Background: The purpose of this study was to elucidate the stages of nurse burnout in hospitals (their states of emotional exhaustion and depersonalization) as well as factors related to the nurses personal characteristics and coping behaviors in order to obtain suggestions for stress and health management strategies that nurses themselves can employ. Methods: We conducted a cross-sectional study using anonymous self-administered questionnaires. The subjects were nurses employed at public hospitals with 500 beds in 3 cities in Hokkaido, Japan. The questionnaire items for burnout were those included on the Japanese Maslach Burnout Inventory (MBI), which are designed to ascertain the subjects’ emotional exhaustion, depersonalization, and sense of personal accomplishment. In addition, we used 11 items related to physical and mental stress responses on the Stress Coping Inventory and the Brief Job Stress Questionnaire to determine factors such as the nurses’ basic attributes, whether or not they worked night shifts, and their overtime hours, etc. Results: We received responses from 1461 hospital nurses. Those whose scores for both emotional exhaustion and depersonalization were the mean or above were 40.2% of those in their twenties, 35.8% of those in their thirties, and 26.8% of those in their forties or older. The results of logistic regression analysis indicated that among those in the group that scored high for both emotional exhaustion and depersonalization, the influential factors were stress score (odds ratio 1.889), twenties age group (odds ratio 1.982), thirties age group (odds ratio 1.720), coping behavior: avoidance-focused behaviors (odds ratio 1.140), and engaged in childcare (odds ratio 0.487). Similarly, when looked at by age group, being in the twenties age group and having a spouse were influential factors (odds ratio 3.114 - 4.171). Conclusion: The results of this study elucidated the fact that for hospital nurses, the burnout stage, age, state of physical and mental stress response, and coping behavior can be effectively used as predictive indices.
Although the job separation rate for Japanese nurses is on a declining trend, in general it hovers around 11% and is 7.5% for new nurses [
Since 2015, in Japan, Industrial Safety and Health Act has required employers with at least 50 employees to provide worksite stress checks [
The purpose of this study was to elucidate the stages of nurse burnout in hospitals (their states of emotional exhaustion and depersonalization) as well as factors related to the nurses themselves.
The subjects were nurses who work in public hospitals with 500 beds in the major cities and regional cities of Hokkaido. Since their normal work schedules, including night shift work, may differ, directors and deputy directors of nursing departments as well as head nurses were excluded. All outpatient and inpatient wards were included among the subjects. The survey period was from December 2015 to January 2016. The survey was an anonymous, self-administered drop-off survey. The survey description and questionnaire forms were distributed to the subjects by the nursing departments of the participating hospitals and they were recovered by the researcher from each hospital. The subjects were also guaranteed that their participation in the survey would be of their own free will. Consent was assumed when the subjects returned their completed questionnaire forms to the researcher.
Survey items were as follows;
1) Burnout: Burnout was defined as “A long-term stress response that occurs as a result of experiencing long-term and repeated stress.” We used the Japanese Burnout Scale created by Kubo that was based on the Maslach Burnout Inventory (MBI) of Maslach & Jackson [
2) Physical and mental stress state: We utilized the “physical and mental stress response” question items on the Workplace Stress Simple Questionnaire that was examined by the Ministry of Health, Labour and Welfare group (representative: Terukazu Shimomitsu) [
3) Stress coping: We used the Coping Scale developed by Ozeki et al. (1993) [
4) Nurses’ basic attributes: Age, sex, marital status, engaged in childcare, engaged in nursing care, number of years employed at their hospital, work schedule and taking of annual paid leave, and monthly hours of overtime.
