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Japan Journal of Nursing Science (2012)
doi:10.1111/j.1742-7924.2012.00221.x
OTHER
Academic report on burnout among Japanese nurses
jjns_221
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Kazuyo KITAOKA1 and Shinya MASUDA2 1
School of Nursing, Kanazawa Medical University, Ishiwaka and 2Faculty of Nursing and Medical Care, Keio University, Kanagawa, Japan
Abstract Aim: Japanese nurses have increasingly experienced “burnout” in the past several years. Studies on Japanese nurses are required in order to explore how to prevent nursing burnout. The objectives of this report were to: (i) introduce the concept, definition, and measurement of burnout; (ii) look at an overview of the prevalence, possible causes, and consequences of burnout among Japanese nurses; and (iii) explore how to prevent burnout among nurses. Methods: The authors and co-researchers have been studying burnout among Japanese workers for more than 15 years. Therefore, previously performed studies were reviewed and summarized. Results: In Japan, approximately 36% of human services professionals, such as nurses, were burned out compared to 18% of civil servants, and 12% of company employees. It was quite obvious that nurses are prone to burnout. The possible causes and consequences of burnout among Japanese nurses were reviewed. Excessive workloads and interpersonal conflict in the workplace were possible causes of burnout among Japanese nurses. The consequences of nurse burnout are potentially very serious, including medical accidents/errors. Issues to prevent nursing burnout were then reviewed. Enhancement of cognitive coping skills for female nurses and problem-solving skills for male nurses could contribute to prevention of burnout in nurses. Conclusion: The authors’ previous study revealed that the new model of the organizational context of burnout developed by Leiter and Maslach could be applied to Japanese. Further examination is needed. This report supports the call to scale up burnout prevention strategy for Japanese nurses. Key words: burnout, Japan, Maslach Burnout Inventory, nurses, review.
INTRODUCTION “Burnout” was originally viewed as a specific hazard for naive, idealistic, young service professionals. But that was long ago (Schaufeli, Leiter, & Maslach, 2009). An increasing number of workers are suffering from burnout with considerable consequences in terms of long-term sickness absence (Borritz et al., 2010; Labriola, Lund, & Burr, 2006; Lund, Labriola, & Villadsen, 2007; Wieclow, Agerbo, Mortensen, & Bonde, 2005, 2006). Burnout
Correspondence: Kazuyo Kitaoka, School of Nursing, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa 920-0293, Japan. Email: [email protected] Received 27 December 2011; accepted 23 May 2012.
has been medically diagnosed as one of the subcategories of adjustment disorders in the Dutch practice guidelines for managing adjustment disorders in occupational and primary health care. In the Netherlands, approximately half of the work disability caused by mental disorders is due to adjustment disorders (Van der Klink & van Dijk, 2003). Although it is hard to establish the costs in terms of absenteeism, loss of productivity, and healthcare consumption, these must be considerable. The International Labour Organization estimated the cost of work absence for all mental health reasons and loss of productivity at $US 200 billion a year in the USA (International Labour Organization, 1993). Japanese nurses also have experienced an increase in burnout in the past several years (Inoue, 2004). Therefore, studies on burnout among Japanese nurses are
© 2012 The Authors Japan Journal of Nursing Science © 2012 Japan Academy of Nursing Science
K. Kitaoka and S. Masuda
Japan Journal of Nursing Science (2012)
required in order to explore how to prevent burnout. The authors have studied burnout among Japanese workers for more than 15 years. In this report, the authors reviewed studies they had previously performed and examined burnout among nurses in Japan. First, the authors will introduce the concept, definition, and measurement of burnout. Second, an overview of the prevalence, possible causes and consequences of burnout among Japanese nurses will be presented. Lastly, the authors want to discuss how to prevent burnout among nurses.
SECTION 1: CONCEPT, DEFINITION, AND MEASUREMENT OF BURNOUT Burnout is a metaphor that is commonly used to describe a state or process of the draining of energy, similar to the smothering of a fire or the extinguishing of a candle (Kitaoka-Higashiguchi & Schaufeli, 2007; Schaufeli & Buunk, 2003; Schaufeli et al., 2009). Freudenberger (1974) is generally considered to be the “founding father” of the burnout syndrome. His influential paper on “staff burn-out” set the stage for the introduction of the burnout concept. As an unpaid psychiatrist, Freudenberger was employed in a New York free clinic for drug addicts. The clinic was mainly staffed by young and idealistically motivated volunteers. Freudenberger observed that many of them experienced a gradual energy depletion and loss of motivation and commitment, which usually occurred approximately 1 year after the volunteers started working in the clinic. To label this particular state of exhaustion, Freudenberger borrowed the colloquial term, burnout, from the illicit drug scene. Burnout referred to the devastating effect of chronic drug abuse. Independently and simultaneously, Maslach (1976), a social psychology researcher, came across the term in California. Maslach became interested in the way human services workers cope with emotional arousal on the job. When Maslach was interviewing people in human services professions, she noticed that the term burnout was used by Californian poverty lawyers to describe the process of gradual exhaustion, cynicism, and loss of commitment in their colleagues. Maslach and her co-workers decided to adopt this term (Schaufeli & Buunk, 2003; Schaufeli et al., 2009). Therefore, Maslach could be considered the “founding mother” of the burnout syndrome. The most often cited definition of burnout comes from Maslach and Jackson (1986): “Burnout is a syn-
