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Burnout and depression among nurses in Japan and China:
the moderating effects of job satisfaction and absence
Louise Tourigny
a
*, Vishwanath V. Baba
b
and Xiaoyun Wang
c
a
Management Department, University of Wisconsin-Whitewater, Whitewater, WI, USA;
b
DeGroote
School of Business, McMaster University, Hamilton, Ontario, Canada;
c
I.H. Asper School of
Business, University of Manitoba, Winnipeg, Manitoba, Canada
This study focuses on the relationships between emotional exhaustion and other
dimensions of burnout as well as depression among nurses in Japan and China.
Attitudinal and behavioral moderators as coping mechanisms are suggested to mitigate
the effect of emotional exhaustion on depersonalization, diminished personal
accomplishment and depression. More specifically, we analyze the alleviating effect
of absence and the moderating effect of job satisfaction as a compensatory coping
mechanism. Data were collected from 239 nurses in Japan and 550 nurses in mainland
China. The study used existing measures with appropriate translations. The instruments
exhibited satisfactory psychometric properties for both samples. Descriptive statistics,
correlation, and hierarchical moderated regression using both two-way and three-way
interactions were employed to analyze the data. Job satisfaction and absence were
found to moderate the relationship between emotional exhaustion and depression
simultaneously among both Japanese and Chinese nurses. Job satisfaction and absence
simultaneously moderated the effect of emotional exhaustion on diminished personal
accomplishment among Japanese nurses only. The theoretical role of job satisfaction
and absence in alleviating the detrimental effects of emotional exhaustion, and their
practical significance for healthcare in general, and for the management of nurses in
Japan and China in particular are discussed.
Keywords: absenteeism; burnout; China; depression; Japan; job satisfaction
Healthcare is becoming a major concern around the globe. As a result, there is an
increasing demand to understand organizations that provide healthcare as well as the
organizational behavior of healthcare workers. While there are many studies focusing on
the management of the healthcare sector, most of the empirical studies are located in
Europe and North America where there are many more resources invested in healthcare.
This study attempts to offer a different perspective by focusing on two countries that went
through some important restructuration in their respective healthcare sector (Ikegami and
Campbell 2004; Eggleston, Ling, Qingyue, Lindelow and Wagstaff 2008).
The economic decline and the problem of an aging population in Japan has
transformed the work context as it puts additional pressure on nurses to increase their level
of efficiency (Dedoussis 2001; Ovretveit 2001; Takemura, Kanda, Matsumoto and
Yamagishi 2002). The growth of medical care expenditure exceeded the growth of Japan’s
gross domestic product in 1997 (Wagstaff 2007). As a result, the Japanese government
explicitly requested hospitals to lower their costs in its 1999 healthcare reforms (Ikegami
ISSN 0958-5192 print/ISSN 1466-4399 online
q 2010 Taylor & Francis
DOI: 10.1080/09585192.2010.528656
http://www.informaworld.com
*Corresponding author. Email: tourignl@uww.edu
The International Journal of Human Resource Management,
Vol. 21, No. 15, December 2010, 2741–2761
and Campbell 2004). Thus, nurses are required to assume new roles so as to serve the
needs of the elderly and deal with an important shortage of resources (Takemura et al.
2002). In addition, there is a growing shortage of nurses in Japan that contributes to the
additional workload (Ovretveit 2001). Indeed, studies on nursing compared to other
professions in Japan reveal a prevalence of burnout resulting from the mounting workload
along with other occupational risk factors since more than a decade (e.g., Hisashige 1991).
Japanese nurses have expressed a need for training in stress coping techniques and for
psychological support primarily to alleviate their symptoms of burnout (Ueno, Yamamoto,
Hayashi and Tanaka 2000). Moreover, Japanese female workers in general report high
rates of irritability, depressive symptoms, and fatigue which seem to be related to the
amount of overtime worked and excessive workload (Araki, Muto and Asakura 1999).
Typically, about 77% of Japanese women employees report working overtime, and about
44% do shift work (Araki et al. 1999). We can expect these figures to be higher among
nurses who also have to work night shifts as well. Survey research on the demographics of
nurses in Japan, further reveal that approximately 61% of nurses are under 29 years of age
and about 50% have less than five years of experience in the profession (Higashiguchi et al.
1998). Therefore, we anticipate that nurses should report higher levels of burnout and
depressive symptoms as they need to develop experience in coping with stressful job
demands (Baba, Tourigny and Lituchy 1999).
China is currently experiencing a rapid transformation of both work and lifestyles (Nee
and Cao 2005). Demographic changes constitute important challenges to healthcare
systems (Ying et al. 2007). There has been an increase in the proportion of elderly people
relative to the total population in China since 1998 due to the effects of the one child policy
and greater life expectancy (Gao, Tang, Tolhurst and Rao 2001). Healthcare for a larger
group of elderly patients requires additional resources (Lipson 2004). Simultaneously,
nurses are expected to devel op new skills to serve the needs of the higher income group who
demand better care. To precipitate matters further, thes e changes are taking place in the
context of an acute shortage of nurses in China (Haley, Zhao, Nolin, Dunning and Qiang
2008). All these factors contribute to escalating workload that can affect the mental health
of nurses. Nurses in China have recently been experiencing high levels of job burnout
which can be attributed to the current shortage of nurses and insufficient job training that
exacerbate symptoms of emotional exhaustion, a core component of burnout (Taormina
and Law 2000). Moreover, a recent Chinese survey research indicates that medical doctors
and nurses experience high levels of emotional exhaustion and that female employees tend
to report higher scores on emotional exhaustion than their male counterparts, which
suggests that there should be some effort dedicated to the prevention and treatment of job
burnout among female health care workers in China (Li, Shi and Luo 2003).
Healthcare systems and healthcare delivery differ from country to country and from
region to region (Gerdtham and Jo
¨
nsson 2000). For example, differences between the
West and Asia in terms of health care consumption such as outpatient care and drug usage
have been documented and attributed to cultural, institutional, and economic factors
(Wagstaff, van Doorslaer and Paci 1989; OECD 2005). More recently, there have been
calls for a comparison of healthcare systems and delivery within a region with particular
reference to East Asia (Wagstaff 2007). It has been argued that current healthcare delivery
in China leaves room for improvement in terms of quality, responsiveness to patients,
efficiency, cost, and equity (Eggleston et al. 2008). Given the cultural similarity among
East Asian countries, there is room for learning and improvement through processes of
comparison within East Asia (Wagstaff 2007). Comparison with Japan is viewed as
particularly useful as it has had a mature system of universal healthcare since 1961 and
L. Tourigny et al.2742
a long history of effective healthcare management (Ikegami and Campbell 2004; Wagstaff
2007). More importantly there is a need for comparative studies using micro-level data
from healthcare providers (Eggleston et al. 2008). Our research is a step in that direction.