The nurses’ characteristics, burnout scores, stress scores, and coping scores were calculated as the fundamental statistics. Since decline in personal accomplishment has a weaker relation to burnout than the other 2 factors, only the 2 sub-items of emotional exhaustion and depersonalization were used in analysis as the central concepts of burnout. In order to investigate the relation of the 2 sub-scales of burnout and personal attributes to the stress scores and coping, we used the independent t-test and one-way analysis of variance. We also divided the burnout sub-scales of emotional exhaustion and depersonalization into 2 groups based on means scores (High-score group and Low-score group). We considered cases in which both items were in the High-score group as the “Emotion/depersonalization group.” Those that had low emotional exhaustion scores but high depersonalization scores were considered the “Depersonalization group.” Those that had high emotional exhaustion scores and low depersonalization scores were considered the “Emotion group.” Finally, those who had low scores in both sub-scales were considered the “Low-score group.” Coping scores were also handled similarly using a cutoff for the mean scores for the Problem, Emotion, and Avoidance/Escape items in order to divide the subjects into a High-score and a Low-score group. In order to investigate the relation of the 4 types of burnout and the nurses’ characteristics with physical/mental stress and stress coping, we performed multiple logistic regression analysis with the 4 types of burnout as the dependent variable and the stress scores, coping scores, and nurses’ attributes as the independent variables. Analysis was performed using SPSS23.0v.
This survey was conducted with the approval of the Institutional Review Board of the Graduate School of Health Sciences, Hokkaido University and the Institutional Review Boards of the surveyed facilities. The facilities were provided with an overview of the survey and the ethical considerations in writing. The questionnaires were distributed to the individual subjects by the nursing departments at each facility and were recovered by the researcher later.
A total of 1890 survey forms were distributed and 1509 were recovered. The 1461 forms that did not have invalid or missing responses were used for the purpose of analysis (recovery rate: 79.8%, effective recovery rate: 96.8%). The subjects were comprised of 1335 women (91.8%), 610 subjects were in their twenties (41.8%), 452 subjects were in their thirties (30.9%), and 399 subjects were in their forties (27.3%). Five hundred two subjects were married (34.6%), 421 were raising children at the time of the survey (29.0%), and 120 were engaged in nursing care (8.2%). Three hundred five subjects were receiving treatment as outpatients for some reason (20.9%). The mean number of years of experience as a nurse was 11.6 ± 9.0 years. Our investigation of their work schedules indicated that 296 worked the normal day shift (20.4%) and 1125 worked other shifts (76.3%). The number of hours of overtime per month were as follows: 71 subjects reported they worked no overtime (4.9%), while most subjects (703 subjects; 48.9%) reported working under 10 hours of overtime, followed by 444 subjects who reported working 10 - 20 hours of overtime (30.9%). Analysis of the geographical location of the subjects indicated that 1074 lived in cities (73.5%) and 387 lived in regional cities (26.5%) in
The mean scores for the 3 burnout sub-scales were as follows: Emotional exhaustion was 3.4 ± 0.9, depersonalization was 2.1 ± 0.8, and decline in sense of personal accomplishment was 3.7 ± 0.7. Cronbach’s alpha was 0.829 (5 items), 0.852 (6 items), and 0.774 (6 items). Mean coping scores were as follows: Problems
N = 1461 | ||||
---|---|---|---|---|
Item | N | % | ||
Sex (a) | Female | 1335 | 8.2 | |
Male | 119 | 91.8 | ||
Age group | 20s | 610 | 41.8 | |
30s | 452 | 30.9 | ||
40s and older | 399 | 27.3 | ||
Marital status (a) | Unmarried | 950 | 65.4 | |
Married | 502 | 34.6 | ||
Engaged in childcare (a) | No | 1031 | 71.0 | |
Yes | 421 | 29.0 | ||
Engaged in nursing care (a) | No | 1338 | 91.8 | |
Yes | 120 | 8.2 | ||
Years of experience as a nurse | 11.6 ± 9.0 | |||
No. of years at present position | 3.7 ± 3.5 | |||
Work schedule | Day shift | 296 | 20.4 | |
Other shifts | 1125 | 78.4 | ||
Other | 20 | 1.2 | ||
No. of overtime hours worked in the previous month (a) | None | 71 | 4.9 | |
Under 10 | 703 | 48.9 | ||
10 to under 20 | 444 | 30.9 | ||
20 to under 30 | 145 | 10.1 | ||
30 to under 40 | 52 | 3.6 | ||
40 or more | 24 | 1.7 | ||
No. of paid vacation days taken during the previous fiscal year (a) | 0 to under 10 | 932 | 65.8 | |
10 to under 20 | 448 | 31.6 | ||
20 to under 30 | 27 | 1.9 | ||
30 to under 40 | 4 | 0.3 | ||
40 to under 50 | 4 | 0.3 | ||
50 or more | 2 | 0.1 | ||
Receiving outpatient care (a) | No | 1154 | 79.1 | |
Yes | 305 | 20.9 | ||
Location of hospital | Major city | 1074 | 73.5 | |
Regional city | 387 | 26.5 | ||
(a): Indicates the frequency and rate of the respondents.