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drome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who do ‘people-work’ of some kind.” Initially, Maslach claimed that burnout exclusively occurred among professionals who deal directly with recipients such as students, clients, or patients. Hence, in their view, burnout was restricted to the helping professions. But in 1996, the concept of burnout was broadened and defined as a crisis in one’s relationship with work in general and not necessarily as a crisis in one’s relationship with people at work (Maslach, Jackson, & Leiter, 1996). As a consequence, the three original burnout dimensions were redefined. “Exhaustion” now refers to fatigue irrespective of the cause. “Cynicism” reflects an indifferent or distant attitude towards work instead of other people. Lastly, lack of “professional efficacy” encompasses both social and non-social aspects of occupational accomplishment. Different ideas of the definition of burnout have been proposed by researchers, but Schaufeli and Enzmann (1998) created an overview definition of burnout: Burnout is the result of prolonged exposure to chronic work stress. Burnout is a persistent, negative, work-related state of mind in normal individuals. It is primarily characterized by exhaustion, which is accompanied by development of dysfunctional attitudes and behaviors at work, so called, cynicism, and reduced professional efficacy, distress, a sense of reduced effectiveness, and decreased motivation at work. Burnout cannot be seen, but there are instruments to measure the symptoms or behaviors. The most popular instrument is the Maslach Burnout Inventory (MBI) (Maslach & Jackson, 1981, 1986; Maslach et al., 1996). The MBI has dominated the field as a research tool (Maslach, Leiter, & Schaufeli, 2009). It was used in 93% of the journal articles by the end of the 1990s (Schaufeli & Enzmann, 1998), although the MBI has not often been used in the Japanese nursing domain. It is a self-report measure. Three versions exist: the Human Services Survey (HSS), the Educators Survey (ES), and the General Survey (GS). The HSS and the ES are virtually identical except that “recipients” is replaced by “students”. Both contain three scales: emotional exhaustion; depersonalization; and reduced personal accomplishment. The MBI-GS is more generic and includes exhaustion, cynicism, and reduced professional efficacy. The psychometric quality of the MBI is encouraging: the three scales are internally consistent and the three-factor structure has been confirmed in various studies (Schaufeli & Enzmann, 1998). Similar positive psychometric results were obtained with the French
© 2012 The Authors Japan Journal of Nursing Science © 2012 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2012)
(Dion & Tessier, 1994), Germans (Büssink & Perrar, 1992), Dutch (Schaufeli & Van Dierendonck, 1993), and Swedes (Söderfeldt, Söderfeldt, Warg, & Ohlson, 1996). The MBI-GS is not well known in the Japanese nursing domain. In this report, the authors introduce the MBI-GS. It is a 16-item measure containing five items dealing with exhaustion, five dealing with cynicism, and six dealing with professional efficacy. Sample items dealing with exhaustion, cynicism and professional efficacy: “I feel used up at the end of the workday”, “I doubt the significance of my work”, and “I feel I am making an effective contribution to what this organization does” are shown, respectively. Items are scored on a seven-point scale ranging from 0 (“never”) to 6 (“everyday”), and the total scores for each subscale are divided by the number of items for the subscale. The total scale score is not calculated because the subscores are more meaningful. A Japanese MBI-GS was translated by Kitaoka et al. (Kitaoka, Masuda, Ogino, & Nakagawa, 2011; Kitaoka-Higashiguchi, Nakagawa, Morikawa, Ishizaki, Miura et al., 2004; Kitaoka-Higashiguchi, Ogino, & Masuda, 2004). Construct validity and reliability have been ascertained for the Japanese MBI-GS.
SECTION 2: PREVALENCE OF SEVERE BURNOUT Burnout of human service workers including nurses has been a major concern in the field of occupational health. It means that human services workers are prone to burnout when compared with other occupations. Kitaoka, Nagai, Nakagawa, Masuda, and Ogino (2010) showed the evidence. It is commonly held that in the process of burnout, exhaustion comes first, followed by cynicism and diminished professional efficacy. In line with this idea, subjects with intense exhaustion and either a high level of cynicism or a low level of professional efficacy, or both, are considered to have “burned out”. This criterion is called “exhaustion + 1” (Brenninkmeijer & VanYperen, 2003) and was applied to the Japanese working population datasets collected by the authors and their co-researchers (Kitaoka-Higashiguchi, 2005b; Kitaoka-Higashiguchi, Nakagawa, Morikawa, Ishizaki et al., 2004; Kitaoka-Higashiguchi, Tanimoto, Hayasi, Fuchisaki, Syomura et al., 2004; KitaokaHigashiguchi, Ogino, & Masuda, 2004; Maeno et al., 2006; Yoshino et al., 2007). Then, the MBI-GS scale scores of the Japanese working population datasets were divided into a healthy group and a burnout group. Overall, there were 6737 subjects (3720 men, 2951
Burnout in Japanese nurses
women, 66 unknown), all of whom were aged between their 20s and 60s. Subjects’ occupations included company employees (new employees, general employees, and managers), civil servants, and human services professionals (e.g. medical doctors, clinical nurses, teachers, and social workers). In total, 76.0% of the population was categorized into the healthy group, and the remaining 24.0% into the burnout group. In the female group, 32.3% suffered burnout, compared to 17.3% of the men. In their 20s, 30.0% of the Japanese workers were burned out. But as age increased, the risk of burnout clearly declined. In their 50s, 17.6% of workers were burned out. In the human services professionals, 36.1% were burned out, whereas only 17.8% of civil servants and 12.2% of company employees were affected. It is quite obvious that human services workers such as nurses and medical doctors are more prone to burnout compared to civil servants or company employees.
