[Environmental Health and Preventive Medicine 11, 286–291, November 2006]
Original Article
Prevalence of Burnout among Public Health Nurses in Charge of Mental Health Services and Emergency Care Systems in Japan Hirohisa IMAI1, Hiroyuki NAKAO2, Yoshihiko NAKAGI3, Satoko NIWATA1, Yoshihiko SUGIOKA3, Toshihiro ITOH3 and Takahiko YOSHIDA3 1 Department of Epidemiology, National Institute of Public Health, Saitama, Japan Department of Public Health, School of Medicine, University of Miyazaki, Miyazaki, Japan 3 Department of Health Science, School of Medicine, Asahikawa Medical College, Hokkaido, Japan 2
Abstract Objectives: The Community Health Act came into effect in 1997 in Japan. This act altered the work system for public health nurses (PHNs) in public health centers (PHCs) nationwide from regionspecific to service-specific work. Such major changes to working environment in the new system seem to be exposing PHNs to various types of stress. The present study examined whether prevalence of burnout is higher among PHNs in charge of mental health services (psychiatric PHNs) than among PHNs in charge of other services (non-psychiatric PHNs), and whether attributes of emergency mental health care systems in communities are associated with increased prevalence of burnout. Methods: A questionnaire including the Pines burnout scale for measuring burnout was mailed to 525 psychiatric PHNs and 525 non-psychiatric PHNs. The 785 respondents included in the final analysis comprised 396 psychiatric PHNs and 389 non-psychiatric PHNs. Results: Prevalence of burnout was significantly higher for psychiatric PHNs (59.2%) than for non-psychiatric PHNs (51.5%). When prevalence of burnout in each group was analyzed in relation to question responses regarding emergency service and patient referral systems, prevalence of burnout for psychiatric PHNs displayed significant correlations to frequency of cases requiring overtime emergency services, difficulties referring patients, and a feeling of “restriction”. Conclusions: Prevalence of burnout is high among psychiatric PHNs, and inadequate emergency mental health service systems contribute to burnout among these nurses. Countermeasures for preventing such burnout should be taken as soon as possible. Key words: burnout, public health nurses, emergency mental health service systems
sidered to result from a long-term accumulation of stressors associated with occupation and working environments (5). Increasing tension has been developing in the circumstances surrounding medical professions owing to the problems associated with an aging society, the introduction of increasingly complex medical technologies and increased demands for high-quality medical care (6–8). Medicoeconomic crises have triggered various reforms to medical care systems and institutions such as health insurance (9, 10). In April 1997, the Community Health Act came into effect in Japan. The enforcement of this act changed the work system for public health nurses (PHNs) in public health centers (PHCs) nationwide, from a region-specific work system to a service-specific work system (11–13). Such major changes to working environments in the newly introduced system seem to be exposing PHNs to various types of stress. The present study focused on PHNs who were in charge
Introduction The term “burnout” is used to indicate a syndrome characterized by emotional exhaustion, depersonalization and reduced feelings of personal accomplishment (1). Burnout can be viewed as a response to stressful environmental factors, rather than stressful personal factors (2). Numerous studies have investigated burnout, revealing that the condition is more likely to develop in human service professions, particularly the medical and educational professions (3, 4). Burnout is con-
Received Nov. 24, 2004/Accepted Jul. 28, 2006 Reprint requests to: Hirohisa IMAI Department of Epidemiology, Hirohisa Imai, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama 351-0197, Japan TEL: +81(48)458-6167, FAX: +81(48)469-2677 E-mail:
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Environ. Health Prev. Med.
Burnout among PHNs and Emergency Care Systems
the 21 items, 17 are negative and four are positive. Responses to all items are made using a 7-point frequency scale. The composite burnout score is determined as the mean response to all items, with positive items reversed. The present study adopted criteria that were used in a previous study to identify the prevalence of burnout among healthcare professionals (18). Depending on composite burnout score, PHNs were divided into 3 groups. PHNs scoring less than three were rated as mentally stable and healthy PHNs (Group A). PHNs scoring in the range of 3–3.9 were rated as displaying some signs of burnout (Group B). PHNs scoring four or higher were regarded as exhibiting burnout (Group C). Groups B and C were regarded as nurses suffering from burnout. This scale was previously validated on the basis of a sample of more than 5000 individuals, comprising Americans, Canadians, Japanese, Australians, and Israelis (19). Construct validity was established using discriminant validity methods, which utilize correlation-type analysis of the target test, with several other relevant measures. The burnout scale has also shown high testretest reliability and internal consistency (19). Furthermore, a separate questionnaire was prepared to investigate emergency mental health service and patient referral systems involving the PHNs. This questionnaire also contained items asking about individual characteristics (e.g., age of the respondent, population size of region covered by the PHC, and length of nursing career). The Pearson chi-square test was used to compare proportions of subjects with burnout between the psychiatric and control groups. In order to evaluate the relationship between burnout and risk factors, the significance of monotonic trends was assessed by treating the categorical answers as continuous variables in multiple logistic regression models that included age and number of years in current service. These analyses were performed for both groups. Values of p
