2021 Volume 21 Issue 1 Pages 25-37
This study examined the factors associated with nursing professionals' attitudes toward second-trimester abortion care. A cross-sectional survey of nursing professionals working in hospitals providing birthing services in Japan was conducted. The Japanese short version of the Utrecht Work Engagement Scale, the Professional Quality of Life Scale-Japanese version-V, and a measurement of nurses' job satisfaction with their work situation were employed. Overall, 266 nursing professionals responded (response rate 26.6%), of whom 236 (90.4%) who had experience of assistance in second-trimester abortions were included in the analysis. A logistic regression analysis identified the following factors to be associated with attitude towards the second-trimester abortion care: nursing occupational category, work position, years of experience, job satisfaction subscales including “Pay,” “Compassion Fatigue/Secondary Trauma” on the professional quality of life, and age. As compared to the nursing professionals with reluctant attitudes, those with active ones toward their role had higher work engagement, greater satisfaction with second-trimester abortion care, and lower compassion fatigue. Increasing the level of job satisfaction may prevent burnout among the nursing professionals. Furthermore, the development of well-designed training and support systems might augment active attitudes toward abortion care.
Nurses care more frequently for patients and their families experiencing traumatic events [1]. Nursing professionals in the perinatal field provide care for women and their families who experience not only the birth of infants but also their loss due to miscarriage or stillbirth. Furthermore, they are often involved in induced abortions, nursing professionals who care for women having abortions are a high-risk group for posttraumatic stress disorder (PTSD) [2]. Particularly for midwives providing care in second-trimester abortions, this is a stressful experience that can affect their mental health and working life [3]. For nurses delivering abortion care, there is a conflict between resistance and acceptance of abortion [4]. In midwives, the conflict between personal and professional values contribute to the inability to perceive second-trimester abortion care as their responsibility, indicating the difficulty of providing nursing care [5]. Thus, it can be said that nurses who provide second-trimester abortion care experience unique occupational stress; if it remains unsolved, it can cause burnout [6] and affect job performance. Furthermore, due to the nature of the work, nursing demands sympathy and compassion, thus involving a risk of compassion fatigue. In addition, compassion fatigue impacts their health status negatively, indirectly reducing productivity in healthcare settings and increasing the rate at which nurses quit their jobs [7].
Nevertheless, in examining the mental health of workers, work engagement has been proposed as a concept that expresses an attitude toward work that confronts the negative concept of burnout.
Its determinants include both job and personal resources. This relationship has been observed in the “Job Demands–Resources Model” (Figure 1) [8,9]. In previous research on nurses' work engagement, nurses' occupational stress and midwives' job comfort (consisting of relationships, compensation, job content, and human resources) related to work engagement, in addition, it has been observed that a conscious effort to act as a professional reduces moral distress and raises the work engagement of individual nurses [10,11,12]. Additionally, work engagement has been examined in relation to attitudes toward work as a mediating factor [9]. These findings suggest that work engagement and burnout are associated with whether or not nurses provide nursing care with an awareness of their role as professionals. However, it has been pointed out that they are easily influenced by the characteristics of the nursing subject and the workplace; it has been anticipated that reports will take into account the differences in departments and job types [10]. Thus far, an examination of the relationship between work engagement and attitudes toward second-trimester abortion care has not been conducted.
Previous results suggest that factors related to occupational stress and work engagement may influence nursing professionals' attitudes toward abortion care. Therefore, this study purported to identify the factors related to the Japanese nursing professionals' attitudes toward second-trimester abortion care. The clarifications of these factors will lead to proposals for support measures to alleviate nurses' stress and improve the quality of the care provided by them.
1. Subjects
In all, 500 institutions were randomly selected from those that provided birthing services listed on the website of the Japan Association of Obstetricians and Gynecologists in each prefecture. Two sets of survey forms were circulated in each hospital. The survey was conducted between June 2018 and March 2019. The survey forms were collected from 266 nursing professionals (response rate: 26.6%), of which 261 provided valid responses (valid response rate: 98.1%). Of these 261 respondents, 236 (90.4%) who had experience in assisting in second-trimester abortions were included in the analysis.
