The Journal of Emergency Medicine, Vol. 31, No. 1, pp.

7–11, 2006
Copyright © 2006 Elsevier Inc.
Printed in the USA. All rights reserved
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doi:10.1016/j.jemermed.2005.08.008

Original
Contributions

IMPACT OF POST-TRAUMATIC STRESS DISORDER AND JOB-RELATED

STRESS ON BURNOUT: A STUDY OF FIRE SERVICE WORKERS
Satoko Mitani, RN, PhD,* Masatoshi Fujita, MD, PhD,† Keiji Nakata, MA,‡ and Taro Shirakawa, MD, PhD*

*Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Public Health, Kyoto, Japan,
†Department of Laboratory Science, School of Health Science Faculty of Medicine Kyoto University, Kyoto, Japan, and ‡Department
of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
Reprint Address: Satoko Mitani, Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Public
Health, Yoshida-konoe cho, Sakyo-ku, Kyoto 606-8501, Japan

e Abstract—Burnout and stress are common, related health care providers, burnout has become an issue of
problems in service professionals, and post-traumatic stress important national concern. Burnout is a syndrome char-
disorder (PTSD) is a major concern among fire service acterized by emotional exhaustion, depersonalization in
workers. The purpose of this study was to evaluate the
relationships with coworkers or clients, and a sense of
impact of PTSD and job-related stressors on burnout. A
total of 243 fire service workers completed questionnaires,
inadequacy or reduced personal accomplishment (2).
including the Impact of Event Scale-Revised (IES-R), Particular concerns have been expressed about the high
Maslach Burnout Inventory (MBI), and Japan Brief Job levels of physical and mental problems, including burn-
Stress Questionnaire. Relationships were found between out, among health care workers (3,4). Over recent de-
PTSD and burnout, and between job stressors and burnout. cades, job stress has emerged as a major psychosocial
Social support reduced the impact on burnout. Stressors influence on physical and mental health, associated with
that impacted on burnout in fire service personnel were burnout.
PTSD-related acute stress and general job-related chronic For more than a century, the relationship between
stress. Countermeasures, not only against job stress, but
traumatic stress and psychiatric distress has been studied
also against PTSD-related stress, are essential to prevent
burnout. Social support and the development of human from various points of view. Numerous studies have
relationships in the work place are crucial in mitigating been conducted on victims; for example, 5– 8 weeks after
burnout. © 2006 Elsevier Inc. the September 11 terrorist attacks in New York, 7.5% of
Manhattan residents reported symptoms consistent with
e Keywords— burnout; fire service personnel; job stress; a diagnosis of current post-traumatic stress disorder
post-traumatic stress disorder (PTSD); social support (PTSD) (5). As regards rescue service personnel, fire-
fighters, paramedics, police, and medical staff, they are
frequently exposed to traumatic events as part of their
INTRODUCTION occupation. Some studies have reported the prevalence
of PTSD among fire service workers, such as ambulance
Burnout and stress are common, related problems in personnel, firefighters and rescue workers, to be from
health-service workers (1). Burnout can be defined as a 18% to 30% (6,7). Therefore, not only disaster and
long-term reaction to occupational stress, involving, in accident victims, but also rescue workers involved in
particular, the caring professions. In physicians and other life-threatening incidents suffer with PTSD.

RECEIVED: 11 August 2004; FINAL SUBMISSION RECEIVED: 28 July 2005;

ACCEPTED: 2 August 2005
7
8 S. Mitani et al.

The response to job stress is a chronic reaction against items, which assess emotional, informative and instru-
long-term stressors, with difficulty in finding the causes. mental support from superiors, co-workers and family.
On the other hand, PTSD is an acute or chronic stress Burnout was assessed according to the Maslach Burn-
reaction, capable of being linked to specific traumatic out Inventory (MBI) (2). This instrument contains 17
events. As regards the duties of fire service workers, items that measure the cumulative effects of work-re-
stress responses involve these two factors; nevertheless, lated pressure on three states: ‘emotional exhaustion,’
the relationships among PTSD, job stress, and burnout ‘depersonalization,’ and ‘personal accomplishment.’
are unclear. Each question is assessed on a scale ranging from 1 (not
This study was conducted to ascertain the factors that at all) to 5 (yes, absolutely). The first state, ‘emotional
are influential in burnout and stress reaction of fire ser- exhaustion,’ refers to the condition of being overex-
vice workers. Post-traumatic stress disorder, job stress, tended and emotionally drained. The second state, ‘de-
and burnout were investigated to define the relationship personalization,’ refers to a loss of concern and compas-
of PTSD with the psychological and physical welfare of sion towards others. The third state, ‘personal
fire service personnel. accomplishment,’ reflects the subject’s sense of personal
achievement at work. High scores for the first two scales
and low scores for the last scale are associated with
METHODS burnout.
In addition, a questionnaire was designed to obtain
Subjects additional information, including age, sex, and subjective
feelings as regards health and distress. Subjective feeling
All 243 subjects belonged to two Fire Departments, one of health was assessed on a scale ranging from 1 (quite
(n ⫽ 131) located in the countryside and the other (n ⫽ healthy) to 5 (unwell), and subjective feeling of distress
112) in an urban area in Japan. The samples included all was assessed on a scale ranging from 1 (quite stressful)
personnel of the two fire stations. to 5 (no feeling of stress at all).
Questionnaires were handed out at the work place and The software program SPSS for windows (version
sealed in individual envelopes, by each subject, upon 10.0; SPSS Inc., Chicago, IL) was used to analyze the
completion. Written informed consent was obtained by a data.
form attached to the questionnaire package. The study was conducted under the guidelines of
Administration No. 403 of the Ethics Committee of
Kyoto University Graduate School and Faculty of Med-
Measurements icine (2002).