Although training in better coping strategies among nurses in Asian countries is a
pressing need (Araki et al. 1999; Ueno et al. 2000; Taormina and Law 2000), there is little
empirical research on the factors that can alleviate burnout. From a managerial standpoint
such studies are essential to identify effective coping strategies that are occupation-
specific and that can be influenced by policies implemented by healthcare administrators.
These can provide useful information on how organizational policies can be modified so as
to enhance the mental health of nurses, and to increase their retention rate in the nursing
profession.
There is a need to better understand how nurses effectively cope with episodes of
burnout by using alleviating mechanisms which can be influenced by organizational
policies and managerial practices. In essence, the motivation for this paper stems from the
need to understand the dynamics of burnout in the presence of coping mechanisms among
nurses in Japan and China. Here, we focus on compensatory mechani sms as coping
strategies, and analyze how these can reduce symptoms of burnout and mitigate its
negative consequences. We present an analysis of the relationships between emotional
exhaustion and depersonalization, diminished personal accomplishment and symptoms of
depression, and inve stigate how nurses in Japan and China use coping strategies aimed at
alleviating the detrimental effect of emotional exhaustion.
Theory
Job burnout is a chronic affective response pattern to stressful working conditions that
feature high levels of interpersonal contact and excessive job demands (Ganster and
Schaubroeck 1991; Cordes and Dougherty 1993). Burnout is quite stable over time across
the same person and its chronic nature does not seem to be related to the genetic or
personality factors of an individual but rather to the quality of the social envi ronment at
work (Sears, Urizar and Evans 2000; Shirom 2005; Shirom, Melamed, Toker, Berliner and
Shapira 2005). Maslach (1978) originally proposed that emotional exhaustion occurs as
excessive job demands drain one’s emotional resources, resulting in loss of energy, or
chronic fatigue. A psychological reaction to emotional exhaustion leads to depersonalizing
those who are demanding service or in emotional detachment. Depersonalization is a
negative defensive strategy, an emotional buffer, aimed at limiting one’s involvement with
others (Cordes and Dougherty 1993). As such, depersonalization is counterproductive in the
nursing profession as it leads to negative attitudes toward the recipients of nursing services.
Nurses start to experience feelings of inadequacy as a result of their inabilities to deal with
job demands and begin to suffer from a sense of diminished personal accomplishment.
Burnout is also episodic in nature and its frequency and intensity vary in terms of several
work-related stressors, such as heavy workloads, that engender chronic job stress. An
episode of burnout is often accompanied by symptoms of depression. There is existing
empirical evidence supporting that symptoms of depression tend to increase when nurses
experience high levels of emotional exhaustion. Indeed, some studies conducted with nurses
revealed that perceived lack of control at work leads to burnout which, in turn, induces
depressive symptomatology (Glass and McKnight 1996). Therefore, it seems likely that
such relationships develop in tandem (Shirom 1989; Cherniss 1992). Research further
indicates that depre ssive symptomatology is very unlikely to induce burnout (Glass
and McKnight 1996). Thus, it seems that there is a logical sequential order between burnout
The International Journal of Human Resource Management 2743
and depressive symptomatology which suggests cause and effect relationship. A plausible
explanation for such findings is that the association between burnout and depressive
symptomatology is not dependent on the long-term after effects of stressful aspects of work.
Rather, burnout would tend to be episodic, meaning that it is triggered by actual or perceived
work-related stressors, and that depressive symptomatology increases during a burnout
episode. Therefore, it can be inferred that burnout and depressive symptomatology are not
progressive but rather episodic and recurrent phenomena.
However, there is a debate in the literature as to whether symptomatology scales of
burnout and depression that share some common variance could possibly indicate
isomorphism. More recent research findings tend to discredit such argument. Indeed, a
recent study comparing men and women clearly indicates that burnout and depression
have differential effects on inflammation biomarkers, namely C-reactive protein and
fibrinogen (Toker, Shirom, Shapira, Berliner and Melamed 2005). Therefore, even if
symptoms of burnout and depression can be concomitant, they have distinct effects on
individual physiological reactions.
Conceptually, burnout is a resultant of the quality of the social environment at work,
whereas depression is considered a global state that pervades virtually all spheres of one’s
life. Depression is primarily viewed in terms of negative feelings, self-depreciation,
selfdestructive thoughts, and social withdrawal (Leiter and Durup 1994). It is manifested
through symptoms such as feelings of ‘sadness, emptiness, hopelessness, helplessness,
dysphoric feelings, and low energy’ (Toker et al. 2005, p. 356). Because burnout is
associated with fatigue it has been said that depressive symptomatology overlaps with
burnout due to the fact that is also encompasses low energy (Shirom 2005). However, even
if these two psychological concepts share some dysphoric symptomatology in common
they differ in terms of their respective content, psychological signs, and nomological
network (Sears et al. 2000; Toker et al. 2005). The discriminant validity of burnout and
depression has been established in the existing literature (Leiter and Durup 1994). The
high correlation between burnout and depression can be explained by the fact that their
respective symptoms are often concomitant or synchronic (Sears et al. 2000; Toker et al.
2005). Therefore, the variance shared by burnout and depression indicates that these are
likely to develop concurrently or in tandem. However, it is important to note that
emotional exhaustion is key to the etiology of burnout in that it has been found to predict
depersonalization, diminished personal accomplishment and depression (Ganster and
Schaubroeck 1991; Cordes and Dougherty 1993; Leiter 1993; Lee and Ashforth 1993,
1996; Glass and McKnight 1996). In brief, burnout and depression are conceptually and
empirically distinct, are associated with different sets of symptoms, and have differential
physiological impacts on one’s health. Moreover, it has been suggested that a burnout
episode, if not properly managed and alleviated in a timely manner, can indeed trigger an
onset of a depressive disorder (Tennant 2001). Indeed, work-related stressors such as role
overload and role ambiguity predict depressive symptoms even after controlling for
nonwork stressors, thereby suggesting a spillover effect of work-related stressors on
depressive symptomatology in other life domains (Tennant 2001). Based on the existing
evidence concerning the linear association between burnout and depressive symptomatol-
ogy, such a spillover effect normally happens through burnout.