2. Survey content
1) Background of the subjects
The subject information consisted of 10 items: age, type of work institution, years of experience, years of work, position, license possessed, basic nursing education background, number of deliveries in institutions where they work, number of second-trimester abortions in institutions where they work, and whether they had any religious faith.
There were seven items regarding the experience of second-trimester abortion care: whether or not the individual had such an experience; if the subject reported having previous experience, then information regarding the number of times, years of service the first time the individual first provided such care, the support system, the background for second-trimester abortion experiences, the environment of second-trimester abortion care, and the timing of most recent abortion were examined.
2) Attitudes toward second-trimester abortion care
The attitudes toward second-trimester abortion care were assessed using the following: “I think nurses and midwives have a professional care role even in second-trimester abortions,” “I want to be actively involved in assisting second-trimester abortions,” “Assisting in second-trimester abortions is contrary to my beliefs, and if possible, I do not want to be involved,” “Assisting in second-trimester abortions is difficult, and if possible, I do not want to be involved,” and “I do not think that assisting in second-trimester abortions is the work that should be performed by nurses and midwives.” The respondents were requested to choose the alternative that corresponded most accurately to their feelings.
3) Work engagement
The Japanese short version of the Utrecht Work Engagement Scale, translated by Shimazu [13,14] from the scale developed by Schaufeli et al. was used. It has a total of nine items in three subscales: “Vigor,” “Dedication,” and “Absorption” (3 items each). Each item was evaluated using a 7-point Likert scale ranging from “Never” to “Always (Everyday)” (0 and 6 points, respectively). Higher scores indicated a greater positive and fulfilling work-related state of mind. The scores of 27 or below, 28 to 35, and 36 and above were interpreted as low, moderate, and high levels, respectively [15]. Both the original and the Japanese version [14] of this scale have been demon-strated to have good validity. The results of a con-firmatory factor analysis of the latter showed a fitness superior to that of the former [16]. Therefore, this study employed the short version. It can be utilized freely for non-profit purposes.
4) Professional quality of life (ProQOL)
The Japanese version of the ProQOL-5, translated by Goto [17] from a scale developed by Stamm [18] was used to evaluate the ProQOL. It has 3 subscales comprising 30 items: “Compassion satisfaction,” “Burnout,” and “Compassion fatigue/Secondary trauma” (10 items each). Each subscale was evaluated using a 5-point Likert scale ranging from “Never,” “Rarely,” “Sometimes,” “Often,” and “Very often” (1, 2, 3, 4, and 5 points, respectively). The scores of 22 or below, 23 to 41, and 42 or above were interpreted as low, moderate, and high levels, respectively [18]. The reliability of the English version has been confirmed [18]. The ProQOL is defined as the QOL that human service professionals experience in relation to their work. It is conceptualized as having both negative and positive aspects [18]. High scores on the compassion satisfaction subscale indicate that the satisfaction related to the ability to provide effective assistance in work settings is high. High burnout scores are indicative of a great risk of burnout. Compassion fatigue/secondary trauma is related to vicarious traumatization and an indirect exposure to extremely stressful events. This scale can possibly measure human service professionals. Furthermore, it can be employed for people in other occupations by revising the term “helper” to the occupational title in question [18]. In this study, the occupation was changed to “nurse/midwife.” This scale can be reproduced and used freely, provided that the users comply with the specified conditions [17].
5) Job satisfaction
Job resources refer to the physical, social, and organizational factors at work. These are indicated by support from superiors, workplace climate, compensation, and value congruence between the organization and the individual [8]. To ascertain whether these factors were present or absent, they were measured in terms of the fulfillment of the nursing professionals' demands for job resources.
