Even before the COVID-19 pandemic, 35% to 45% of nurses and 40% to 54% of physicians in the United States reported experiencing burnout [1-5]. Higher levels of burnout have been linked to lower job satisfaction and higher job turnover, as well as increased medical errors, poor patient health outcomes, and lower patient satisfaction scores [3,6-8]. Burnout may also threaten clinicians’ own health over the long term [9,10].

The triple aim, which sought to enhance patient experience and improve population health while reducing costs, was expanded to the quadruple aim, recognizing the critical threat of burnout among health care providers (HCPs) [11]. Most recently, a proposed “quintuple aim” suggests that the future of health care involves the early recognition and mitigation of health disparities [12]. This push, as well as emergent work on differential experiences of burnout among providers of color [13], argues for an expanded and nuanced view of HCP burnout that is contextualized within their cultural, racial/ethnic, and other socially informed or self-selected group memberships, such as the Korean American HCP group who often gets lumped with other Asian American groups [14], despite being one of the largest and fastest-growing Asian American groups.

In 2020, approximately 24 million US residents self-identified as Asian. Of these 24 million US residents, approximately 1.9 million self-identified as Korean [15]. Korean immigrants are among the fastest-growing ethnic minority groups and make up the fifth-largest Asian group in the United States [16].

Studies across the health care literature have demonstrated that ethnic minority adults, including Korean American individuals, display a preference for providers from their background, those able to speak their native language, and who are familiar with historical challenges to accessing needed service [17]. Given this preference for cultural congruence, the need for Korean American HCPs has never been greater and is growing in alignment with demographic trends nationally [17]. Critical to the retention of Korean American HCPs is an understanding of what factors burn them out, potentially impacting their longevity in the field.

Discrimination, bullying, and incivility, especially in the workplace, undermine the culture of safety for both HCPs and patients alike. As such, in 2018, the Joint Commission has issued a Sentinel Event Alert on the physical and verbal violence against health care workers [18]. Numerous studies have found that mistreatment and discrimination toward HCPs are associated with higher levels of HCP burnout [19,20]. Additionally, a study on North American Asian HCPs and their experiences of discrimination during the COVID-19 pandemic demonstrated a surge of microaggressions related to the pandemic and a lack of institutional and public acknowledgment of the issue [21].

The Job Demands-Resources Theory suggests that job strain occurs when there is a mismatch between the demands placed on an individual and their ability to meet those demands [22-24]. It considers a wide range of both positive and negative work environment factors with indicators of employee well-being. Hence, burnout is often the result of high job demands including heavy workload, role ambiguity, role conflict, role stress, stressful events, and work pressure, among others [22-24]. As such, work environment factors such as work process inefficiencies; excessive workloads; organizational climate factors; and deterioration in control, autonomy, and meaning at work have been associated with burnout among physicians and nurses [1,5,25-28].

Although there is a growing number of studies on HCP burnout, a limited number of studies specifically focus on the experience of ethnic minority HCPs, particularly during the COVID-19 pandemic. A better understanding of the work environment factors that cause a mismatch between the demands placed on the HCPs and their ability to meet those demands leading to burnout may guide the development of targeted strategies to help mitigate HCP burnout. In light of these gaps in literature, the aim of this study was to assess burnout among Korean American HCPs and to identify work conditions during a pandemic that may be associated with Korean American nurse and primary care provider (PCP) burnout.

Registered nurses (RNs), nurse practitioners (NPs), Doctors of Medicine (MDs), and physician assistants (PAs) who provide direct patient care in Southern California were eligible to participate. The participants were grouped into RNs or PCPs (NPs, MDs, and PAs) based on their scope of practice. The decision to organize providers into these groups was informed by previous studies, which have shown that burnout levels are impacted by specific patient care tasks performed by different members of the health care team [29,30]. Although NPs are also RNs, they were grouped with PCPs since their scope of practice more closely aligns with PCPs, including but not limited to diagnosing patient conditions, initiating or managing medical treatment, and prescribing medications or nonpharmacologic treatments [31].

Recruitment methods included the distribution of an informational flyer (in English) via email to approximately 196 RN and NP members of the Korean American Nurses Association of Southern California and approximately 4440 Korean American PCPs (MDs and PAs) within the Seoul Medical Group, Independent Practitioner Association; 200 members of the Korean American Medical Association of Southern California; and 40 members of the Korean American Graduate Medical Association. Recruitment fliers (in English) were also used as an advertisement through the social media platforms Facebook, Instagram, and KakaoTalk. Additional participants were referred to the study via word of mouth from participants of the study.