Work stressors are likely to differ from one occupation to another, whereas burnout
and depression, which depend on the subjective experiences of individuals, should be
affected by the unique frames of reference used by subjects in analyzing their working
conditions. Therefore, we suggest here that the relationship between burnout and
depressive symptomatology largely depends on the subjectivity of an individual, and that
L. Tourigny et al.2744
such a relationship is likely to remain quite consistent over time across the same
individual. Such subjectivity determines the assessment of work-related stressors, working
conditions and the selection of coping mechanisms aimed at adjusting to the perceived
work environment as well.
Burnout episodes may occur at different points in one’s career. Indeed, we observe
higher symptoms of burnout among younger nurses (Higashiguchi et al. 1998). Burnout
episodes may occur midlife and toward the end of one’s career as well (Glass and
McKnight 1996). It is when such episodes occur that symptoms of depression are likely to
increase unless effective coping mechanisms are applied.
So far, as presented above, the literature focused on the antecedents and consequences
of burnout and depression and on their reciprocal interrelationships (Baba, Tourigny and
Lituchy 1999). However, there is a need to further investigate the relationship between
burnout and depression itself so as to better understand its complexity. Research is needed
to increase knowledge on the connection among these symptoms and on the coping
mechanisms that can be used to moderate them.
Based on the existing literature surveyed here, we suggest that symptoms of depression
increase with high levels of emotional exhaustion in the absence of effective coping
mechanisms. In light of this sugges tion and previous empirical observation on the
sequential natu re of the burnout episode (Lee and Ashforth 1993, 1996; Leiter 1993; Glass
and McKnight 1996), we posit that emotional exhaustion is a precursor of
depersonalization, diminished personal accomplishment, and symptoms of depression in
the etiological network of the burnout process.
Hypothesis 1: Emotional exhaustion positively predicts depersonalization, diminished
personal accomplishment and depression.
Job satisfaction
Research among Japanese employees indicates that coping strategies, which involve a
psychological compensation for excessive external demands, are shown to be more
effective than passive coping strategies in alleviating symptoms of burnout (Shimazu and
Kosugi 2003). There is also research evidence from Taiwan that cognitive appraisal of
extrinsic and intrinsic rewards, a component of job satisfaction, can alleviate burnout and
work-related depression among nurses (Lu 1999). Consequently, job satisfaction, which
involves a continual interplay between cognitive appraisal and coping, can have an effect
on occupational mental health. Indeed, job satisfaction involves a cognitive appraisal and
an emotional reaction to one’s job conditions leading to subsequent attitudinal and
behavioral adjustments. As such, job satisfaction is conceived as a reaction to role
stressors, and as a predictor of occupational mental health (Baba, Jamal and Tourigny
1998). Job satisfaction mediates the relationship between a person’s environment and
adaptational outcomes (Hart and Cooper 2001). Nurses can adjust to perceived job
conditions by changing their job attitudes and behaviors so as to maintain their
psychological equilibrium. Through cognitive appraisal of their job conditions, nurses
constantly monitor their environment to determine whether their job conditions are
conducive to optimal mental health and consequently, adjust to these conditions (Hart and
Cooper 2001). Thus, job satisfaction, which involves both cognitive appraisal and coping,
can alleviate the negative effects of emotional exhaustion by providing a psychological
compensation for excessive work demands. In essence, we suggest that it serves as
a compensatory coping mechanism. Nurses can decide to act upon their work ing
The International Journal of Human Resource Management 2745
conditions so as to increase their job satisfaction or engage in psychological rationalization
toward readjustment of their job satisfaction with respect to extrinsic and intrinsic rewards
associated with work demands. Research in occupational mental health considers that the
effect of job satisfaction on employee performance can manifest itself through increased
employee well-being and positive job attitudes (Griffin, Hart and Wilson-Evered 2000).
Thus, we conceive job satisfaction as an active coping strategy that has a compensatory
effect which can alleviate the negative consequences of emotional exhaustion by
maintaining one’s optimal level of well-being. As a result, high job satisfaction should
reduce the impact of emotional exhaustion on its psychological outcomes and low job
satisfaction should exacerbate such impact due to the absence of compensatory effect.
Understanding the role of job satisfaction in the etiological network of burnout is
particularly relevant to Japanese workers who report greater psychological distre ss and
lower job satisfaction compared with US workers (Kawakami and Haratani 1999). It is
also relevant to Chinese workers who report moderate to high levels of emo tional
exhaustion (Li et al. 2003). There is a paucity of rese arch in occupational mental health
linking burnout and job attitudes in Japan and China from year 2000 thus far. As a
consequence, examining the moderating effect of job satisfaction on emotional exhaustion
remains exploratory in this research. Therefore, it is hypothesized:
Hypothesis 2: Job satisfaction moderates the effect of emotional exhaustion on
depersonalization, diminished personal accomplishment and depression.
High job satisfaction will alleviate the effect of emotional exhaustion
whereas low job satisfaction will exacerbate it.
Absence
Absence has been considered as an indicator of organizational performance and an
outcome variable that is influenced by job satisfaction, and psychological distress (Hart and
Cooper 2001; Hardy, Woods and Wall 2003). It has been suggested that the experience of
intense psychological distress that results from poor job conditions can lead employees to
absent themselves from obligations that are aversive (Nicholson and Johns 1985).