SECTION 3: POSSIBLE CAUSES OF BURNOUT It is desirable to have an overview of the possible causes of burnout among Japanese nurses. In a study of Japanese clinical nurses working at a municipal general hospital, possible causes of burnout were investigated (Kitaoka-Higashiguchi, 2005a). One hundred and eighty-three effective datasets were obtained. Structural equation modeling was used for analysis. The results of the analyses indicated that interpersonal conflict had an indirect relationship via role conflict, but that workload demands exhibited a significant positive correlation to exhaustion. In addition, the coefficient of the path from exhaustion to cynicism confirmed a positive correlation. Cynicism exhibited a negative correlation to organizational resources, that is, supervisor support. The other organizational resource, namely, job decision authority, exhibited a positive correlation to professional efficacy. Using the model obtained by this study, the process of burnout will be discussed. When nurses continue to work in a stressful environment, they experience exhaustion as a stress response. This is the first stage of burnout. Exhaustion is influenced by interpersonal relationships in the workplace. With interpersonal conflict, nurses experience exhaustion as a result of psychological conflict. In the next stage of burnout, nurses lose interest and passion for work as a means of selfdefense against exhaustion and become disinterested
© 2012 The Authors Japan Journal of Nursing Science © 2012 Japan Academy of Nursing Science
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by creating a psychological distance between the self and work. In accordance with the above-mentioned exhaustion and cynicism, nurses lose self-efficacy in the workplace. Having supervisor support in the workplace can prevent nurses from developing a cynical attitude. Moreover, burnout can be prevented if nurses are allowed to participate in the decision-making processes. In summary, work overload and interpersonal conflict with other staff might be possible causes of burnout among nurses in Japan. In the burnout study among Japanese nurses, it was considered that lack of nursing staff, work overload, and intensive tasks were not directly related to nurse burnout (Inaoka, Matsuno, & Miyazato, 1984). The authors have strong evidence to support the hypothesis that excessive workload is a primary contributor to burnout for Japanese nurses (Higashiguchi et al., 1999; Kitaoka-Higashiguchi & Nakagawa, 2003; Kitaoka-Higashiguchi, Tanimoto, Hayasi, Fuchisaki, Syomura et al., 2004). Large workloads are common in the nursing profession in every country. However, the nurse : patient ratio in Japan is more than three times higher than in the USA. Japanese nurses have too many tasks and too little time to complete those tasks (Kitaoka-Higashiguchi & Nakagawa, 2003).
SECTION 4: CONSEQUENCES OF BURNOUT The consequences of nurse burnout are potentially very serious for patients and institutions, as well as for the nurses themselves. The causal relationship of burnout to medical errors was examined (Kitaoka-Higashiguchi, 2005b). The subjects included 1684 nurses working at psychiatric hospitals. The self-administered survey was conducted and 1295 effective datasets obtained. A causal model was constructed showing the correlation among job stressors, individual style of coping, burnout, and medical errors. Results were as follows: Excessive work load and interpersonal conflict with patients leads to exhaustion, the first step of the burnout. Exhaustion subsequently leads to cynicism, the second step of the burnout. Those nurses who have difficulty dealing with patients are more likely to be cynical, callous, and indifferent towards patients. Those nurses who have an interpersonal conflict with supervisors or co-workers are also prone to have cynical attitudes. Further, it was found that nurses with an emotionally expressive coping style were more likely to experience burnout and to cause accidents. Burnout can lead to deterioration in the
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quality of the care or service that is provided by nurses. Burnout can consequently lead to medical accidents or errors.
SECTION 5: HOW TO PREVENT BURNOUT Preventing nursing burnout is a significant and serious issue. Generally, stress management intervention includes some kind of cognitive–behavioral strategy such as cognitive restructuring, problem-solving training, or relaxation training. However, the difference in efficacy among those intervention strategies has not been determined. Especially with regard to nurses, it is necessary to provide stress management training in a limited time period. Thus, it is important to understand which intervention strategy is most effective for nurses. Therefore, the authors of the present study explored efficacy of existing interventions and then focused on the concept of coping with stress. Sasaki, KitaokaHigashiguchi, Morikawa, and Nakagawa (2009) examined the relationship between coping with stress and burnout in Japanese psychiatric nurses. Complete datasets were collected from 1291 participants, 335 men and 956 women. The data were analyzed using structural equation modeling. In summary, a relationship between coping with stress and positive outcome was seen only for problem solving in men. Both cognitive reinterpretation and problem solving were associated with positive outcomes in women. However, interestingly, problem solving was also associated with negative outcomes in women. The findings obtained in that study suggested that enhancement of cognitive coping skills for female nurses, and problem-solving skills for male nurses, could contribute to prevention of burnout in nurses. Effective intervention strategies might be different for men and women. This difference should be taken into account in stress management interventions for nurses.