PTSD was assessed according to the Japanese-language

version of the Impact of Event Scale-Revised (IES-R) RESULTS
(8), which was used to determine the frequency of the
self-reported post-traumatic symptoms—re-experienc- Of the 297 subjects, 81.8% (243/297) returned the ques-
ing, avoidance and arousal—according to the Diagnostic tionnaire. A total of 96.5% (237/243) were men and
and Statistical Manual of Mental Disorders – Fourth 1.6% (4/243) women, and two were missing gender data.
Edition (DSM-IV) criteria (9). This instrument contained Mean age was 42.5 ⫾ 9.90 (mean ⫾ SD) years.
22 items. Each question was assessed on a scale ranging A total of 12 subjects on IES-R and five on MBI were
from 0 (not at all) to 4 (yes, absolutely); PTSD was excluded from analysis due to missing data. For the total
diagnosed using a cutoff point of 24/25.
Japan Brief Job Stress Questionnaire was developed
by a stress assessment study group of the Japanese Min- Table 1. Questionnaire Results
istry of Health, Labor, and Welfare (1995–1998). This Subjects (n) Mean ⫾ SD
questionnaire was used to assess total job-related issues,
i.e., job stressor, job strain and social support. Each Age 241 42.5 ⫾ 9.9 years
IES-R 231 13.0 ⫾ 14.3
question was assessed on a scale ranging from 1 (not at Job stressor 239 42.1 ⫾ 6.6
all) to 4 (yes, absolutely). In this study, subscales, related Social support 239 25.6 ⫾ 4.5
to job stressor and social support, were also used. The Burn out
Emotional exhaustion 238 11.5 ⫾ 4.4
job stressor subscale contains 17 items, seeking to define Depersonalization 238 11.0 ⫾ 4.5
quality and quantity of workload, psychological stress, Personal accomplishment 238 13.8 ⫾ 4.4
challenges, workplace environment, aptitude, and human Subjective feeling of health 237 2.7 ⫾ 0.9
Subjective feeling of distress 237 2.5 ⫾ 0.9
relationships. The social support subscale contains nine
PTSD- and Job-Related Stress on Burnout 9

Table 2. Correlation Coefficients

Job Social Emotional Personal

Age IES-R stressor support exhaustion Depersonalization accomplishment

Age – – – – – – –
IES-R 0.06 – – – – – –
Job stressor ⫺0.25** 0.37** – – – – –
Social support ⫺0.16** ⫺0.28* ⫺0.30** – – – –
Emotional exhaustion ⫺0.09 0.52** 0.61** ⫺0.32** – – –
Depersonalization ⫺0.09 0.51** 0.51** ⫺0.36** 0.74** – –
Personal accomplishment ⫺0.11 ⫺0.02 ⫺0.06 0.28** 0.02 ⫺0.07 –

* p⬍ 0.05; ** p⬍ 0.01.

sample of 231 responders, the mean score on IES-R was complishment (t⫽ 0.02, p⫽ 0.99) (Figure 1). In compar-
13.0 ⫾ 14.3. Using a 24/25 cutoff point for total score, an ison with the low-risk group, self-administered job
IES-R above 25 points was recorded in 43 subjects stressor was significantly higher (t⫽ 3.01, p⫽ 0.003) and
(17.7%). Those above 25 points were defined as a PTSD social support was significantly lower (t⫽ 3.39, p⫽
high-risk group (HR), and those below 24 points as a 0.001) in the PTSD high-risk group (Figure 2). The
PTSD low-risk group (LR) (Table 1). According to the PTSD high-risk group suffered from significantly poorer
brief job stress questionnaire, the total score for job health (t⫽ 2.93, p⫽ 0.005) and significantly more dis-
stressor was 42.1 ⫾ 6.6. On the MBI, scores for the 238 tress (t⫽ 5.26, p⬍ 0.001) in comparison with the low-
responders on the three sub-scales were: ‘emotional ex- risk group (Figure 3).
haustion’ 11.5 ⫾ 4.4, ‘depersonalization’ 11.0 ⫾ 4.5 and
‘personal accomplishment’ 13.8 ⫾ 4.4. DISCUSSION
Pearson’s correlation coefficients for IES-R, job stres-
sor, total social support (support by superiors, co-work- PTSD, Job Stressor and Burnout
ers and family) and burnout are shown in Table 2.
Among the MBI subscales, emotional exhaustion was In the MBI subscales, emotional exhaustion and deper-
correlated with IES-R (r⫽ 0.52, p⬍ 0.01) and job stres- sonalization had a strong positive correlation with IES-R
sor (r⫽ 0.61, p⬍ 0.01), and depersonalization was cor- and job stressor, and a negative correlation with social
related with IES-R (r⫽ 0.51, p⬍ 0.01) and job stressor support (Table 2). These results show that a worker who
(r⫽ 0.51, p⬍ 0.01). However, personal accomplishment suffers from acute or chronic stress feels emotional ex-
haustion and depersonalization. However, the score for
was not significantly correlated with these factors.
personal accomplishment, which is also an MBI sub-
Regarding burnout, t-tests showed significant differ-
score, showed no correlation with IES-R or job stressor.
ences between the PTSD high- and low-risk groups in
According to an MBI investigation into burnout in
emotional exhaustion (t⫽ 5.48, p⬍ 0.001) and deperson-
alization (t⫽ 5.65, p⬍ 0.001), but not in personal ac-

