined symptoms of depression and anxiety using validated measures. In these studies, White nurses were more likely to report anxiety than Hispanic nurses (
similarly found that White nurses were more likely than Hispanic nurses to report symptoms compatible with a major depressive episode, whereas the second study (
) found no significant differences in depression scores based on race/ethnicity.
Discussion and Recommendations
To the best of our knowledge, this scoping review is the first review of its type to explore the psychological well-being of racial and ethnic minority nurses in the United States during the COVID-19 pandemic. Our review found few significant differences between racial and ethnic groups. Studies of exclusively nurses found that if a difference existed, White nurses were more likely to report mental health symptoms than nurses of other racial/ethnic groups. When study participants included a heterogeneous group of HCW's, including nurses, most findings indicated no racial/ethnic differences in this same outcome. These findings were unexpected given the disproportionate physical, mental, and emotional impact of the COVID-19 pandemic on communities of color, including nurses (
From a methodological perspective, the two studies documenting greater anxiety among White nurses contained relatively small, unrepresentative samples that were predominantly (69%, 79%) White, therefore findings for the nurses of color may not be reliable because the samples included few racial and ethnic minority nurses. These two studies were also the only studies that used an instrument designed to screen for generalized anxiety disorder (Montoya et al. GAD-7; Kovner et al. Generalized Anxiety Disorder-2 [GAD-2]) as their measure of psychological distress. If nurses of color were feeling more emotionally exhausted or burned out than anxious, the researchers may not have captured the type of psychological symptoms experienced by racial and ethnic minority nurses. That is, perhaps the range of measures used to assess mental health was too limited to capture the specific ways pandemic stress affected mental health in nurses of color. Future research should address a broad range of emotional experiences and the patterns of coping among nurses to further elucidate the pandemic's impact on the profession.
Another plausible alternative explanation for these findings may be that fear of experiencing negative repercussions such as stigmatization, marginalization, or job loss—a finding that has been documented among racial and ethnic minority groups in the US (
Systematic review of cultural aspects of stigma and mental illness among racial and ethnic minority groups in the United States: Implications for interventions.
American Journal of Community Psychology.2021; 68: 486-512
) – may have dampened willingness to share emotional symptoms for nurses/HCWs of color. Indeed, prior research conducted with communities of color has engendered a lack of trust in the medical research establishment that could affect how willing nurses/HCWs of color may be to participate in research or trust the researcher's agenda (
A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders.
). This could result in selection biases that undermine the quality of the data collected. Future research should address these challenges to ensure robust sampling and response from nurses of color.
Several other contextual issues may help explain these findings and warrant further discussion. The media portrayal of nurses and other HCWs has not been consistent throughout the pandemic. In the early days of the pandemic, when COVID-19 had no effective treatments and vaccines were not available, HCW's were hailed as “Health care Heroes,” sacrificing their own health and welfare to serve those in need. This narrative, while meant to convey appreciation and support, may have actually been deleterious to HCW's mental health (
). This hero narrative also stands in stark contrast to the negative attitudes nurses and other HCW's experienced later in the pandemic from anti-vaxxers and COVID non-believers (
). Given this, it would be helpful to put the dates of data collection in temporal context when evaluating findings because most of the studies included in this review collected data in the early months during the “Health care Heroes” stage of the pandemic when there was a great deal of fear, uncertainty, and socio-economic upheaval. Only one study (
) collected data for over a year, well into the time when vaccines were available for all adults in the US. Thus, the findings from this study are likely to reflect HCWs mental health and well-being as they responded to the shifting societal contexts of the pandemic. Research is needed to examine the well-being trajectories of nurses of color over time as the pandemic evolved alongside several other compounding, cascading collective stressors (
) which may have produced a greater impact on the psychological well-being of nurses. However, data collected from nurses/HCW's in these specific metro areas cannot be generalized to the larger population of nurses and other HCW's in the US.