However, contrary to popular belief and a few exceptions (e.g., Hardy et al. 2003), the
hypothesis that low job satisfaction increases the frequency of absence has received little
empirical support (Matrunola 1996). Instead of conceiving absence as a withdrawal
behavior that can be costly and counterp roductive (Sagie, Birati and Tziner 2002), absence
can be considered as an effective maintenance mechanism (Johns 2002) used by an
individual to alleviate burnout. Indeed, research reveals that nurses may use absence as a
therapeutic device to restore their psychological equilibrium and recover from emotional
and physical fatigue (Hackett and Bycio 1996). Research also indicates that satisfaction
with pay, supervisor, and co-workers is not predictive of absence (Johns 2002). Therefore,
instead of using absence as a passive means to simply remove oneself from stressful work
conditions, one may use absence as a positive and proactive restorative mechanism in
response to stress. In this research, absence is conceived as a proactive coping mechanism
that is self-applied in reaction to stress in order to prevent chronic strain and minimize the
negative consequences of burnout on one’s health. Absence can serve as an additional
compensatory coping mechanism by increasing non-work time, which is a form of work-
related compensation. Nurses can use absence as a proactive strategy to compensate for
excessive work demands. When nurses take time off the job they can restore their mental
health and consequently maintain a satisfactory level of performance. Furthermore, this
L. Tourigny et al.2746
coping strategy may serve as a means to balance work and non-work demands. As such,
absence can make an additional contribution to one’s psychological well -being (Hart and
Cooper 2001). Absence can also compensate for unmet expectations that usually result in a
violation of the psychological contract (Rousseau and Parkes 1993). Therefore, absence
can be used to redress the perceived effort-reward imbalance (Siegrist 1996) that would
otherwise provoke adverse health effects among nurses (Killmer, Siegrist and Schaufeli
2000). Finally, absence is unlikely to reflect withdrawal behavior in Asian collectivistic
societies where one is expected to engage in self-sacrifice for the benefit of the collectivity
(Johns 2002). As such, nurses in Asian collectivistic cultures would tend to use absence as a
last resort when it is the norm to do so and when it does not have negative repercussions on
others. Therefore, we suggest that absence in Japan and China constitutes a compensatory
and restorative coping strategy, not a withdrawal or counterproductive behavior. As such,
absence can have a preventive effect in the sense that it reduces the likelihood that burnout
will have a spillover effect on one’s other spheres of life by increasing symptoms of
depression. Therefore, we suggest that absence, due to its compensatory and restorative
effects, can actually buffer the detrimental effect of emotional exhaustion on its
psychological resultants by moderating its impact. Indeed, we offer:
Hypothesis 3: Absence moderates the effect of emotional exhaustion on depersonaliza-
tion, diminished personal accom plishment and depression. The use of
absence will reduce the detrimental effect of emotional exhaustion.
Apart from a few exceptions (e.g., Sagie 1998; Eby and Freeman 1999) there has been
little empirical investigation on the interplay between absence and job satisfaction in
predicting occupational mental health. Research is needed to analyze when and how
compensatory mechanisms – in this case, job satisfaction and absence – can be used
effectively as coping strategies so as to alleviate the symptoms of emotional exhaustion and
minimize its effect on its psychological resultants. The above discussion leads to a model
shown in Figure 1 for guiding the empirical component of the research. Here, we focus on
the moderating effects of job satisfaction and absence on the relationship between emotional
exhaustion and its negative psychological outcomes. Emotional exhaustion leads to
depersonalization, and diminished personal accomplishment, which occurs when one feels
Emotional exhaustion
Depersonalization
Diminished
personal
accomplishment
Depression
Absence
Job satisfaction
Figure 1. The moderating effects of job satisfaction and absence on emotional exhaustion.
The International Journal of Human Resource Management 2747
inadequate in responding to job-related demands. Furthermore, emotional exhaustion
predicts symptoms of depression (Hart and Cooper 2001). We employ this model to capture
these interrelationships and to analyze how nurses in Japan and China apply coping
strategies such as job satisfaction and absence in managing their mental health at work.
Furthermore, we hypothesize that when nurses use absence in the context of high job
satisfaction, the effect of emotional exhaus tion on its psychological resultants will be
lowered such that nurses will be able to maintain better mental health. Therefore, we
propose that absence and job satisfaction have a compounding moderating effect.
However, we want to expl ore the possibility that the use of absen ces in the context of low
job satisfacti on is primarily reflecting the need for compensation and that as such, it does
not provide the alleviating effect that would normally result from recuperation. In other
words, absence is restorative only when nurses report high job satisfaction. When absence
is used in lieu of job satisfaction or as substitute compensatory mechanism it is unlikely to
have a restorative effect. Therefore, we hypothesize:
Hypothesis 4: Job satisfaction and absence simultaneously interact with emotional
exhaustion in predicting depersonalization, diminished personal
accomplishment and depression. The use of absence in the context of
high job satisfaction lowers the detrimental effect of emotional
exhaustion. In the context of low job satisfaction absen ce will not
affect the detrimental effect of emotional exhaustion.
Methodology
Sample
Data were gathered from 239 nurses in Japan and 550 nurses in China through a cross-
sectional field survey. This method was used because we analyze primarily the relationships
among symptoms of mental health that can be concomitant, recurrent, and fluctuating in
interchanging patterns, as well as moderated by self-applied coping mechanisms at any
point in time during their occurrences. Indeed, we focus on the alleviating effects of such
coping mechanisms in relation to the frequency of the symptoms of burnout and depressive
symptomatology in a linear fashion. In other words, we are not concerned with the long-term
effect of burnout or time differential in the application of coping mechanisms.
The sample of Japanese nurses is composed of a majority of females with only three
males. The age of respondents ranges between 21 and 67 with a mean of 35 and a median
of 34. About 41% of the respondents are married; 37% of them are single. About 73% of
the respondents have been employed in their current jobs for more than five years. The
sample of Chinese nurses is exclusively composed of females. The age of respondents
ranges between 20 and 55 with a mean of 32 and a median of 30. About 75% of the
respondents are married; 23% are single. About 73% of the respondents work in their
current jobs for more than five years as well.
Measurement
Survey instruments
Questionnaires that had been translated into Japanese and into modern Mandarin by
professional translators were used for the purpose of collecting data. The translated
versions had been verified and back-translated into English by independent translators
before data collection to insure accuracy of meaning.