Data were collected on the web between February and April 2021, using the REDCap (Research Electronic Data Capture; Vanderbilt University) system. Participants completed the electronic survey, which includes items from the demographic questionnaire, MBI-HSS, AWS, and PEPS. Each participant was assigned a unique record ID number automatically by REDCap upon the completion of the survey. The only identifiable data record linking the participant to the record ID number was their email address. The principal investigator reviewed all data collection forms on an ongoing basis for data completeness, duplication, and accuracy as well as protocol compliance.

Univariate analysis included descriptive statistics used to analyze participant demographics, levels of burnout, areas of worklife, and pandemic experience and perception. To assess for differences between RNs and PCPs, 2-tailed t tests were used for continuous variables and chi-square analyses were used for categorical variables. Bivariate Pearson correlation analysis was used to explore statistically significant factors associated with the 3 subcategories of burnout. All results with P<.05 were included in the multivariate linear regression analysis using the backward elimination method, to develop the most parsimonious final model to assess for factors associated with the 3 subcategories of burnout. All analysis was conducted using SPSS statistical software (version 24; IBM Corp).

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Cedars Sinai Medical Center (STUDY00000931; approved on August 27, 2020). Informed consent was obtained from all individual participants included in the study.

Table 1 describes responses from 184 Korean American HCPs (RNs: n=97; PCPs: n=87). Most of the participants were female (RNs: 76/97, 78%; PCPs: 72/87, 83%) and married (RNs: 59/97, 61%, PCPs: 58/87, 67%). The average age was 38.9 (SD 9.9) years for RNs and 41.5 (SD 9.8) years for PCPs. A majority of RNs (63/97, 65%) reported working in acute care settings with average of 4.6 years of work experience, whereas a majority of PCPs (62/87, 71%) reported working in ambulatory or outpatient care settings with an average of 5.3 years of work experience. Although no statistically significant differences were seen in emotional exhaustion (P=.85) or depersonalization (P=.52) between the 2 HCP groups, PCPs reported statistically significant higher levels of personal accomplishment (P=.03). There were also no significant differences in their perceptions of workload (P=.99), control (P=.33), community (P=.84), fairness (P=.30), value (P=.86), worklife (P=.10), and leadership (P=.08); however, significant differences were noted in reward (P<.001), resource availability (P=.03), and risk perception (P=.02).

Multimedia Appendix 1 describes the statistically significant factors associated with the 3 subcategories of burnout. The variables found to be statistically significant (P<.05) were entered into the multivariate linear regression models.

Table 2 describes the statistically significant areas of worklife and pandemic experience and perceptions factors associated with the 3 subcategories of burnout. For RNs, greater workload (P<.001), lower resource availability (P=.04), and higher risk perception (P=.02) were associated with higher emotional exhaustion. Greater workload was also associated with higher depersonalization (P=.003), whereas a greater (professional) community (P=.03) and higher risk perception (P=.006) were associated with higher personal accomplishment. For PCPs, greater workload (P<.001) and poor work-life balance (P=.005) were associated with higher emotional exhaustion (workload: P<.001; worklife: P=.005) and depersonalization (workload: P=.01; worklife: P<.001), whereas only reward was associated with personal accomplishment (P=.006).

This study identified several aspects of the work environment associated with burnout for Korean American RNs and PCPs. As mentioned previously, the Job Demands-Resources Theory states that job demands such as heavy workload contribute to HCP burnout, whereas job resources, such as resource availability and social support, as well as recognition (reward) from peers and supervisors, contribute to professional well-being [22-24], which our findings support.

Higher workload was associated with higher emotional exhaustion and depersonalization for RNs. With higher workloads come increased nurse encounters with patients and their caregivers and families, which may potentiate higher levels of emotional exhaustion and depersonalization. This may be particularly related to “emotional dirty work,” including diffusing charged patient interactions and other nuanced components of nursing tasks [35-37].

Emotionally draining or contentious interactions with patients’ families changed for nursing staff in the era of COVID-19. Although many hospitals sought to limit the number of visitors, nurses had to find creative ways to support patient-family interactions through phone- or web-based platforms [38]. Additionally, increased physical barriers were created by personal protective equipment (PPE), which limited the visibility of nurses’ facial expressions and discouraged other means of nonverbal shows of support, such as casual touching [39,40], thus creating additional communication barriers.

Furthermore, many nurses themselves were dealing with increased patient assignments from their coworkers calling in sick or from dealing with childcare or other issues resulting from the pandemic. This may possibly provide additional context for how our participants interpreted the concept of “workload.”

Higher risk perception and lower resource availability were also associated with higher emotional exhaustion, which has also been shown in other studies [41,42]. The critical shortage of N95 masks and other PPEs at the beginning of the pandemic, as well as risk perception including concerns of transmitting COVID-19 to their families or communities, may have contributed to the higher RN emotional exhaustion.

