FEATURE: JAPAN – Professional quality of life of Japanese nurses/midwives providing abortion/childbirth care

by Maki Mizuno, Emiko Kinefuchi, Rumiko Kimura, Akiko Tsuda

Nursing Ethics 2013;20(5) 539–550  (Open access)  +  PHOTO


This study explored the relationship between professional quality of life and emotion work and the major stress factors related to abortion care in Japanese obstetric and gynecological nurses and midwives. Between October 2011 and January 2012, questionnaires that included questions concerning eight stress factors, the Professional Quality of Life Scale, and the Japanese version of the Frankfurt Emotional Work Scale, were answered by 255 nurses and midwives working in abortion and childbirth services. Professional Quality of Life scores (compassion fatigue, compassion satisfaction, burnout) were significantly associated with stress factors and emotion work. Multiple regression analysis revealed that of all the evaluated variables, the Japanese version of the Frankfurt Emotional Work Scale score for negative emotions display was the most significant positive predictor of compassion fatigue and burnout. The stress factors ‘‘thinking that the aborted fetus deserved to live’’ and ‘‘difficulty in controlling emotions during abortion care’’ were associated with compassion fatigue. These findings indicate that providing abortion services is a highly distressing experience for nurses and midwives.

From the Introduction

In Japan, hospital-based midwives (MWs) provide childbirth as well as abortion services. Therefore, they manage reproductive health in its broadest sense. Abortion is a complex issue, and controversies regarding abortion exist not only in the general public arena but also within the midwifery and nursing professions. Abortion care involves extreme conflict between personal convictions and professional duty among many nurses and MWs. The Japanese law allows women to request termination of pregnancy or abortion up to 21 weeks of gestation for reasons that are considered justifiable, such as rape, physical health, or socioeconomic hardship. The departments of obstetrics and gynecology (maternity units) in the general hospitals of Japan are usually designed to function as outpatient clinics and inpatient units. Therefore, women seeking prenatal care as well as those seeking abortion services are cared for within the same unit. As a result, MWs working in the maternity units of general hospitals assist in childbirth as well as abortion. The effects of this juxtaposition of care for these diametrically opposed situations on nurses and MWs require further investigation. According to a previous qualitative study, many nurses and MWs struggle with the conflict between their personal convictions and emotions and their professional duty when it comes to abortion care.

Compassion fatigue and burnout is an important issue for health care and social workers, and the relationships between different aspects of job satisfaction, compassion fatigue and risk of burnout have been explored. Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that occurs with people-oriented and social work. It is associated with difficulties and feelings of hopelessness while dealing with work or doing a job effectively. These negative feelings usually have a gradual onset. Emotion work and burnout have often been studied in care-giving professionals, such as clinicians, psychologists, social workers, and nurses. Indeed, several studies have directly measured the emotional aspects of job demands when dealing with emotion work or burnout. However, no studies have investigated the relationship between Professional Quality of Life (ProQOL), that is, compassion fatigue, compassion satisfaction and burnout, and emotion work and stress factors among nursing and healthcare professionals, particularly those working in Japanese obstetric and gynecological departments.

From the Background

The phenomenon of compassion fatigue was first identified by Joinson in a study of burnout in nurses who worked in an emergency department. This research identified behaviors that were characteristic of compassion fatigue, including chronic fatigue, irritability, dread of going to work, aggravation of physical ailments, and a lack of joy in life. Figley also suggested that compassion fatigue is a state of tension and preoccupation caused by individual or cumulative traumas of clients. On the other hand, burnout is cumulative stress caused by the demands of daily life. It is a state of physical, emotional, and mental exhaustion and is caused by a depletion of the ability to cope with one’s environment, particularly work environment. Burnout results from prolonged high levels of stress at work, and if not addressed, it leads to resignation of health-care providers from work. Figley regarded compassion fatigue as a form of burnout. The concepts of compassion fatigue and burnout are closely related and sometimes ambiguously defined. In a study conducted by Leiter et al, an inverse correlation was found between burnout in nurses and patient evaluations of the quality of care. Their study revealed that nurses felt exhausted or frequently expressed a desire to quit if their patients were less satisfied with the care provided to them. Recently, burnout has been conceptualized as a psychological syndrome that occurs in response to chronic on-the-job interpersonal stressors. According to Zapf et al, burnout renders individuals incapable of adequately managing their emotions while interacting with clients. A relationship between burnout and emotion work was recently reported in a health-care setting. Health-care professionals, especially nurses, are at a high risk of burnout because their job requires a high level of emotion work.

From the Aim

This study aimed to explore the relationship between ProQOL and emotion work and stress factors related to abortion care in Japanese obstetric and gynecological nurses and MWs. Although cultural contexts and specific care practices among nurses and MWs exhibit international variation, understanding their impact on nursing and midwifery staff in Japan may help in understanding factors associated with abortion better. A deeper insight into this subject will allow service providers to institute processes, maximize staff well-being, and improve the quality of patient care. This study was initiated as a result of service managers realizing the lack of adequate information on abortion care providers and the need for a greater professional understanding while dealing with patients.

From the Design

The study was a cross-sectional survey involving registered nurses (RNs), licensed practice nurses (LPNs), and MWs from 341 Japanese hospitals of similar size and geographical location. Sample: The research protocol and participant selection processes were initially proposed to 1,015 hospitals (obstetrics and gynecology) selected using the Japanese Welfare and Service Network System. Of these, 341 hospitals (33.6%) agreed to participate in this study. Only those nurses and MWs who worked in the maternity units of these hospitals and dealt with childbirth as well as abortion care were included. A suitable sample of nurses and MWs was thus recruited.

Study limitations

This study had several limitations. First, those who chose not to respond to the survey could have had higher or lower risk for burnout and compassion fatigue. Second, this study had a cross-sectional design, so the analysis does not provide an understanding of whether the prevalence of burnout and compassion fatigue varies over time. Third, in addition to the measured variables, there may have been others that could have aided in the prediction of ProQOL in these participants. Fourth, working conditions and educational background also affect professional confusion and ethical dilemmas; these factors were not considered in this study. Future studies should assess the working environment of participants, the method of abortion, and the relative contribution of different exposure levels to the development of stress symptoms in the participants.

From the Conclusion

This study showed that there was a lack of awareness regarding the relationship between ProQOL and emotion work in nursing and midwifery staff providing abortion and childbirth services in Japan. ProQOL scores obtained for the respondents in this study suggest that providing abortion services was a highly distressing experience. In addition, their jobs required a high level of emotion work. Nursing staff who were involved in a higher number of first-trimester abortion cases handled in the previous year had a higher risk of compassion fatigue and burnout, while they also had a lower degree of compassion satisfaction. This situation could be improved by increasing awareness about the significant impact of abortion care on nurses and MWs working in obstetrics and gynecology departments. Decreasing the professional confusion and distress related to abortion care in nursing and midwifery professionals in Japan should be a priority. In addition, the expectations of abortion caregivers should be clarified, and the system must be altered to reduce distress symptoms in hospital staff and help them acquire enhanced skills for dealing with stress.

Editor’s Note: This study, published in 2013, popped up during a search of PubMed for something else. It was in a journal I have never read. I tried to contact the authors, who hold the copyright, for permission to reprint here more of the text than I would usually have done, but none of them has published anything for four or five years and the email provided for the first author bounced. Sage’s copyright permissions webpage was down and the alternative email suggested to contact has not replied. The article is full of detailed statistical tables and calculations that many of us would not understand. The text excerpted here is really the thought part of the paper. It teaches a lot about the need to deal with “emotion work in nursing and midwifery”, including but not only in abortion care.