L. Tourigny et al.2748
Job burnout
Job burnout is measured with 22 items from the Maslach Burnout Inventory using a
frequency scale ranging from 1 (a few times a year) to 5 (every day) (see Maslach and
Jackson 1986). Respondents were asked to indicate how often they experienced each
described statement during the past year. A sample item for emotional exhaustion is: ‘I feel
emotionally drained from my work’. For the Japanese sample, the alpha reliability
coefficient, mean and standard deviation were .91, 2.82, and .92 respectively for emotional
exhaustion. For the Chinese sample , the alpha reliability coefficient, mean and standard
deviation were .89, 3.18, and .82 respectively. A sample item for depersonalization is: ‘I feel
I treat some people as if they were impersonal objects’. For the Japanese sample, the alpha
reliability coefficient, mean and standard deviation were .71, 1.71, and .66 respectively for
depersonalization. For the Chinese sample, the alpha reliability coefficient, mean and
standard deviation were .72, 1.29, and .45 respectively. A sample item for diminished
personal accomplishment is: ‘I have accomplished many worthwhile things in this job’
(reverse scored). For the Japanese sample, the alpha reliability coefficient, mean and
standard deviation were .85, 3.14, and .72 respectively for diminished personal
accomplishment. For the Chinese sample, the alpha reliability coefficient, mean and
standard deviation were .77, 2.26, and .58 respectively. Mean frequency scores were
computed for each dimension of job burnout. A high score indicates a high level of job
burnout.
Depression
Depression was measured with 20 items from the Center for Epidemiological Studies
Depression Survey (CES-D) (Radloff, 1977) using a four-point frequency scale ranging
from 1 (rarely or none of the time) to 4 (most or all of the time). The CES-D consists of a
list of generic symptoms of depression. This instrument is primarily used in
symptomatology where the relationships between sets of symptoms of mental health are
analyzed. Respondents were asked to indicate how often they experienced each described
statement in the week that preceded the date of the survey. A sample item is: ‘I thought my
life had been a failure’. For the Japanese sample, the alpha reliability coefficient, mean and
standard deviation were .85, 2.08, and .39 respectively for depression. For the Chinese
sample, the alpha reliability coefficient, mean and standard deviation were .89, 2.06, and
.62 respectively.
Job satisfaction
Job satisfaction is measured with 15 items developed and validated by Stephen Kerr
(personal communication) using a five-point scale ranging from 1 (highly dissatisfied) to 5
(highly satisfied). This instrument was selected because it provides an assessment of several
facets of job satisfaction that are relevant to the nursing profession. Responde nts were
asked, to which extent each item represents either a reward or a drawback in their present
job. Sample items are: ‘the degree of challenge’, ‘the amount of appreciation/recognition
received from others’. For the Japanese sample, the alpha reliability coefficient, mean and
standard deviation for job satisfaction were .79, 3.00, and .41 respectively. For the Chinese
sample, the alpha reliability coefficient, mean and standard deviation were .81, 3.10, and .51
respectively.
It has been said in the literature that Japanese employees tend to report lower job
satisfaction due to a response bias which is attributed to the tendency to suppress the
The International Journal of Human Resource Management 2749
expression of positive feelings (Kawakami and Takashi 1999). However, the means and
standard deviations found in the current study do not reveal such tendency. Indeed, we did
not find any significant difference between the two samples.
Absence
A self-report item was used to measure the number of days of absence in the year that
preceded the one in which the survey was conducted. We specified this time frame because
we are using absence as a coping mechanism that moderates current and possible
subsequent deterioration in mental health. Days of absence were used rather than
frequency as an indicator of the amount of time one spent off work. Self-report measures
are subject to self-serving bias such as underreporting. However, self-report measures of
absence are valid measures of actual absenteeism (Johns 1994). Furthermore, Sagie (1998)
found that self-report measures and personnel records show consistent correlations with
attitudinal variables. Moreover, subjects who report high symptoms of depression are less
likely to underreport absence, which reduces the potential for common method variance.
Respondents answered the following question: ‘Not counting vacation or holidays, how
many days have you been absent from work during the past year?’ For the Japanese sample,
the number of days of absence ranged from 0 to 30 with a mean and standard deviation of
3.41 and 5.24 respectively. For the Chinese sample, the number of days of absence ranged
from 0 to 90 with a mean and standard deviation of 1.06 and 6.52 respectively.
Reasons for absence were collected and analyzed so as to determine whether absence
could be explained primarily by some specific factors. Among Japanese nurses we found
that older nurses with more seniority and who work day time are more likely to take
absence in order to take care of family matters or take part in leisure activity. Absence was
not correlated with number of children, personal illnesses and sick leave. Therefore, there
did not seem to be any particular reason for which nurses would take absence and which
could interfere with the interpretation of the results.
In the Chinese sample, absence was not corr elated with number of children, age,
tenure, sick leave or personal illnesses. The frequency of absence did not vary depending
on shift work. Therefore, in comparison to Japanese nurses, Chinese nurses are less likely
to take absence based on seniority and shift work.
Control variable
Age has variously shown significant relationship with burnout and depression in different
samples and as such is not of theoretical interest for our study. However, our samples
reveal that Japanese nurses who are older can take more days of absence, and that the mean
age of nurses is lower in China. Therefore, we have included age as a control variable.
Results
Japanese nurses
Table 1 presents the means, standard deviations, reliabilities and correlations for the study
variables for the Japanese sample. Results indicate that age is negatively related to
diminished personal accomplishment (r ¼ 2 .25, p , .01) and depression (r ¼ 2 .14,
p , .05). Age is positively related to job satisfaction (r ¼ .18, p , .01), and absenteeism
(r ¼ .16, p , .05). As expected, emotional exhaustion is positively related to
depersonalization (r ¼ .41, p , .01), depression (r ¼ .57, p , .01), and is negatively
related to job satisfaction (r ¼ 2 .42, p , .01). However, contrary to expectations,
L. Tourigny et al.2750
emotional exhaustion is negatively related to diminished personal accomplishment
(r ¼ 2 .17, p , .05). Depersonalization is positively related to depression (r ¼ .40,
p , .01) and is negatively related to job satisfaction (r ¼ 2 .31, p , .01). Diminished
personal accomplishment is also positively related to depression (r ¼ .20, p , .01) and is
negatively related to job satisfaction (r ¼ 2 .18, p , .01). Although diminished personal
accomplishment does not seem to be related to the other dimensions of burnout, it presents
consistent relationships with the expected consequences of burnout. For instance,
depression is positively related to emotional exhaustion (r ¼ .57, p , .01), depersonaliza-
tion (r ¼ .40, p , .01), and diminished pers onal accomplishment (r ¼ .20, p , .01).