was 7.1 ± 2.9, Emotions was 4.5 ± 2.0, and Avoidance/Escape was 8.7 ± 3.2. Cronbach’s alpha was 0.670 (5 items), 0.564 (3 items), and 0.696 (6 items). The state of physical and mental stress was calculated as the stress score, and the mean figure was 5.1 ± 2.9 (range: 0 - 11 points). The Cronbach’s alpha for the stress score was 0.821 (11 items;
Analysis of the burnout categories indicated that 514 subjects (35.2%) were in the “Emotion/Depersonalization Group” in which both emotional exhaustion and depersonalization were high, 129 subjects (8.8%) were in the “Depersonalization Group” in which emotional exhaustion was low but depersonalization was high, 303 subjects (20.7%) were in the “Emotion Group” in which emotional exhaustion was high but depersonalization was low, and 515 subjects (35.2%) were in the “Low Group” in which both emotional exhaustion and depersonalization were low. Analysis of the data by age group indicated that in the Emotion/Depersonalization Group 40.2% were in their twenties, 35.8% were in their thirties, and 26.8% were in their forties. However, in the Low Group 28.6% were in their twenties, 35.6% were in their thirties, and 45.1% were in their forties. Analysis by geographical region indicated that more nurses who were in their twenties and in the Emotion/Depersonalization Group were located in major cities rather than regional cities (major cities:regional cities = 43.6%:39.4%). More of those in their thirties were located in regional cities than in major cities (major cities:regional cities = 25.9%:39.3%;
N = 1461 | |
---|---|
mean ± SD | |
Burnout score | |
Emotional exhaustion | 3.4 ± 0.9 |
Depersonalization | 2.1 ± 0.8 |
Decline in sense of personal accomplishment | 3.7 ± 0.7 |
Coping score | |
Problem-focused | 7.1 ± 2.9 |
Emotion-focused | 4.5 ± 2.0 |
Avoidance-focused | 8.7 ± 3.2 |
Stress score ( range: 0 - 11) | 5.1 ± 2.9 |
Stress score: Total score of 11 items that indicate the state of physical and mental stress (No appetite, become excited, have anxiety, feel listless, feel blue, feel bothersome, cannot calm down, cannot sleep, feel severely tired, feel exhausted, feel depressed).
4 Types of Burnout | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Low Group | Emotion Group | Depersonalization Group | Emotion/Depersonalization Group | |||||||
n | (%) | n | (%) | n | (%) | n | (%) | total | ||
All | Age 20 and above | 174 | (28.5) | 145 | (23.8) | 46 | (7.5) | 245 | (40.2) | 610 |
(n = 1461) | Age 30 and above | 161 | (35.6) | 87 | (19.2) | 42 | (9.3) | 162 | (35.8) | 452 |
Age 40 and above | 180 | (45.1) | 71 | (17.8) | 41 | (10.3) | 107 | (26.8) | 399 | |
Major city | Age 20 and above | 36 | (30.8) | 24 | (20.5) | 6 | (5.1) | 51 | (43.6) | 117 |
(n = 1074) | Age 30 and above | 52 | (44.8) | 21 | (18.1) | 13 | (11.2) | 30 | (25.9) | 116 |
Age 40 and above | 63 | (40.9) | 26 | (16.9) | 14 | (9.1) | 51 | (33.1) | 154 | |
Regional city | Age 20 and above | 138 | (28.0) | 121 | (24.5) | 40 | (8.1) | 194 | (39.4) | 493 |
(n = 387) | Age 30 and above | 109 | (32.4) | 66 | (19.6) | 29 | (8.6) | 132 | (39.3) | 336 |
Age 40 and above | 117 | (47.8) | 45 | (18.4) | 27 | (11.0) | 56 | (22.9) | 245 |
Analysis of the relation of burnout score to the other variables indicated that age group (twenties and thirties), married, raising children, high stress score, and the 3 coping sub-scales were significantly correlated (p < 0.001). There was no correlation with outpatient care, number of overtime hours, or work schedule (including night shift).