Figure 1. Mean scores for three burnout subscales. PTSD Figure 2. Mean scores for job stressor and social support.
low-risk group: open bars; PTSD high-risk group: solid PTSD low-risk group: open bars; PTSD high-risk group: solid
bars. bars.
10 S. Mitani et al.

accomplishment subscale had no relation with other

subscales.
Traumatic events, however, cause demonstrable
and chronic long-term effects on psychological and
physical health (12). Obviously, for fire service work-
ers, problems with job stressors are very important, as
are problems with PTSD. It is imperative, therefore, to
have insight into the association between acute and
chronic stressors, in relation to the welfare of fire
service workers. Our study specifies the importance of
psychological and physical effects in critical incident
stress.
Figure 3. Mean scores for subjective feeling of health and
distress. PTSD low-risk group: open bars; PTSD high-risk
group: solid bars.
PTSD and the Other Factors

Table 2 shows that age had a significant, but weak,

Japanese nurses, a score for ‘emotional exhaustion’
negative correlation with self-reported job stressor (r⫽
above 19, a score for ‘depersonalization’ above 15 and
⫺0.25, p⬍ 0.001). It is assumed that the reason why fire
a score of ‘personal accomplishment’ below 15 were
service workers with a long work history exhibit lower
the critical levels of burnout (10). In our study, 24
job stressor is that they have learned skills enabling them
subjects (10.0%) were above 19 on emotional exhaus-
to cope with problems at work. As they say, ‘it gets
tion, 41 (17.2%) were above 15 on depersonalization,
easier with experience’; years of service moderate vari-
and 158 (66.3%) were below 15 on personal accom-
ous job-related stressors. However, the impact was quite
plishment. Furthermore, two subjects on emotional small. According to the IES-R score, it was not related to
exhaustion (above 24 points), 12 on depersonalization age (r⫽ 006, ns). Critical incidents occur without warn-
(above 21), and 46 on personal accomplishment (be- ing, and PTSD symptoms are not prevented by age.
low 9) were at risk of burnout (Table 3). As regards Subjective feelings of health and distress show a
emotional exhaustion and depersonalization, almost significant difference between the high- and low-risk
all subjects were healthy. However, between 10% and groups. Subjective feelings, such as “I don’t know why,
20% of fire service workers need to pay attention to but I feel so unhealthy” or “I don’t know why, but I feel
the danger of burnout. On the other hand, it may be distressed,” are useful indices in evaluating a subject’s
due to modesty or embarrassment that a very low score psychological and physical health, when there is no
was achieved on personal accomplishment. Japanese instrument or questionnaire to assess his stress. The
fire service workers tend not to be self-assertive of PTSD high-risk group feels unhealthy and distressed in
their accomplishments. Brookings et al. argued that comparison with the low-risk group. The high risk group,
emotional exhaustion and depersonalization are which scored high in the IES-R (ⱖ 25 point cutoff
strains, which arise from the stressor of job surround- score), is said to be at high risk of psychiatric and
ings, whereas the regression of personal accomplish- emotional disorders, such as post-traumatic stress disor-
ment is an emotion, which arises from a service rela- der. In this study, the number of subjects at high risk of
tionship with clients (11). It is partly because this PTSD was 43 (18.6%). Thus, to prevent the burnout in
study was imposed on fire service personnel, and did fire service workers, countermeasures, not only against
not involve a client relationship, that the personal job stressors, but also against PTSD, are essential.

Table 3. Distribution of Three Burnout Subscales

Emotional exhaustion Depersonalization Personal accomplishment

Score n (%) Score n (%) Score n (%)

Safe 5–15 195 (82.0) 6–11 148 (62.2) 25–18 54 (22.7)

Average 16–18 19 (7.9) 12–14 49 (20.6) 17–16 26 (10.9)
Notice 19–20 14 (5.9) 15–17 19 (8.0) 15–13 61 (25.6)
Caution 21–23 8 (3.3) 18–20 10 (4.2) 12–10 52 (21.8)
Danger 24–25 2 (0.8) 21–30 12 (5.0) 9–6 45 (18.9)
PTSD- and Job-Related Stress on Burnout 11

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