The nurses' job satisfaction with their professional situation was measured using the translated version by Ozaki et al. of the nurses' job satisfaction scale developed by Stamps et al. [19]. It consists of 7 factors having 48 items, “Pay,” “Autonomy,” “Task requirements,” “Nursing administra-tion,” “Nurses interaction,” “Professional status,” and “Doctor-nurse relationship” (9, 5, 6, 10, 7, 8, and 3 items, respectively). These were evaluated on a 7-point Likert scale ranging from “Agree completely” (0 to 6 points) to “Disagree completely” (6 to 0 points), with the scores of reversed items converted. The highest possible score was 288, with higher scores indicative of greater job satisfaction. Currently, no standard methods other than this scale have been established to assess nurses'job satisfaction, and the scale enables comparisons with past research. Additionally, it has a high frequency of use in research on job satisfaction among Japanese nurses; its reliability and validity have also been confirmed. Thus, this scale was employed in the present study.
3. The conceptual framework
This study's conceptual framework was based on the “Job Demands-Resources Model” and is shown in Figure 2 as a model in nursing professionals working with women who have experienced the traumatic event of a second-trimester abortion.
4. Analysis
The descriptive statistics were calculated for each survey item. To confirm the reliability and validity of the data obtained from each scale, the Cronbach's α reliability coefficient was computed. The scales were analyzed using the Pearson's correlation coefficient. To analyze differences by variables for the scores of each scale, a t-test, one-way analysis of variance, and multiple comparisons were employed. A χ2 test was performed for comparisons between attitudes toward second-trimester abortion care and attributes. Subsequently, for the factors related to the former toward second-trimester abortion care, a binomial logistic regression analysis was conducted with a backward stepwise method (likelihood ratio) to investigate these factors while excluding the effects between variables. The attitudes toward care were considered as the objective variable, and work engagement, the ProQOL subscales, job satisfaction and its subscales, and attributes (age, years of experience, nursing occupation, position, and work institution) were used as explanatory variables.
The SPSS ver. 26 statistical software was employed; a level of significance of 5% was considered.
5. Ethical considerations
This study was approved by the ethics committee of the Niigata University of Health and Welfare (approval no. 17950-180202). A written request stating the study aims was attached to the survey form, and the return of the response sheet was considered as consent. The study complied with the standard ethical requirements, such as the confidentiality of the subjects' main data.
1. Background of the subjects
Table 1 shows the demographic characteristics of the study subjects.
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1) The second-trimester abortion care experience
The first time that the respondents had assisted in a second-trimester abortion was 3.42 years (SD=5.04 years) after they had started working, and the number of cases they had helped in thus far was 1–5 for 73 subjects (30.9%), the largest number. This was followed by 10–29 cases in 67 subjects (28.4%), 6–9 in 56 (23.7%), 30 or more in 38 (16.1%), and no response in 2 (0.8%). The most recent time when they had assisted in a second-trimester abortion was 6 or more months ago for 111 respondents (47.0%), which was the most common. This was followed by 3–5 months ago for 39 (16.5%), within the past month for 32 (13.6%), 1–2 months ago for 27 (11.4%), and unsure for 27 (11.4%). Overall, 26 respondents (11.0%) had a specific religious faith, while 207 did not (87.7%).
2) The nursing professionals' attitudes toward the second-trimester abortion care
The subjects selected the option that was closest to their own feeling toward being involved in the care associated with second-trimester abortions. The most common choice was “I think nurses and midwives have a professional care role even in second-trimester abortions,” selected by 159 respondents (67.4%). In addition to them, 11 respondents (4.7%) who answered “I want to be actively involved in assisting second-trimester abortions” were considered an “Active group” with respect to care. The second most common choice was “Assisting in second-trimester abortions is contrary to my beliefs, and if possible, I do not want to be involved” responded by 36 respondents (15.3%). In addition to them, 21 (8.9%) and 3 (1.3%) respondents who answered, “Assisting in second-trimester abortions is difficult, and if possible, I do not want to be involved” and “I do not think that assisting in second-trimester abortions is work that should be performed by nurses and midwives,” respectively, were considered as a “Reluctant group” with respect to care. The number of others was 5 (2.1%).