We performed multiple logistic regression analysis with the 4 types of burnout as the dependent variables and the items found to have a significant relation to burnout (nurses’ attributes, coping, and stress score) as the independent variables, and we divided the results by age group. The results indicated that, when we used the Burnout Low Group as a reference category, being in the twenties age group (odds ratio 2.073, p = 0.001) and the stress score (odds ratio 1.461, p < 0.000) had an effect in the Emotion Group, while childcare (odds ratio 0.517), emotionally-focused behaviors related to coping behaviors (odds ratio 0.767, p < 0.000), and avoidance behaviors (odds ratio 1.190, p < 0.000) had an effect in the Depersonalization Group regardless of the age group of the subject.
In the Emotion/Depersonalization Group, the influential factors were being in the twenties age group (odds ratio 1.982, p = 0.002), being in the thirties age group (odds ratio 1.720, p = 0.010), childcare (odds ratio 0.497, p < 0.000), and stress score (odds ratio 1.889, p < 0.000;
N = 1461 | |||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
4 Types of Burnout | Factor | Odds ratio | 95% Confidence Interval | p-value | Odds ratio | 95% Confidence Interval | p-value | Odds ratio | 95% Confidence Interval | p-value | |||||||
20s (n = 610) | 30s (n = 452) | 40s and older (n = 399) | |||||||||||||||
Emotion High Group | Personal attributes | Spouse | 3.114 | 1.288 | - | 7.526 | 0.012 | 1.081 | 0.501 | - | 2.334 | 0.842 | 0.683 | 0.332 | - | 1.405 | 0.300 |
Children | 0.235 | 0.057 | - | 0.964 | 0.044 | 0.652 | 0.308 | - | 1.381 | 0.264 | 1.009 | 0.489 | - | 2.083 | 0.981 | ||
Night shift | 1.222 | 0.494 | - | 3.027 | 0.664 | 0.826 | 0.426 | - | 1.604 | 0.573 | 0.570 | 0.294 | - | 1.105 | 0.096 | ||
Coping | Problem-focused | 1.070 | 0.974 | - | 1.175 | 0.158 | 1.002 | 0.894 | - | 1.122 | 0.977 | 1.008 | 0.899 | - | 1.130 | 0.893 | |
Emotion-focused | 0.918 | 0.797 | - | 1.056 | 0.232 | 0.977 | 0.832 | - | 1.147 | 0.775 | 0.982 | 0.816 | - | 1.182 | 0.848 | ||
Avoidance-focused | 1.026 | 0.944 | - | 1.115 | 0.553 | 1.023 | 0.929 | - | 1.126 | 0.648 | 1.020 | 0.921 | - | 1.130 | 0.699 | ||
Stress | Stress score | 1.521 | 1.363 | - | 1.696 | 0.000 | 1.411 | 1.252 | - | 1.590 | 0.000 | 1.472 | 1.295 | - | 1.674 | 0.000 | |
Depersonalization Group | Personal attributes | Spouse | 4.171 | 1.467 | - | 11.862 | 0.007 | 0.675 | 0.250 | - | 1.824 | 0.438 | 0.945 | 0.397 | - | 2.246 | 0.898 |
Children | 0.924 | 0.228 | - | 3.737 | 0.912 | .503 | 0.188 | - | 1.343 | 0.170 | 0.539 | 0.224 | - | 1.296 | 0.167 | ||
Night shift | 0.702 | 0.244 | - | 2.020 | 0.512 | 1.198 | 0.460 | - | 3.125 | 0.711 | 1.074 | 0.469 | - | 2.460 | 0.867 | ||
Coping | Problem-focused | 1.080 | 0.943 | - | 1.237 | 0.268 | 0.991 | 0.859 | - | 1.144 | 0.902 | 1.058 | 0.923 | - | 1.213 | 0.417 | |
Emotion-focused | 0.742 | 0.608 | - | 0.906 | 0.003 | 0.837 | 0.685 | - | 1.023 | 0.082 | 0.746 | 0.600 | - | 0.928 | 0.009 | ||
Avoidance-focused | 1.227 | 1.092 | - | 1.379 | 0.001 | 1.141 | 1.006 | - | 1.295 | 0.040 | 1.190 | 1.055 | - | 1.343 | 0.005 | ||
Stress | Stress score | 1.250 | 1.075 | - | 1.453 | 0.004 | 1.191 | 1.025 | - | 1.384 | 0.022 | 1.376 | 1.190 | - | 1.591 | 0.000 | |