DISCUSSION Approximately 36% of human services professionals such as nurses in Japan were burned out, whereas 18% of civil servants, and 12% of company employees seemed to be affected. It is quite obvious that nurses are prone to burnout. The possible causes and consequences of burnout among Japanese nurses were reviewed through studies that had been performed by the authors of the present study and other researchers. The MBI-GS,
© 2012 The Authors Japan Journal of Nursing Science © 2012 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2012)
which is most universally accepted as the standard for assessing burnout, was used in the authors’ studies. Excessive workload and interpersonal conflict in the workplace were possible causes of burnout among Japanese nurses. The consequences of nurse burnout are potentially very serious. Nurse burnout can lead to medical accidents or errors. Strategies to prevent nursing burnout were then reviewed. Enhancement of cognitive coping skills for female nurses, and problem-solving skills for male nurses, could contribute to prevention of burnout in nurses. Ban (2011) took a systematic review to assess the effect of stress management interventions on nurses and caregivers in Japan. The Japan Medical Abstracts Society-Web ver. 4 was searched restricting by date between 2000 and 2011. Ban found that communication skill training on nurses showed long-term effectiveness to prevent burnout (Shimizu, Mizoue, Kubota, Mishima, & Nagata, 2003; Suzuki et al., 2009). Those results imply that communication skill training, such as assertiveness training, might have favorable long-term effects on burnout among Japanese nurses. However, the effect of other stress management was not evident. On the other hand, leading burnout researchers Leiter and Maslach (2004) developed a new model of the organizational context of burnout with direct reference to a new measure, the Areas of Worklife Scale (AMS) (Leiter, 2006). The model proposed a structured framework for considering six areas of worklife: (i) workload; (ii) control; (iii) reward; (iv) community; (v) fairness; and (vi) values. Those six areas have resonated through the published work on burnout over the previous two decades. Then, Leiter and Maslach (2005) proposed six strategies for preventing job burnout. Masuda, Kitaoka and Ogino (2008) translated their book into Japanese and organized the certain strategy for preventing burnout that could be applied to Japanese workers. Further examination is needed although the authors have found some effectiveness in their intervention (Kitaoka, Morikawa, Nakagawa, Nagai, & Masuda, 2011). Both of the present report and Ban’s review (2011) support the call to scale up burnout prevention strategy for Japanese nurses.
ACKNOWLEDGMENTS This report includes the studies supported by Grantsin-Aid for Scientific Research of Japan (grant no. 14572238, 20592642, 23593416).
Burnout in Japanese nurses
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Kitaoka-Higashiguchi, K. (2005b). [Causal relationship of burnout to medical accident among psychiatric nurses.] Journal of Japanese Academy of Nursing Science, 25, 31–40. (in Japanese with English abstract). Kitaoka-Higashiguchi, K. & Nakagawa, H. (2003). Job strain, coping, and burnout among Japanese nurses. Japan Journal of Health & Human Ecology, 69, 66–79. Kitaoka-Higashiguchi, K., Nakagawa, H., Morikawa, Y., Ishizaki, M., Miura, K., Naruse, Y. et al. (2004). Construct validity of the Maslach burnout inventory-general survey. Stress and Health, 20, 255–260. Kitaoka-Higashiguchi, K., Ogino, K. & Masuda, S. (2004). [Validation of Japanese research version of Maslach burnout inventory-general survey.] Japanese Journal of Psychology, 75, 415–419. (in Japanese with English abstract). Kitaoka-Higashiguchi, K. & Schaufeli, W. B. (2007). [Burnout: An overview of 25 years of concept and research.] Hokuriku Journal of Public Health, 34, 1–7. (in Japanese with English abstract). Kitaoka-Higashiguchi, K., Tanimoto, C., Hayasi, M., Fuchisaki, T., Syomura, Y., Fukushima, H. et al. (2004). [Burnout and job stressor among psychiatric nurses.] Ishikawa Journal of Nursing, 1, 7–12. (in Japanese with English abstract). Labriola, M., Lund, T. & Burr, H. (2006). Prospective study of physical and psychosocial risk factors for sickness absence. Occupational Medicine, 56, 469–474. Leiter, M. (2006). The areas of worklife survey manual (4th edn). Wolfville, Novia Scotia, Canada: Academia University, Canada: Centre for Organizational Research and Development. Leiter, M. P. & Maslach, C. (2004). Areas of worklife: A structured approach to organizational predictors of job burnout. In: P. L. Perrewé & D. C. Ganster (Eds), Emotional and physiological processes and positive intervention strategies research in occupational stress and well being (Vol. 3, pp. 91–134). Oxford: Elsevier. Leiter, M. P. & Maslach, C. (2005). Banishing burnout: Six strategies for improving your relationship with work. San Francisco, CA: John Wiley & Sons. Lund, T., Labriola, M. & Villadsen, E. (2007). Who is at risk for long-term sickness absence?: A prospective cohort study of Danish employees. Work, 28, 225–230. Maeno, K., Kajiwara, H., Kawamura, A., Tanaka, K., Kitaoka-Higashiguchi, K. & Nakahashi, K. (2006). [Post arrangement of hospital nurses: Comparison of stress between the expected group and the unexpected group.] Hokuriku Journal of Public Health, 32, 82–85. (in Japanese). Maslach, C. (1976). Burn-out. Human Behavior, 5, 16–22. Maslach, C. & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2, 99–113.