Depression is also negatively related to job satisfaction (r ¼ 2 .48, p , .01). Finally,
absenteeism was not related to any of the study variables except age.
Chinese nurses
Table 2 presents the means, standard deviations, reliabilities and correlations for the study
variables for the Chinese sample . Results indicate that age is positively related to
emotional exhaustion (r ¼ .11, p , .05) and job satisfaction (r ¼ .13, p , .01). Age is
negatively related to depersonalization (r ¼ 2 .17, p , .01), and diminished personal
Table 1. Correlation and descriptive statistics for the Japanese Sample.
M S.D.
a
1234567
1. Age 35.65 9.60 –
2. Emotional
Exhaustion (EE)
2.82 .92 .91 2 .08
3. Depersonalization
(DP)
1.71 .66 .71 2 .12 .41
**
4. Diminished Personal
Accomplishment
(DPA)
3.14 .72 .85 2 .25
**
2 .17* .02
5. Depression (D) 2.08 .39 .85 2 .14* .57
**
.40
**
.20
**
6. Job Satisfaction 3.00 .41 .79 .18
**
2 .42
**
2 .31
**
2 .18
**
2 .48
**
7. Absenteeism 3.41 5.24 – .16* 2 .02 .02 2 .13 2 .04 2 .03
Note:
*
p , .05.
**
p , .01.
***
p , .001.
Table 2. Correlation and descriptive statistics for the Chinese Sample
M S.D.
a
1234567
1. Age 32.2 7.63 –
3
2. Emotional
Exhaustion (EE)
3.18 .82 .89 .11*
3. Depersonalization
(DP)
1.29 .45 .72 2 .17
**
.26
**
4. Diminished Personal
Accomplishment
(DPA)
2.26 .58 .77 2 .21
**
.08 .35
**
5. Depression (D) 2.06 .62 .89 2 .03 .43
**
.39
**
.30
**
6. Job Satisfaction 3.10 .51 .81 .13
**
2 .30
**
2 .24
**
2 .30
**
2 .30
**
7. Absenteeism 1.06 6.52 – .03 .09 .07 .09* .14
**
2 .12*
Note:
*
p , .05.
**
p , .01.
***
p , .001.
The International Journal of Human Resource Management 2751
accomplishment (r ¼ 2 .21, p , .01). Emotional exhaustion is positively related to
depersonalization (r ¼ .26, p , .01), but is not related to diminished personal
accomplishment. As expected, emotional exhaustion is also positively related to
depression (r ¼ .43, p , .01). Finally, it is negatively related to job satisfaction
(r ¼ 2 .30, p , .01). Depersonalization is positively related to diminished personal
accomplishment (r ¼ .35, p , .01), and depression (r ¼ .39, p , .01). Results indicate
that diminished personal accomplishment is positively related to depression (r ¼ .30,
p , .01), and absenteeism (r ¼ .09, p , .05). Diminished personal accomplishment is
negatively related to job satisfaction (r ¼ 2 .30, p , .01). As expected, depression is
positively related to emotional exhaustion (r ¼ .43, p , .01), depersona lization (r ¼ .39,
p , .01), and diminished personal accomplishment (r ¼ .30, p , .01). Depression is also
positively related to absenteeism (r ¼ .14, p , .01) and is negatively related to job
satisfaction (r ¼ 2 .30, p , .01). Finally, job satisfaction is also negatively related to
absenteeism (r ¼ 2 .12, p , .05).
Analysis of the moderating effects of job satisfaction and absenteeism
Japanese nurses
We follow here the theoretical sequencing among the study variables as illustrated in the
model presenting the results. We use hierarchical moderated regression to assess the
predictive effect of emotional exhaustion and the moderati ng effects of absence and job
satisfaction on the relationships between emotional exhaustion and depersonalization,
diminished personal accomplishmen t, and depression.
Table 3 presents the results for the hierarchical regression analysis for the Japanese
sample including the effects of the two-way interactions and the three-way interaction
among emotional exhaus tion, job satisfaction and absenteeism. First, age was entered in
step 1 as control variable. The predictors were entered in step 2. Results reveal that
Table 3. Hierarchical moderated regression results for the Japanese sample.
Dependent variables and standardized
beta coefficients
DP DPA D
Step 1
Age 2 .13 2 .28
***
2 .13
Step 2
Emotional Exhaustion .35
***
2 .29
***
.43
***
Job Satisfaction 2 .21
**
2 .28
***
2 .30
***
Absenteeism .02 2 .11 2 .04
Step 3
Emotional Exhaustion £ Job Satisfaction 2 .28 .28 2 .13
Emotional Exhaustion £ Absenteeism .40 .29 .39
Absenteeism £ Job Satisfaction 2 .35 .33 .16
Step 4
Absenteeism £ Job Satisfaction £ Emotional exhaustion 2 2.02 2 3.37
**
2 3.90
***
Step 1 DR
2
.02 .08
***
.02
Step 2 DR
2
.22
***
.10
***
.37
***
Step 3 DR
2
.02 .01 .01
Step 4 DR
2
.01 .02
**
.03
***
Note:
*
p , .05.
**
p , .01.
***
p , .001.
L. Tourigny et al.2752
emotional exhaustion is a predictor of depersonalization (DR
2¼
.22, p , .001; b ¼ .35,
p , .001), diminished personal accomplishment (DR
2¼
.10, p , .001; b ¼ 2 .29,
p , .001), and depression (DR
2
¼ .37, p , .001; b ¼ .43, p , .001), thereby supporting
hypothesis 1. Second, we found that job satisfaction is also a predictor of
depersonalization (DR
2¼
.22, p , .001; b ¼ 2 .21, p , .01), diminished personal
accomplishment (DR
2¼
.10, p , .001; b ¼ 2 .28, p , .001), and depression (DR
2¼
.37,
p , .001; b ¼ 2 .30, p , .001). Absenteeism is not a predictor of any of the criteria.