It is also important to identify the setting in which nurses work to fully understand the differential impact of the pandemic on the psychological well-being of racial and ethnic minority nurses. White nurses are overrepresented in outpatient settings and non-direct care roles, while HCW's of color are more likely to work in acute or long-term inpatient care and personal care settings (
). These settings are more likely to have inadequate staffing and resources such as personal protective equipment - placing HCW's of color at greater risk of COVID-19 exposure; physical and mental exhaustion; and moral injury (
). Future research should systematically examine the psychological well-being of racial and ethnic minority nurses throughout the pandemic and address how different work settings may have contributed to psychological challenges faced by ethnic/minority nurses.
Studies in this review were inconsistent in the specific professional roles that were included in the category “Nurse.” RN's, including NP's and CNM's (collectively referred to as advanced practice registered nurses, or APRN's); LPN's; and nursing assistants have very different education levels, responsibilities, accountabilities, and pay rates. Failing to differentiate type of nurse in data analysis ignores these differences that may have contributed to the impact of pandemic stressors on the psychological well-being of nurses of color.
There was also inconsistency across studies in reporting of Hispanic/Latino status. Three studies added a Hispanic/Latino category to the variable “race;” participants who indicated Hispanic/Latino ethnicity were included in this category regardless of their reported race. Two studies reported Hispanic/Latino as the participant's race with no further elaboration. One study asked participants if they were “Hispanic” or “not Hispanic,” but chose not to combine the modifier with the variable “race” to create a set of dummy variables such as White Hispanic, White not-Hispanic, etc. when analyzing the data (Kovner, C. personal communication, May 9, 2022). When examining racial differences in psychological well-being it is important to delineate racial identity clearly: The experience of a White Hispanic nurse may be different from a Hispanic nurse of color (
Noe-Bustamante, L., Gonzalez-Berrera, A., Edwards, K., Mora, L. & Lopez, M Majority of Latinos say skin color impacts opportunity in America and shapes daily life.
This review was limited by the small number of studies which met inclusion criteria and the fact that most of the studies occurred early in the pandemic, thereby limiting their ability to address psychological well-being over time as the pandemic has unfolded. Several critical gaps were highlighted by this review. First, up to March 2022, only two studies have been published that address the racial/ethnic breakdown in nurses’ psychological well-being during the pandemic. Second, in both studies focused on nurses and in studies of HCW more generally there is no consistency in the definition used to categorize a “nurse.” Third, identification of work setting is an important variable that has not been analyzed alongside racial/ethnic differences. Finally, there has been inconsistent breakdown of race and ethnicity in these studies. Future studies should include a racially/ethnically diverse nationwide sample of nurses with clear racial/ethnic breakdown, type of licensure, and include work setting in the analysis.
Authors' Contributions
H.A.: Conceptualization, Methodology, Writing - original draft.:; E.A.H.: Conceptualization, Writing - Reviewing and Editing, Supervision.
Conclusion
This scoping review of the psychological well-being of racial and ethnic minority nurses sheds light on the impact of a major pandemic on the largest group of HCW's in the United States. By identifying the types of evidence available and gaps in evidence, this review can help direct future research to better understand the differential impact of the COVID-19 pandemic on underrepresented minority nurses so it can inform development of interventions that support retention of a diverse nursing workforce.
Acknowledgments
The authors with to thank Steve Clancy, MLS, Research Librarian for Health Sciences and Nursing Science, Science Library, University of California, Irvine, for his assistance in developing the database search strategy.
This research did not receive any grant funding from agencies in the public, commercial, or not-for-profit sectors.
Bureau of Labor Statistics, U. S. Department of Labor. (2022a, March 31) Occupational employment and wages: 29-1141 registered nurses. Retrieved April 19, 2022, from https://www.bls.gov/oes/current/oes291141.htm.
Protecting the front line: A cross-sectional survey analysis of the occupational factors contributing to healthcare workers’ infection and psychological distress during the COVID-19 pandemic in the USA.
A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders.
Systematic review of cultural aspects of stigma and mental illness among racial and ethnic minority groups in the United States: Implications for interventions.
American Journal of Community Psychology.2021; 68: 486-512
Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States.
Moral distress in frontline healthcare workers in the initial epicenter of the COVID-19 pandemic in the United States: Relationship to PTSD symptoms, burnout, and psychosocial functioning.
Health-care professionals’ perceptions of critical care resource availability and factors associated with mental well-being during coronavirus disease 2019 (COVID-19): Results from a US survey.
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