Emotion/ Depersonalization Group | Personal factors | Spouse | 3.661 | 1.475 | - | 9.084 | 0.005 | 0.821 | 0.392 | - | 1.720 | 0.601 | 0.572 | 0.278 | - | 1.175 | 0.128 |
Children | 0.371 | 0.097 | - | 1.425 | 0.149 | 0.414 | 0.199 | - | 0.860 | 0.018 | 0.683 | 0.332 | - | 1.405 | 0.301 | ||
Night shift | 1.536 | 0.611 | - | 3.858 | 0.361 | 0.569 | 0.300 | - | 1.081 | 0.085 | 0.499 | 0.259 | - | 0.964 | 0.039 | ||
Coping | Problem-focused | 1.072 | 0.973 | - | 1.180 | 0.158 | 0.946 | 0.849 | - | 1.054 | 0.312 | 1.017 | 0.909 | - | 1.138 | 0.767 | |
Emotion-focused | 0.848 | 0.735 | - | 0.979 | 0.025 | 0.917 | 0.788 | - | 1.067 | 0.264 | 0.872 | 0.728 | - | 1.045 | 0.138 | ||
Avoidance-focused | 1.144 | 1.051 | - | 1.244 | 0.002 | 1.123 | 1.024 | - | 1.231 | 0.014 | 1.152 | 1.040 | - | 1.276 | 0.006 | ||
Stress | Stress score | 2.129 | 1.883 | - | 2.407 | 0.000 | 1.690 | 1.502 | - | 1.900 | 0.000 | 1.874 | 1.635 | - | 2.148 | 0.000 |
The Low Group was used as the reference category. The age groups were 20s, 30s, and 40s and older. Stress score: Total score of 11 items that indicate the state of physical and mental stress (No appetite, become excited, have anxiety, feel listless, feel blue, feel bothersome, cannot calm down, cannot sleep, feel severely tired, feel exhausted, feel depressed). Score range: 0 - 11 points.
Next, we performed multiple logistic regression analysis with the 4 burnout categories by age group as the dependent variables and the items that were found to have a significant correlation to burnout (nurses’ attributes, coping, stress score) as the independent variables. The results indicated that, when the Burnout Low Group was used as a reference category, marital status (odds ratio 3.114, p = 0.012) and childcare (odds ratio 0.235, p = 0.044) only in the twenties age group had an effect in the Emotion Group, and that the stress score had a strong effect regardless of the age group (odds ratio 1.411 - 1.521, p = 0.000). Coping was not found to have had an effect. In the Depersonalization Group, marital status (odds ratio 4.171, p = 0.007) was significant only for those in the twenties age group. No other personal attributes were found to be related. Our analysis of coping indicated that although emotion-focused behaviors (odds ratio 0.742, p = 0.003) were related only in the twenties age group, avoidance behaviors were related to all age groups (odds ratio 1.141 - 1.227, p = 0.001 - 0.040). Stress score was a strong influential factor for all age groups (odds ratio 1.191 - 1.376, P = 0.000 - 0.02). In the Emotion/Depersonalization Group, being married (odds ratio 3.661, p = 0.005) had an effect on those in the twenties age group, childcare (odds ratio 0.414, p = 0.018) had an effect on those in the thirties age group, and night shift (odds ratio 0.499, p = 0.039) had an effect on those in the forties age group. Analysis of coping indicated that emotion-focused behaviors (odds ratio 0.848, p = 0.025) had an effect only on those in the twenties age group, while avoidance had an effect on all age groups (odds ratio 1.123 - 1.152, p = 0.002 - 0.014). Stress score was an influential factor for all age groups (odds ratio 1.690 - 2.129, p < 0.000;
We were able to elucidate the state of burnout among nurses employed in hospitals in regional cities in Hokkaido.