The two-way interaction terms were entered in step 3 and the three-way interaction
terms were entered in step 4. No two-way interaction was found. Therefore, we did not find
support for hypotheses 2 and 3. Results indicated a three-way interaction among emotional
exhaustion, job satisfaction and absenteeism in predicting diminished personal
accomplishment (DR
2¼
.02, p , .01; b ¼ 2 3.37, p , .01) and depression (DR
2¼
.03,
p , .01; b ¼ 2 3.90, p , .01). Figures 2a and 2b present the three-way interaction effect
for diminished personal accomplishment, and Figures 3a and 3b present the results for
depression. When nurses are high in job satisfaction, absen ce mitigat es the detrimental
effect of emotional exhaustion on diminished personal accomplishment. Indeed, we
Figure 2a and 2b. Three-way interaction effect for diminished personal accomplishment for
Japanese sample.
The International Journal of Human Resource Management 2753
observe a negative relationship between emotional exhaustion and diminished personal
accomplishment when nurses take time off. For nurses who are low in job satisfact ion
absence serves to simply maintain one’s equilibrium. Therefore, absence has a restorative
effect on nurses’ mental health. Furthermore, when nurses are high in job satisfaction,
absence mitigates the effect of emotional exhaustion on depression. However, when nurses
are low in job satisfaction and take time off, we observe a positive relationship between
emotional exhaustion and depression. Furthermore, it seems that the base rate of emotional
exhaustion is higher for nurses who are not satisfied with their jobs. For nurses who do not
take time off, we observe a positive relationship between emotional exhaustion and de-
pression for both high and low job satisfaction. However, nurses who are satisfied with their
jobs present higher levels of tolerance to emotional exhaustion. We did not find any three-
way interaction effect for depersonalization. Therefore, hypothesis 4 is partially supported.
The findings offer support to the compounding effect of job satisfaction and absence.
Chinese nurses
Table 4 presents the results for the hierarchical moderated regression analysis for the
Chinese sample including the effects of the two-way interactions and the three-way
Figure 3a and 3b. Three-way interaction effect for depression for Japanese sample.
L. Tourigny et al.2754
interaction among emotional exhaustion, job satisfaction and absenteeism. Results reveal
that emotional exhaustion predicts depersonalization (DR
2¼
.11, p , .001; b ¼ .26,
p , .001), and depression (DR
2¼
.24, p , .001; b ¼ .38, p , .001), thereby offering
partial support for hypothesis 1. Job satisfaction is a predictor of depersonalization
(DR
2¼
.11, p , .001; b ¼ 2 .12, p , .05), diminished personal accomplishment (DR
2¼
.08,
p , .001; b ¼ 2 .25, p , .001), and depression (DR
2¼
.24, p , .001; b ¼ 2 .18, p , 001).
Results also reveal that emotional exhaustion interacts with job satisfaction in predicting
depression (DR
2¼
.02, p , .01; b ¼ 2 .79, p , .01), which offers partial support to
Table 4. Hierarchical moderated regression for the Chinese sample.
Dependent variables and standardized
beta coefficients
DP DPA D
Step 1
Age 2 .17
**
2 .18
***
2 .06
Step 2
Emotional exhaustion .26
***
.03 .38
***
Job Satisfaction 2 .12
*
2 .25
***
2 .18
***
Absenteeism .04 .07 .09
Step 3
Emotional exhaustion £ Job Satisfaction 2 .17 .21 2 .79
**
Emotional exhaustion £ Absenteeism 2 .52 2 .15 2 .05
Absenteeism £ Job satisfaction 2 .52 .43 2 .32
Step 4
Absenteeism £ Job satisfaction £ Emotional exhaustion 2 3.11 2 2.97 2 4.17
*
Step 1 DR
2
.03
**
.03
***
.00
Step 2 DR
2
.11
***
.08
***
.24
***
Step 3 DR
2
.02 .01 .02
**
Step 4 DR
2
.01 .01 .02
*
Note:
*
p , .05.
**
p , .01.
***
p , .001.
Figure 4. Two-way interaction effect for depression for Chinese sample.
The International Journal of Human Resource Management 2755
hypothesis 2. Figure 4 illustrates the interaction terms for depression. The illustration of the
moderating effect of job satisfaction indicates that when nurses are high in job satisfaction
there is no relationship between emotional exhaustion and depression. However, when they
are low in job satisfaction there is a significant positive relationship between emotional
exhaustion and depression. Hypothesis 3 was not confirmed.
Finally, results indicate that there is a three-way interaction effect among emotional
exhaustion, job satisfaction, and absenteeism in predicting depression (DR
2¼
.02, p , .05;
b ¼ 2 4.17, p , .05). Figure 5a and 5b illustrates the three-way interaction effect for the
criterion of depression. When nurses are high in job satisfaction and low in absence there
is no relationship between emotional exhaustion and depression. However, when they are
low in job satisfaction and low in absence we observe a significant positive relationship
between emotional exhaustion and depression. When nurses take time-off and are high in
job satisfaction, there is a positive relationship between emotional exhaustion and
depression, which indicates a need to use absence as a means to mitigate the effect of
emotional exhaustion. Nurses who take time-off and who are low in job satisfaction report
Figure 5a and 5b. Three-way interaction effect for depression for Chinese sample.
L. Tourigny et al.2756
higher levels of emotional exhaustion. Furthermore, we observe a steep positive
relationship between emotional exhaustion and depression. These results indicate that the
use of absence is an effective coping strategy when nurses are high in job satisfaction. The
results offer partial support to hypothesis 4.
Discussion
Empirical research on nurses from both Japan and China seems to corroborate predictions
based on stress and burnout theories and more broadly, theories of occupational mental
health (Baba 2000). This inspires confidence on the portability of occupational mental
health theory to other contexts and cultures as long as the models are sensitive to those
contexts and cultures. The findings also suggest that occupational mental health notions
such as burnout and depression have empirical validity and theoretical relevance for the
healthcare sector in Asia. The findings lend credence to the notion that burnout is an
episodic phenomenon that unfolds to impact on other more general mental health
conditions such as depression. More importantly, the study establishes the usefulness of
both attitudinal and behavioral moderators in mitigating the impact of burnout on other
mental health consequences. It underscores the value of job satisfaction in investigations
of mental health in the workplace. Our findings demonstrate a pervasive influence of job
satisfaction on all aspects of occupational mental health. Further, the study highlights the
constructive use of absence in managing the mental health of the emotionally exhausted
nurses. From a managerial standpoint, more attention should be given to absence
management instead of attendance control. However, this also raises the issue of the
shortage of nurses in Japan and China and the consequences for the group when one is
absent from work. The mean number of days of absence in China is lower than in Japan. In
a collectivist envi ronment such as in China, when a nurse is absent, it inconveniences the
collectivity, namely the nursing team. On the other hand, when there is a turnover, it brings
a replacement to the collectivity. Turnover seems like a more permanent solution
compared to an unpredictable inconvenience caused by unexcused absence.