Our findings also show that a greater sense of community is associated with higher personal accomplishment for Korean American RNs, which may help mitigate the negative effects of burnout. In a highly hierarchy-oriented culture, wherein someone’s role in the organization determines their “status,” established rules (often related to age) may prevent younger (or novice) employees from approaching older, high-status employees for guidance and support, and younger employees may be more susceptible to workplace bullying [43]. Despite some modern shifts, perceived or actual traditional hierarchies within Korean culture often pervade the workplace [43]. Particularly among Korean American nurses in our study, the appreciation for nursing communities may be due to the ability of these groups to challenge hierarchy by creating safe spaces for nurses of all backgrounds and experience levels.

Another interesting finding from this study was the association between higher risk perception and higher personal accomplishment. The association between higher risk perception and higher emotion exhaustion is often a common finding across studies [41,42]; however, the link between higher risk perception and higher personal accomplishment is unexpected. A potential explanation may be that despite the high risks, nurses’ ability to commit to patients on the front lines during the COVID-19 pandemic may have instilled a higher sense of personal accomplishment for the participants of this study.

For PCPS, higher workload and poor sense of worklife were associated with higher emotional exhaustion and depersonalization, whereas higher reward or recognition was associated with personal accomplishment. PCPs may feel particularly vulnerable to higher emotional exhaustion and depersonalization, reflecting a high volume of patient encounters associated with the heightened need for and concurrent deficit of independent practitioners during the COVID-19 pandemic [44]. For providers and ancillary staff, it is also possible that the effects of the “great resignation,” a social phenomenon wherein a large number of employees left their job in 2021, may have exacerbated certain negative aspects of insufficient nonclinical support staff. Specifically, about 25% of Asian adults in a study conducted by the Pew Research Center reported quitting a job in 2021, compared with 17% of White adults, which may possibly have impacted the clinical environment in which these Korean American PCPs practiced [45].

Reward, which is also conceptualized as financial and social recognition for contributions on the job [33], was associated with higher personal accomplishment for the Korean American PCPs in this study. A sense of personal accomplishment may be achieved through a validation of one’s work or effort from their colleagues or certifications, awards, presentation opportunities, and promotions within the health care organization or professional organizations.

Similar to nurses, physicians have been recognized and hailed as health care “heroes” throughout the pandemic for their selfless acts and bravery. Although these PCPs certainly deserve much praise and attention, they deserve recognition in a way that is meaningful and enhances a sense of value to them. For instance, the “7 PM applause for health care heroes” initiative across the nation was a good way to show appreciation initially; however, it is not a sustainable strategy, nor does it address the underlying issue of HCP burnout. Furthermore, the term “health care heroes” masks the normalization of PCPs’ risk of exposure to the virus [46] and other ongoing emotional, psychological, and ethical issues associated with both the COVID-19 and burnout pandemics. An ongoing organization culture of recognition comprised of both personal praise with formal recognition and including multiple platforms for giving and receiving recognition may be the optimal solution for all HCPs.

The study participants were recruited among Korean American nurses and PCPs practicing in Southern California; therefore, the findings from this study may not be generalizable to all nurses and PCPs. Additionally, the total study population could not be confirmed, especially as the participants were referred to the study via word of mouth from other participants. Consequently, the response rates could not be confirmed. Nonetheless, the methods applied and lessons learned from this study may guide further studies that apply more rigorous research methods to evaluate the work environment’s impact on burnout and the well-being of nurses and PCPs from various ethnic minority groups.

Furthermore, the assessment of Korean American nurses’ and PCPs’ experience with discrimination, such as “Asian Hate,” during the pandemic and its impact on burnout was not within the scope of this study. Although we draw attention to the potential relationship between these factors among our study participants, further studies specifically assessing their experience with discrimination are needed to make direct correlations between nurse and PCP discrimination and burnout. Additional aspects of personal identity beyond ethnic/racial group, such as generation in the United States, language preference, and level of acculturation, among others, would allow for a more refined view of this experience among Korean American nurses and PCPs and should be considered in future iterations of this work.

Three years into the start of the pandemic, the COVID-19 endemic seems more hopeful than the burnout endemic. Findings from this study underscore the importance of a multilevel nurse and PCP wellness program sponsored by professional organizations, communities, and the health care institutions in which these nurses and PCPs practice. Finally, a growing recognition of identity-informed burnout experiences across frontline Korean American nurses and PCPs argues for future explorations that capture nuance both across and within this and other ethnic minority nurse and PCP groups. By recognizing and capturing these variations, we may better support the creation of targeted, burnout-mitigating strategies for all.