The nurses who were the subjects of this study included more who were in younger age groups as compared to the statistics indicated in the nurses’ employment survey conducted by the Ministry of Health, Labour and Welfare in 2015 (twenties = 22%, thirties = 31%, forties and older = 47%) [
In comparison to the results of the survey of nurses at hospitals with at least 800 beds conducted by Ogata et al. (emotional exhaustion, depersonalization, sense of personal accomplishment = 3.6, 2.3, 2.5) [
Analysis of coping behaviors indicated that those of all ages in the Depersonalization Group were affected by avoidance behaviors. Depersonalization is thought to be a coping behavior that arises as a result of emotional exhaustion [
The stress scores used for this study are based on items that examine the degree of physical and psychological fatigue. A high stress score is considered to be related to nurse burnout or, in other words, a strong indicator of burnout prediction. Since 2015 it has become mandatory for workplaces with at least 50 employees to conduct workplace stress checks, and therefore many hospitals are conducting workplace stress checks for their nursing staff. The items on our questionnaire that were related to physical and mental stress responses can be used not only for health management but also in order to allow nurses themselves to become more aware of indications that may predict the onset of burnout. Therefore, we believe these questionnaire items are useful in both workplace management and health management. However, since nurses can experience burnout even with a stress score of 6 or less, it is believed that there are multiple factors influencing burnout, some of which are exclusive of psychosomatic stress symptoms. Therefore, it is necessary to educate nurses in their 20s on emotional coping strategies. Moreover, although it is not necessary to have a spouse risk the occurrence of burnout, it is important to consider ways to balance family life and work, taking into account career development as well. It was suggested that efforts geared toward work-life balance for nurses in their 20s and 30s are important. Nurses who are raising children are likely to face difficulties in balancing their nursing career with family life. Restricting night-shift work and decreasing working hours can help prevent burnout among such nurses. Thus, it is necessary to promote a daily work style that supports child rearing. In the case of nurses in their 40s, fatigue may increase due to day-shift work where the workload increases. I think that it is necessary to assign shift work while being mindful of the individual’s workload and the negative impact of night shifts. An appropriate amount of night shifts can ease the pressure. Along with the stress score, it was shown that nurses’ age, whether or not they engaged in child-rearing, and their coping styles are individual factors related to burnout. From this, we consider the complex relationship between stress score and other factors in nurse burnout prediction and examine an algorithm related to burnout.
This study was a cross-sectional study targeting 4 relatively large-scale facilities in Hokkaido, and as a result its representativeness of the nursing population as a whole is limited. In addition, we investigated burnout and related factors of nurses who are employed in hospitals by age group and state of burnout. We did not investigate other factors such as workplace environment or human relations in this study. Therefore, it remains necessary to verify a burnout predictive index as well as nurses’ desire to leave their jobs.
Analysis of the nurses who are employed at hospitals and who are at high risk of burnout due to a high level of emotional exhaustion which causes depersonalization indicated that 40.2% were in their twenties, 35.8% were in their thirties, and 26.8% were in their forties. The factors related to the burnout state differed according to the nurses’ age groups. The factors found to be related to burnout were marital status and childcare for nurses in their twenties, and childcare for nurses in their thirties. Coping behaviors were not influenced by problem-focused behaviors, but non-emotion-focused behaviors and avoidance-focused behaviors were found to be influential factors. It was found that stress score, which indicates physical and mental stress responses, was a factor that influenced all burnout types for all age groups, and in particular could be used as a predictive index for those who had high scores for both emotional exhaustion and depersonalization.
The authors would like to express their appreciation for the kind cooperation of all the nurses who participated in this study.
The authors declare that there were no conflicts of interest to report.
This study was partially funded by a Ministry of Public Management, Home Affairs, Posts and Telecommunications SCOPE regional ICT promotion research and development grant (152301001) and was conducted as an empirical study for use in cloud services and the development of ICT for the purpose of the health management of nurses and the improvement of regional medical care.
Sumi, N., Yoshida, Y., Sugimura, N. and Yano, R. (2018) Experienced by Nurses Working in Hospitals and Related Factors. Open Journal of Nursing, 8, 257-271. https://doi.org/10.4236/ojn.2018.84022