We argue that in China, unexcused absence incurs a loss of face for the absentee and
consequently such absence is not taken lightly. It seems that nurses in China use absence
only as a last resort, when the symptoms of emotional exhaustion are pervasive and job
satisfaction can no longer serve as a means to compensate for excessive work demands.
Therefore, it seems that healthcare managers in China should pay more attention to the
factors that contribute to increased job satisfaction so as to lower the need for absence. On
the other hand, our results show that Japanese nurses handle absence differently to Chinese
nurses. On average, the Japanese nurse is three times more absent than the Chinese nurse.
This is perhaps where institutional differences in HRM practice across China and Japan
matter. The Japanese p ractice of yukyu kyuka or ‘paid holiday’ may indeed provide the
explanation for the higher level of absence among Japanese nurses. When a nurse in Japan
takes yukyu kyuka, she is invoking a prevalent institutional practice. There is neither a
sense of guilt nor a loss of face. So the Japanese nurse is more likely to take time off from
work to cope with stress and exhaustion than her Chinese counterpart.
Insofar as specific results are concerned, it was clear that job satisfaction had a significant
main effect on depersonalization, diminished personal accomplishment as well as on
depression among both Japanese and Chinese nurses. It is a useful finding because we already
know how to enhance job satisfaction through a large volume of empirical and interventionist
studies with different samples and in different cultures. So, healthcare managers need to pay
attention to the job satisfaction of their nurses in both Japan and China. The point here is that
The International Journal of Human Resource Management 2757
regardless of the stage of economic development, job satisfaction remains a fundamental
factor in influencing mental health. In addition, job satisfaction played a significant role in
influencing depressive symptomatology via a three-way interaction involving emotional
exhaustion and absence for both the Japanese and Chinese samples of nurses. It is empirically
demonstrated in this research that absence can alleviate the symptoms of emotional
exhaustion provided that nurses are satisfied with their jobs.
Differences among the samples emerged when we focused on specific burnout
components. As can be seen from Figures 2a and 2b, among Japanese nurses, those who are
high in their job satisfaction used absence as an effective mechanism to minimize the impact
of emotional exhaustion on diminished personal accomplishment. Similarly, as shown in
Figures 3a and 3b, those who are high in job satisfaction also used absence as an effective
mechanism to ward off depressiontriggered by emotional exhaustion. Those who did not avail
themselves of absence to recuperate did not differ much in terms of the effect their emotional
exhaustion had on their diminished personal accomplishment or depression. The fact that
some were more satisfied with their jobs than others did not make a difference in terms of how
they reacted to their emotional exhaustion. It is the simultaneous application of behavioral and
attitudinal moderators that mitigates emotional exhaustion.
Among the Chinese nurses, there was a clear distinction between those who reported
high job satisfaction and those who did not, in terms of their response to emotional
exhaustion. As Figure 4 shows, those nurses who are higher in job satisfaction did not
suffer much from symptoms of depression when exhausted emotionally. Those who were
not satisfied with their jobs showed a stronger positive relationship between emotional
exhaustion and depression. This is very much in line with conventional theory on
occupational mental health. When we looked at the three-way interaction, the pattern was
different for the Chinese nurses as shown in Figures 5a and 5b. Those nurses who absented
themselves less and who were higher in job satisfaction showed the greatest resilience to
depression induced by emotional exhaustion. In other words, absence seems to have
different meanin g or use for the Japanese and the Chinese. This is precisely where one
should look for explanation at a higher level of analysis in order to make sense of these
differences (Hackman 2003). It is likely that due to institutional constraints or cultural
reasons, absenting oneself from work may involve different cognitive appraisal of stressful
situations and interpretations of potential consequences or may have different
organizational implications in Japan and China.
Limitations and future directions
The purpose of this research was to determine whether there can be effective attitudinal
and behavioral coping mechanisms that can buffer the detrimental effect of emotional
exhaustion. Essentially, we analyzed how emotional exhaustion impacts depersonaliza-
tion, diminished personal accomplishment and depressive symptomatology. Results
indicate that absence can play a restorative role and that in the context of high job
satisfaction nurses can much better cope with emotional exhaustion and prevent an
increase in symptoms of depression. The fact that such findings could be replicated in two
different Asian cultures provides sufficient evidence to the practical usefulness of our
theoretical model. However, these results should be interpreted with caution because of
certain methodological limitations. First, our findings are based on cross-sectional data.
Therefore, we cannot assess whether repeated episodes of burnout would actually lead to
higher depressive symptomatology and if the effectiveness of coping mechanisms may
increase or deteriorate over time. Therefore, we do not know if nurses can actually learn to
L. Tourigny et al.2758
prevent symptom s of depression by consistently applying the same coping mechanisms
each time an episode of burnout unfolds. For example, we could not determine whether
nurses who reported high job satisfaction did so because of their proactive action and if
such action could be repeatedly effective over time.
Second, the statistical method emp loyed did not allow for appropriate testing of the
sequencing of the variables. The sample sizes and the theoretical model constitute
important limitations to the use of structural equation modeling. Therefore, we could not
conduct such assessment.
Third, we do not know if there are policies regarding absence that can restrict the
latitude of nurses with respect to voluntary absence. Furthermore, we do not have enough
data to determine whether nurse s who did not take absence worked longer shifts than
others. It is highly possible that the relationships observed between emotional exhaustion
and depressive symptomatology may depend on some common factors such as number of
hours worked, night shifts, and various workload. As these may tend to change within and
between individuals it would be necessary in future research to analyze the extent to which
they may prevent the use of effective coping strategies as well.
Fourth, we used self-report measures only. It may be useful to collect data at the unit level
to assess how organizations can actually enhance job satisfaction by knowing better how
nurses in different units react to their working conditions. This would help to develop tailored
intervention programs and revise employee benefits to produce more healthy nurses.
Acknowledgement
Financial support for the present study from SSHRC (410-2003-1014) is gratefully acknowledged.
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