3) The scores for each scale and the associations between the scales
Table 2 shows the mean scores of work engagement, the ProQOL, and job satisfaction.
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There were highly significant correlations between each scale except for the associations between work engagement and the job satisfaction factors ‘Pay’.
4) Relationship between the background factors of the nursing professionals and each scale
Work engagement, the ProQOL, and job satisfaction and their subscales were compared in terms of the nursing professionals' attributes. No significant differences were observed in work engagement and its subscales with respect to any attribute. Table 3 displays the background factors of the nursing professionals and the significant differences in the mean scores of the scales. No significant differences were identified in either the ProQOL subscales or job satisfaction and its subscales regarding the attributes other than type of work institution, the number of deliveries and second-trimester abortions at the work institution.
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2. Reliability coefficient of each scale
Overall, the Cronbach's α was high for all scales and their respective subscales (0.67–0.95), confirming a good internal consistency. (Table 2)
3. Relationship between the attitudes toward second-trimester abortion care and each scale
Table 4 shows the mean scores of work engagement, the ProQOL, and job satisfaction compared between the two groups of attitudes toward second-trimester abortion care. Significantly higher scores in the “Active” rather than the “Reluctant group” were found for work engagement and its subscales “Vigor,” “Dedication,” “Absorption,” for the ProQOL subscale “Compassion satisfaction,” and for job satisfaction and its subscales “Pay,” “Professional status,” and “Doctor-nurse relationship.” The ProQOL subscale “Compassion fatigue/Secondary trauma” score was significantly lower.
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Figure 3 displays the odds ratios and 95% confidence intervals using a logistic regression analysis for factors associated with attitudes toward second-trimester abortion care. Being a midwife (odds ratio; OR=2.884, 95%CI: 1.060–7.847, p= 0.038), a nursing administrator (OR=2.849, 95%CI: 1.084–7.487, p=0.034), and having many years of experience (OR=1.147, 95%CI: 1.039–1.267, p= 0.007) were identified as the background factors for the “Active group.” Additionally, they were also strongly related to age (OR=0.855, 95%CI: 0.779–0.938, p=0.001), being satisfied with one's pay (OR=1.049, 95%CI: 1.004–1.096, p=0.031), and lower ProQOL “Compassion fatigue/Secondary trauma” (OR=0.911, 95%CI: 0.847–0.979, p= 0.012).
1. Characteristics of work engagement, the ProQOL, and job satisfaction in the subjects
It has been reported that the work engagement scores of Japanese workers were lower than those of employees in 15 other countries, including France, Finland, and South Africa [20]; moreover, this trend was below average in surveys of nurses outside of the country, such as the American nurses [21] and those in acute care wards [12]. However, it was slightly higher for the university hospital nurses [22], hospital nurses [16,23], mid-wives and nurses [24], and Japanese women [25], as reported for nursing professionals in previous studies in Japan. Additionally, reports have indicated that these scores increase with age [22,25]; further, considering the mean age and years of experience, the work engagement in this study was conjectured to be at approximately the same level as that in previous research involving Japanese nursing professionals.
The ProQOL was slightly lower than that reported by a previous study on Japanese nurses [7]. Since there was a difference between “Compassion satisfaction” and “Burnout” depending on the number of deliveries in a subject's institution, it was suggested that nursing professionals can provide care that is professionally rewarding since they are offered a certain number of occasions to be involved in deliveries; therefore, the satisfaction with work increases, while the risk of burnout reduces. In addition, the ProQOL in a report on abortion providers in South Africa [26]. was higher than that of this study; this may be, because, with a subjective awareness of care provided in second-trimester abortions as professional work, individuals are less likely to experience work stress, and receiving specialized training related to abortions could increase compassion satisfaction.