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Maslach, C. & Jackson, S. E. (1986). Maslach Burnout Inventory, Manual research edition. Palo Alto, CA: Consulting Psychologists Press. Maslach, C., Jackson, S. E. & Leiter, M. P. (1996). Maslach burnout inventory manual (3rd edn). Menlo Park, CA: Mind Garden. Maslach, C., Leiter, M. P. & Schaufeli, W. B. (2009). Measuring burnout. In: S. Cartwright & C. L. Cooper (Eds), The oxford handbook of organizational well-being (1st edn, pp. 86–108). England: Oxford University Press. Masuda S., Kitaoka K. & Ogino K. (2008). Burnout: Shigoto to umaku tsukiau tameno 6tsuno senryaku. Tokyo: Kaneko Shobo. Sasaki, M., Kitaoka-Higashiguchi, K., Morikawa, Y. & Nakagawa, H. (2009). Relationship between stress coping and burnout in Japanese hospital nurses. Journal of Nursing Management, 17, 359–365. Schaufeli, W. B. & Buunk, B. P. (2003). Burnout: An overview of 25 years of research and theorizing. In: M. J. Schabracq, J. A. M. Winnubst & C. L. Cooper (Eds), The handbook of work and health psychology (2nd edn, pp. 383–425). England: John Wiley & Sons. Schaufeli, W. B. & Enzmann, D. (1998). The burnout companion to study and research: A critical analysis. pp. 19–99. London: Taylor & Francis. Schaufeli, W. B., Leiter, M. P. & Maslach, C. (2009). Burnout: 35 years of research and practice. Career Development International, 14, 204–220. Schaufeli, W. B. & Van Dierendonck, D. (1993). The construct validity of two burnout measure. Journal of Organizational Behavior, 14, 631–647. Shimizu, T., Mizoue, T., Kubota, S., Mishima, N. & Nagata, S. (2003). Relationship between burnout and communication skill training among Japanese hospital nurses: A pilot study. Journal of Occupational Health, 45, 185– 190. Söderfeldt, M., Söderfeldt, B., Warg, L. E. & Ohlson, C. G. (1996). The factor structure of the Maslach Burnout Inventory in two Swedish human service organization. Scandinavian Journal of Psychology, 37, 437– 443. Suzuki, E., Tagaya, A., Matsuura, R., Saito, M., Maruyama, A. & Azuma, T. (2009). Comparison of burnout scores before and after assertiveness training among nurse managers. The Journal of the Japan Academy of Nursing Administration and Policies, 13, 50–57. (in Japanese with English abstract). Van der Klink, J. J. L. & van Dijk, F. J. H. (2003). Dutch practice guidelines for managing adjustment disorders in occupational and primary health care. Scandinavian Journal of Work and Environmental Health, 29, 478– 487. Wieclow, J., Agerbo, E., Mortensen, P. B. & Bonde, J. P. (2005). Occupational risk of affective and stress-related
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disorders in the Danish workforce. Scandinavian Journal of Work and Environmental Health, 31, 343–351. Wieclow, J., Agerbo, E., Mortensen, P. B. & Bonde, J. P. (2006). Risk of affective and stress related disorders among employees in human service professions. Occupational Environmental Medicine, 63, 314–319.
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Yoshino, S., Sasahara, S., Maeno, T., KitaokaHigashiguchi, K., Tomotsune, Y., Taniguchi, K. et al. (2007). Relationship between mental health of Japanese residents and the quality of medical service. Journal of Physical Fitness, Nutrition and Immunology, 17, 3–11.
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Japan Journal of Nursing Science (2012)
doi:10.1111/j.1742-7924.2012.00221.x
OTHER
Academic report on burnout among Japanese nurses
jjns_221
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Kazuyo KITAOKA1 and Shinya MASUDA2 1
School of Nursing, Kanazawa Medical University, Ishiwaka and 2Faculty of Nursing and Medical Care, Keio University, Kanagawa, Japan
Abstract Aim: Japanese nurses have increasingly experienced “burnout” in the past several years. Studies on Japanese nurses are required in order to explore how to prevent nursing burnout. The objectives of this report were to: (i) introduce the concept, definition, and measurement of burnout; (ii) look at an overview of the prevalence, possible causes, and consequences of burnout among Japanese nurses; and (iii) explore how to prevent burnout among nurses. Methods: The authors and co-researchers have been studying burnout among Japanese workers for more than 15 years. Therefore, previously performed studies were reviewed and summarized. Results: In Japan, approximately 36% of human services professionals, such as nurses, were burned out compared to 18% of civil servants, and 12% of company employees. It was quite obvious that nurses are prone to burnout. The possible causes and consequences of burnout among Japanese nurses were reviewed. Excessive workloads and interpersonal conflict in the workplace were possible causes of burnout among Japanese nurses. The consequences of nurse burnout are potentially very serious, including medical accidents/errors. Issues to prevent nursing burnout were then reviewed. Enhancement of cognitive coping skills for female nurses and problem-solving skills for male nurses could contribute to prevention of burnout in nurses. Conclusion: The authors’ previous study revealed that the new model of the organizational context of burnout developed by Leiter and Maslach could be applied to Japanese. Further examination is needed. This report supports the call to scale up burnout prevention strategy for Japanese nurses. Key words: burnout, Japan, Maslach Burnout Inventory, nurses, review.
