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

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

NursingEthics 2013;20(5) 539–550 (Openaccess) + PHOTO


This study explored the relationship between professionalquality of life and emotion work and the major stress factors related toabortion care in Japanese obstetric and gynecological nurses and midwives.Between October 2011 and January 2012, questionnaires that included questionsconcerning eight stress factors, the Professional Quality of Life Scale, andthe Japanese version of the Frankfurt Emotional Work Scale, were answered by255 nurses and midwives working in abortion and childbirth services.Professional Quality of Life scores (compassion fatigue, compassionsatisfaction, burnout) were significantly associated with stress factors andemotion work. Multiple regression analysis revealed that of all the evaluatedvariables, the Japanese version of the Frankfurt Emotional Work Scale score fornegative emotions display was the most significant positive predictor of compassionfatigue and burnout. The stress factors ‘‘thinking that the aborted fetusdeserved to live’’ and ‘‘difficulty in controlling emotions during abortioncare’’ were associated with compassion fatigue. These findings indicate thatproviding abortion services is a highly distressing experience for nurses andmidwives.

From the Introduction

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

Compassion fatigue and burnout is an important issue forhealth care and social workers, and the relationships between different aspectsof job satisfaction, compassion fatigue and risk of burnout have been explored.Burnout is a syndrome of emotional exhaustion, depersonalization, and reducedpersonal accomplishment that occurs with people-oriented and social work. It isassociated with difficulties and feelings of hopelessness while dealing withwork or doing a job effectively. These negative feelings usually have a gradualonset. Emotion work and burnout have often been studied in care-givingprofessionals, such as clinicians, psychologists, social workers, and nurses.Indeed, several studies have directly measured the emotional aspects of jobdemands when dealing with emotion work or burnout. However, no studies have investigatedthe relationship between Professional Quality of Life (ProQOL), that is,compassion fatigue, compassion satisfaction and burnout, and emotion work andstress factors among nursing and healthcare professionals, particularly thoseworking in Japanese obstetric and gynecological departments.

From the Background

The phenomenon of compassion fatigue was first identified byJoinson in a study of burnout in nurses who worked in an emergency department.This research identified behaviors that were characteristic of compassionfatigue, including chronic fatigue, irritability, dread of going to work,aggravation of physical ailments, and a lack of joy in life. Figley alsosuggested that compassion fatigue is a state of tension and preoccupationcaused 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 stateof physical, emotional, and mental exhaustion and is caused by a depletion ofthe ability to cope with one’s environment, particularly work environment.Burnout results from prolonged high levels of stress at work, and if notaddressed, it leads to resignation of health-care providers from work. Figleyregarded compassion fatigue as a form of burnout. The concepts of compassionfatigue and burnout are closely related and sometimes ambiguously defined. In astudy conducted by Leiter et al, an inverse correlation was found betweenburnout in nurses and patient evaluations of the quality of care. Their studyrevealed that nurses felt exhausted or frequently expressed a desire to quit iftheir patients were less satisfied with the care provided to them. Recently,burnout has been conceptualized as a psychological syndrome that occurs inresponse to chronic on-the-job interpersonal stressors. According to Zapf etal, burnout renders individuals incapable of adequately managing their emotionswhile interacting with clients. A relationship between burnout and emotion workwas recently reported in a health-care setting. Health-care professionals,especially nurses, are at a high risk of burnout because their job requires ahigh level of emotion work.

From the Aim

This study aimed to explore the relationship between ProQOLand emotion work and stress factors related to abortion care in Japaneseobstetric and gynecological nurses and MWs. Although cultural contexts andspecific care practices among nurses and MWs exhibit international variation,understanding their impact on nursing and midwifery staff in Japan may help inunderstanding factors associated with abortion better. A deeper insight intothis subject will allow service providers to institute processes, maximizestaff well-being, and improve the quality of patient care. This study wasinitiated as a result of service managers realizing the lack of adequateinformation on abortion care providers and the need for a greater professionalunderstanding while dealing with patients.

From the Design

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

Study limitations

This study had several limitations. First, those who chosenot to respond to the survey could have had higher or lower risk for burnoutand compassion fatigue. Second, this study had a cross-sectional design, so theanalysis does not provide an understanding of whether the prevalence of burnoutand compassion fatigue varies over time. Third, in addition to the measuredvariables, there may have been others that could have aided in the predictionof ProQOL in these participants. Fourth, working conditions and educationalbackground also affect professional confusion and ethical dilemmas; thesefactors were not considered in this study. Future studies should assess theworking environment of participants, the method of abortion, and the relativecontribution of different exposure levels to the development of stress symptomsin 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.