The job satisfaction was slightly lower than that indicated by a literature review of studies on nurses using the same scale [27]. The differences observed depended on the “Professional status,” “Task requirement,” and “Nurses' interactions,” suggesting that there are discrepancies in how demanding the work is and the subjective awareness toward one's job as a professional based on the size of the institution regarding staffing or number of beds. Since a difference was indicated in “Nursing administration” with the number of second-trimester abortions in one's work institution, support from nursing administration could be significant for the nursing professionals involved in second-trimester abortions. It has been reported that, with sufficient support from superiors and co-workers, even nursing professionals who frequently experience negative emotions when providing care to difficult patients do not experience decreased work satisfaction [28]. This suggested that job satisfaction may increase with receiving positive feedback and approval for one's work from nursing administrators and work assignments that are unbiased toward abortion care. Furthermore, there is a relationship between support from superiors and the professional autonomy of nurses [29]; it is thought to be crucial in enhancing professional autonomy with respect to second-trimester abortion care.
2. Relationships between the attitudes toward second-trimester abortion care and work engagement, the ProQOL, and job satisfaction
Those with high work engagement were proud of and enthusiastic about their work, and derived vitality from it [9]. The work engagement of the nursing professionals with active attitudes toward second-trimester abortion care was higher than that of those with reluctant attitudes, thus indicating a relationship between active attitudes toward care and work engagement, even when it involves abortions. Providing care in cases of second-trimester abortions can be highly stressful. In this study, the finding that attitudes toward second-trimester abortion care were associated with job satisfaction,“Compassion satisfaction” and “Compassion fatigue/Secondary trauma” suggested that the nurses with active attitudes experienced satisfaction with second-trimester abortion care and did not suffer from PTSD. Satisfaction with the care provided by the nursing professionals is also important in preventing PTSD. In addition, the nursing professionals with positive attitudes were more satisfied with “Pay,” “Professional status,” and “Doctor-nurse relationship” than that of those with reluctant attitudes, indicating a relationship between attitudes towards care and awareness of the professionalism of care in the second-trimester abortion care.
3. The factors that affected attitudes toward second-trimester abortion care
The predictors that affected attitudes toward second-trimester abortion care were occupational category, position, and years of experience. Being a midwife or, a nursing administrator, and having many years of experience were related to having an active attitude toward care. The midwives provide care for second-trimester abortion through trial and error, referring to care during childbirth [3]. Therefore, it is conjectured that they have a high level of professional knowledge associated with deliveries and an attitude of respect for women. The nursing administrators probably have several years of experience related to their specializations and have experienced the anguish of women undergoing second-trimester abortions as well as thoughts about aborted fetuses. It is believed that through these experiences, they discover the nursing role and form a positive attitude toward second-trimester abortion care. Additionally, “Compassion fatigue/Secondary trauma” also affected the nurses' attitudes. Previous studies have reported that “Compassion satisfaction” is high in medical personnel who have less than one year of experience in abortion care, there is a “dose-response” relationship between the length of care experience and “Compassion satisfaction,” and providers with many years of experience may have experienced many negative effects from providing abortion care [26]. Therefore, it is necessary to emphasize not only the experience in second-trimester abortion care, but also its content.
It is necessary to provide educational support for professional knowledge and skills and support in the workplace to prevent the stress caused by the experience of care for the nurses to provide care with an awareness of the role of nursing in second-trimester abortions. However, the educational content and systems for professional autonomy specific to second-trimester abortion care have not been developed thus far; moreover, the training content for nurses and nurse managers needs to be examined. Satisfaction with pay was also related to attitudes toward second-trimester abortions; therefore, receiving remuneration commensurate with the content of the work may be important to improve professionals' autonomy and attitudes.
3. Study limitations
Since this was a cross-sectional study, a longitudinal study to clarify the relationships between these factors is warranted in the future. Moreover, it will also be necessary to consider other influencing factors and to increase the sample size, such as the content of second-trimester abortion care, as well as clarify the relationships between other influencing factors and the work engagement of the nursing professionals involved in second-trimester abortion care in Japan.
This study was supported by JSPS KAKENHI (Grant Number 18K10490).
We would like to thank Dr. T. Takiguchi for their statistical advice on this survey.
There are no conflicts of interest or financial relationships to disclose.