INTRODUCTION “Burnout” was originally viewed as a specific hazard for naive, idealistic, young service professionals. But that was long ago (Schaufeli, Leiter, & Maslach, 2009). An increasing number of workers are suffering from burnout with considerable consequences in terms of long-term sickness absence (Borritz et al., 2010; Labriola, Lund, & Burr, 2006; Lund, Labriola, & Villadsen, 2007; Wieclow, Agerbo, Mortensen, & Bonde, 2005, 2006). Burnout
Correspondence: Kazuyo Kitaoka, School of Nursing, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa 920-0293, Japan. Email: [email protected] Received 27 December 2011; accepted 23 May 2012.
has been medically diagnosed as one of the subcategories of adjustment disorders in the Dutch practice guidelines for managing adjustment disorders in occupational and primary health care. In the Netherlands, approximately half of the work disability caused by mental disorders is due to adjustment disorders (Van der Klink & van Dijk, 2003). Although it is hard to establish the costs in terms of absenteeism, loss of productivity, and healthcare consumption, these must be considerable. The International Labour Organization estimated the cost of work absence for all mental health reasons and loss of productivity at $US 200 billion a year in the USA (International Labour Organization, 1993). Japanese nurses also have experienced an increase in burnout in the past several years (Inoue, 2004). Therefore, studies on burnout among Japanese nurses are
© 2012 The Authors Japan Journal of Nursing Science © 2012 Japan Academy of Nursing Science
K. Kitaoka and S. Masuda
Japan Journal of Nursing Science (2012)
required in order to explore how to prevent burnout. The authors have studied burnout among Japanese workers for more than 15 years. In this report, the authors reviewed studies they had previously performed and examined burnout among nurses in Japan. First, the authors will introduce the concept, definition, and measurement of burnout. Second, an overview of the prevalence, possible causes and consequences of burnout among Japanese nurses will be presented. Lastly, the authors want to discuss how to prevent burnout among nurses.
SECTION 1: CONCEPT, DEFINITION, AND MEASUREMENT OF BURNOUT Burnout is a metaphor that is commonly used to describe a state or process of the draining of energy, similar to the smothering of a fire or the extinguishing of a candle (Kitaoka-Higashiguchi & Schaufeli, 2007; Schaufeli & Buunk, 2003; Schaufeli et al., 2009). Freudenberger (1974) is generally considered to be the “founding father” of the burnout syndrome. His influential paper on “staff burn-out” set the stage for the introduction of the burnout concept. As an unpaid psychiatrist, Freudenberger was employed in a New York free clinic for drug addicts. The clinic was mainly staffed by young and idealistically motivated volunteers. Freudenberger observed that many of them experienced a gradual energy depletion and loss of motivation and commitment, which usually occurred approximately 1 year after the volunteers started working in the clinic. To label this particular state of exhaustion, Freudenberger borrowed the colloquial term, burnout, from the illicit drug scene. Burnout referred to the devastating effect of chronic drug abuse. Independently and simultaneously, Maslach (1976), a social psychology researcher, came across the term in California. Maslach became interested in the way human services workers cope with emotional arousal on the job. When Maslach was interviewing people in human services professions, she noticed that the term burnout was used by Californian poverty lawyers to describe the process of gradual exhaustion, cynicism, and loss of commitment in their colleagues. Maslach and her co-workers decided to adopt this term (Schaufeli & Buunk, 2003; Schaufeli et al., 2009). Therefore, Maslach could be considered the “founding mother” of the burnout syndrome. The most often cited definition of burnout comes from Maslach and Jackson (1986): “Burnout is a syn-
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drome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who do ‘people-work’ of some kind.” Initially, Maslach claimed that burnout exclusively occurred among professionals who deal directly with recipients such as students, clients, or patients. Hence, in their view, burnout was restricted to the helping professions. But in 1996, the concept of burnout was broadened and defined as a crisis in one’s relationship with work in general and not necessarily as a crisis in one’s relationship with people at work (Maslach, Jackson, & Leiter, 1996). As a consequence, the three original burnout dimensions were redefined. “Exhaustion” now refers to fatigue irrespective of the cause. “Cynicism” reflects an indifferent or distant attitude towards work instead of other people. Lastly, lack of “professional efficacy” encompasses both social and non-social aspects of occupational accomplishment. Different ideas of the definition of burnout have been proposed by researchers, but Schaufeli and Enzmann (1998) created an overview definition of burnout: Burnout is the result of prolonged exposure to chronic work stress. Burnout is a persistent, negative, work-related state of mind in normal individuals. It is primarily characterized by exhaustion, which is accompanied by development of dysfunctional attitudes and behaviors at work, so called, cynicism, and reduced professional efficacy, distress, a sense of reduced effectiveness, and decreased motivation at work. Burnout cannot be seen, but there are instruments to measure the symptoms or behaviors. The most popular instrument is the Maslach Burnout Inventory (MBI) (Maslach & Jackson, 1981, 1986; Maslach et al., 1996). The MBI has dominated the field as a research tool (Maslach, Leiter, & Schaufeli, 2009). It was used in 93% of the journal articles by the end of the 1990s (Schaufeli & Enzmann, 1998), although the MBI has not often been used in the Japanese nursing domain. It is a self-report measure. Three versions exist: the Human Services Survey (HSS), the Educators Survey (ES), and the General Survey (GS). The HSS and the ES are virtually identical except that “recipients” is replaced by “students”. Both contain three scales: emotional exhaustion; depersonalization; and reduced personal accomplishment. The MBI-GS is more generic and includes exhaustion, cynicism, and reduced professional efficacy. The psychometric quality of the MBI is encouraging: the three scales are internally consistent and the three-factor structure has been confirmed in various studies (Schaufeli & Enzmann, 1998). Similar positive psychometric results were obtained with the French
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(Dion & Tessier, 1994), Germans (Büssink & Perrar, 1992), Dutch (Schaufeli & Van Dierendonck, 1993), and Swedes (Söderfeldt, Söderfeldt, Warg, & Ohlson, 1996). The MBI-GS is not well known in the Japanese nursing domain. In this report, the authors introduce the MBI-GS. It is a 16-item measure containing five items dealing with exhaustion, five dealing with cynicism, and six dealing with professional efficacy. Sample items dealing with exhaustion, cynicism and professional efficacy: “I feel used up at the end of the workday”, “I doubt the significance of my work”, and “I feel I am making an effective contribution to what this organization does” are shown, respectively. Items are scored on a seven-point scale ranging from 0 (“never”) to 6 (“everyday”), and the total scores for each subscale are divided by the number of items for the subscale. The total scale score is not calculated because the subscores are more meaningful. A Japanese MBI-GS was translated by Kitaoka et al. (Kitaoka, Masuda, Ogino, & Nakagawa, 2011; Kitaoka-Higashiguchi, Nakagawa, Morikawa, Ishizaki, Miura et al., 2004; Kitaoka-Higashiguchi, Ogino, & Masuda, 2004). Construct validity and reliability have been ascertained for the Japanese MBI-GS.
SECTION 2: PREVALENCE OF SEVERE BURNOUT Burnout of human service workers including nurses has been a major concern in the field of occupational health. It means that human services workers are prone to burnout when compared with other occupations. Kitaoka, Nagai, Nakagawa, Masuda, and Ogino (2010) showed the evidence. It is commonly held that in the process of burnout, exhaustion comes first, followed by cynicism and diminished professional efficacy. In line with this idea, subjects with intense exhaustion and either a high level of cynicism or a low level of professional efficacy, or both, are considered to have “burned out”. This criterion is called “exhaustion + 1” (Brenninkmeijer & VanYperen, 2003) and was applied to the Japanese working population datasets collected by the authors and their co-researchers (Kitaoka-Higashiguchi, 2005b; Kitaoka-Higashiguchi, Nakagawa, Morikawa, Ishizaki et al., 2004; Kitaoka-Higashiguchi, Tanimoto, Hayasi, Fuchisaki, Syomura et al., 2004; KitaokaHigashiguchi, Ogino, & Masuda, 2004; Maeno et al., 2006; Yoshino et al., 2007). Then, the MBI-GS scale scores of the Japanese working population datasets were divided into a healthy group and a burnout group. Overall, there were 6737 subjects (3720 men, 2951
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women, 66 unknown), all of whom were aged between their 20s and 60s. Subjects’ occupations included company employees (new employees, general employees, and managers), civil servants, and human services professionals (e.g. medical doctors, clinical nurses, teachers, and social workers). In total, 76.0% of the population was categorized into the healthy group, and the remaining 24.0% into the burnout group. In the female group, 32.3% suffered burnout, compared to 17.3% of the men. In their 20s, 30.0% of the Japanese workers were burned out. But as age increased, the risk of burnout clearly declined. In their 50s, 17.6% of workers were burned out. In the human services professionals, 36.1% were burned out, whereas only 17.8% of civil servants and 12.2% of company employees were affected. It is quite obvious that human services workers such as nurses and medical doctors are more prone to burnout compared to civil servants or company employees.
SECTION 3: POSSIBLE CAUSES OF BURNOUT It is desirable to have an overview of the possible causes of burnout among Japanese nurses. In a study of Japanese clinical nurses working at a municipal general hospital, possible causes of burnout were investigated (Kitaoka-Higashiguchi, 2005a). One hundred and eighty-three effective datasets were obtained. Structural equation modeling was used for analysis. The results of the analyses indicated that interpersonal conflict had an indirect relationship via role conflict, but that workload demands exhibited a significant positive correlation to exhaustion. In addition, the coefficient of the path from exhaustion to cynicism confirmed a positive correlation. Cynicism exhibited a negative correlation to organizational resources, that is, supervisor support. The other organizational resource, namely, job decision authority, exhibited a positive correlation to professional efficacy. Using the model obtained by this study, the process of burnout will be discussed. When nurses continue to work in a stressful environment, they experience exhaustion as a stress response. This is the first stage of burnout. Exhaustion is influenced by interpersonal relationships in the workplace. With interpersonal conflict, nurses experience exhaustion as a result of psychological conflict. In the next stage of burnout, nurses lose interest and passion for work as a means of selfdefense against exhaustion and become disinterested
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by creating a psychological distance between the self and work. In accordance with the above-mentioned exhaustion and cynicism, nurses lose self-efficacy in the workplace. Having supervisor support in the workplace can prevent nurses from developing a cynical attitude. Moreover, burnout can be prevented if nurses are allowed to participate in the decision-making processes. In summary, work overload and interpersonal conflict with other staff might be possible causes of burnout among nurses in Japan. In the burnout study among Japanese nurses, it was considered that lack of nursing staff, work overload, and intensive tasks were not directly related to nurse burnout (Inaoka, Matsuno, & Miyazato, 1984). The authors have strong evidence to support the hypothesis that excessive workload is a primary contributor to burnout for Japanese nurses (Higashiguchi et al., 1999; Kitaoka-Higashiguchi & Nakagawa, 2003; Kitaoka-Higashiguchi, Tanimoto, Hayasi, Fuchisaki, Syomura et al., 2004). Large workloads are common in the nursing profession in every country. However, the nurse : patient ratio in Japan is more than three times higher than in the USA. Japanese nurses have too many tasks and too little time to complete those tasks (Kitaoka-Higashiguchi & Nakagawa, 2003).
SECTION 4: CONSEQUENCES OF BURNOUT The consequences of nurse burnout are potentially very serious for patients and institutions, as well as for the nurses themselves. The causal relationship of burnout to medical errors was examined (Kitaoka-Higashiguchi, 2005b). The subjects included 1684 nurses working at psychiatric hospitals. The self-administered survey was conducted and 1295 effective datasets obtained. A causal model was constructed showing the correlation among job stressors, individual style of coping, burnout, and medical errors. Results were as follows: Excessive work load and interpersonal conflict with patients leads to exhaustion, the first step of the burnout. Exhaustion subsequently leads to cynicism, the second step of the burnout. Those nurses who have difficulty dealing with patients are more likely to be cynical, callous, and indifferent towards patients. Those nurses who have an interpersonal conflict with supervisors or co-workers are also prone to have cynical attitudes. Further, it was found that nurses with an emotionally expressive coping style were more likely to experience burnout and to cause accidents. Burnout can lead to deterioration in the
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quality of the care or service that is provided by nurses. Burnout can consequently lead to medical accidents or errors.
SECTION 5: HOW TO PREVENT BURNOUT Preventing nursing burnout is a significant and serious issue. Generally, stress management intervention includes some kind of cognitive–behavioral strategy such as cognitive restructuring, problem-solving training, or relaxation training. However, the difference in efficacy among those intervention strategies has not been determined. Especially with regard to nurses, it is necessary to provide stress management training in a limited time period. Thus, it is important to understand which intervention strategy is most effective for nurses. Therefore, the authors of the present study explored efficacy of existing interventions and then focused on the concept of coping with stress. Sasaki, KitaokaHigashiguchi, Morikawa, and Nakagawa (2009) examined the relationship between coping with stress and burnout in Japanese psychiatric nurses. Complete datasets were collected from 1291 participants, 335 men and 956 women. The data were analyzed using structural equation modeling. In summary, a relationship between coping with stress and positive outcome was seen only for problem solving in men. Both cognitive reinterpretation and problem solving were associated with positive outcomes in women. However, interestingly, problem solving was also associated with negative outcomes in women. The findings obtained in that study suggested that enhancement of cognitive coping skills for female nurses, and problem-solving skills for male nurses, could contribute to prevention of burnout in nurses. Effective intervention strategies might be different for men and women. This difference should be taken into account in stress management interventions for nurses.
DISCUSSION Approximately 36% of human services professionals such as nurses in Japan were burned out, whereas 18% of civil servants, and 12% of company employees seemed to be affected. It is quite obvious that nurses are prone to burnout. The possible causes and consequences of burnout among Japanese nurses were reviewed through studies that had been performed by the authors of the present study and other researchers. The MBI-GS,
© 2012 The Authors Japan Journal of Nursing Science © 2012 Japan Academy of Nursing Science
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which is most universally accepted as the standard for assessing burnout, was used in the authors’ studies. Excessive workload and interpersonal conflict in the workplace were possible causes of burnout among Japanese nurses. The consequences of nurse burnout are potentially very serious. Nurse burnout can lead to medical accidents or errors. Strategies to prevent nursing burnout were then reviewed. Enhancement of cognitive coping skills for female nurses, and problem-solving skills for male nurses, could contribute to prevention of burnout in nurses. Ban (2011) took a systematic review to assess the effect of stress management interventions on nurses and caregivers in Japan. The Japan Medical Abstracts Society-Web ver. 4 was searched restricting by date between 2000 and 2011. Ban found that communication skill training on nurses showed long-term effectiveness to prevent burnout (Shimizu, Mizoue, Kubota, Mishima, & Nagata, 2003; Suzuki et al., 2009). Those results imply that communication skill training, such as assertiveness training, might have favorable long-term effects on burnout among Japanese nurses. However, the effect of other stress management was not evident. On the other hand, leading burnout researchers Leiter and Maslach (2004) developed a new model of the organizational context of burnout with direct reference to a new measure, the Areas of Worklife Scale (AMS) (Leiter, 2006). The model proposed a structured framework for considering six areas of worklife: (i) workload; (ii) control; (iii) reward; (iv) community; (v) fairness; and (vi) values. Those six areas have resonated through the published work on burnout over the previous two decades. Then, Leiter and Maslach (2005) proposed six strategies for preventing job burnout. Masuda, Kitaoka and Ogino (2008) translated their book into Japanese and organized the certain strategy for preventing burnout that could be applied to Japanese workers. Further examination is needed although the authors have found some effectiveness in their intervention (Kitaoka, Morikawa, Nakagawa, Nagai, & Masuda, 2011). Both of the present report and Ban’s review (2011) support the call to scale up burnout prevention strategy for Japanese nurses.
ACKNOWLEDGMENTS This report includes the studies supported by Grantsin-Aid for Scientific Research of Japan (grant no. 14572238, 20592642, 23593416).
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