Understanding and Preventing Worker Burnout
Kirsi Ahola, Finnish Institute of Occupational Health
Burnout has been defined as a prolonged response to chronic emotional and interpersonal stresses on the job. It manifests itself as exhaustion, cynicism, and diminished professional efficacy. There is a risk of burnout when a discrepancy prevails between the expectations of a motivated employee and the reality of an unfavourable work situation. This discrepancy progresses towards burnout via dysfunctional ways of coping. Severe burnout is related to performance deficits, mental disorders, and physical illnesses. It is also related to a higher risk of work disability, as indicated by sickness absence and disability pension. Prevention of burnout is quite similar to management of work-related stress. To achieve a successful recovery from burnout it is essential to change the working conditions where burnout has developed.
Definition of burnout
Burnout describes an individual's psychological response to chronic stressors at work. It is not regarded as a medical condition, i.e., it is not included as a diagnosis in the medical classification systems. However, in the International Classification of Diseases (version 10) burnout can be coded as a factor that influences health status and in the Diagnostic Statistical Manual (version IV) it is listed as a condition that may require clinical attention.
The burnout phenomenon was originally discovered in professionals employed in human service work; particularly among professional care groups. A major part of this work involves contact with a variety of people, which can subsequently develop into a source of stress. Relative to human service work, the symptoms of burnout were labelled as emotional exhaustion, depersonalization, and diminished personal accomplishment. They centred on the relationship with clients. It was later realised that burnout can result from prolonged work stress in a wider range of occupations. Following this, burnout was conceptualised much more as a crisis in one's relationship with work in general.
Burnout is widely understood as a multidimensional syndrome. According to the original definition, burnout manifests itself by symptoms of exhaustion, cynicism, and diminished professional efficacy:
- Exhaustion refers to feelings of overstrain, tiredness, and fatigue, which result from long-term involvement in an over-demanding work situation.
- Cynicism reflects an indifferent and distant attitude towards work, disengagement, and a lack of enthusiasm for work. It is a dysfunctional way of coping with exhausting situations, reducing the possibilities of finding creative solutions at work.
- Professional efficacy consists of feelings of competence, successful achievement, and accomplishment in one's work, which diminishes as burnout develops.
Relative to the symptoms of burnout, studies have found support for the exhaustion and cynicism factors. However, authors have postulated that diminished professional efficacy may be a separate but related entity. Therefore the dimensional definition of burnout has been criticized for lacking a theoretical basis in its grouping of different concepts. In the alternative definitions of burnout, the exhaustion alone is usually considered to constitute burnout. According to these alternative definitions, burnout is defined as, for example, a state of physical fatigue, emotional and mental exhaustion, and cognitive weariness.
Assessment of burnout
Burnout can be assessed by the utilisation of validated self-report questionnaires. The most widely used instrument is the Maslach Burnout Inventory (MBI), which is targeted for human service professionals. The MBI consists of 22 items. Its general version, the Maslach Burnout Inventory – General Survey, comprises of 16 items and can be used in a variety of workplaces. Other burnout measures include, for example, the Oldenburg Burnout Inventory and the Copenhagen Burnout Inventory.
There are no universal guidelines on how to assess burnout syndrome on the basis of the scores on the sub scales of exhaustion, cynicism, and diminished professional efficacy. In addition, the cut points to define when an employee is burned out are lacking. Dutch researchers have developed a procedure which compares individual scores against those in a given population. It has helped to identify cases of work-related neurasthenia. Other ways to identify burned out employees, for example by occupational health care professionals, use additive or weighted combination of exhaustion, cynicism, and diminished professional efficacy scores to create a sum score, which is then categorized into tertiles or according to another criteria.
Prevalence and cost of burnout
Due to the lack of consensus on a universal definition of burnout and the assessment criteria, the prevalence estimates for burnout are not comparable across countries and studies. In addition, it is probable that the prevalence of burnout fluctuates with work-life balance and the economy in general. However, at the level of the individual, burnout tends to show remarkable stability over time.
It is estimated that about 3-16% of the Dutch human service professionals suffer from severe burnout, which affects their work ability. In Scandinavian working populations, the estimated prevalence for severe burnout is between 2-7 %.
There is no detailed information on the costs of burnout. Based on studies of its individual and organisational consequences (i.e., performance deficits, health problems, and work disability), burnout can be indirectly linked to economic losses. The yearly cost of work stress, an antecedent of burnout, was estimated to be €1,768 per worker in the Netherlands. This amount was attributable to prevention and work-related illnesses. In the United Kingdom, 10 million working days were lost due to anxiety, depression, and stress caused by work. Additionally, stress-related illnesses cost France between € 830 and €1,656. In the U.S. labour force, workers who experienced context-free fatigue, which resembles the exhaustion dimension of burnout, experienced a loss in work time due to ill health. The cost of this was estimated at $136 billion annually, an excess of $101 billion compared to workers without fatigue.
Risk factors and antecedents of burnout
Theoretical models on burnout
Several theoretical viewpoints on the origins of burnout have been presented. These range from individual and interpersonal level explanations to organizational and societal level approaches. Examples of the explaining factors in the different levels are given in Table 1. Many of the models share a basic assumption, that there is some form of chronic discrepancy between the expectations of a motivated employee, on one hand, and the reality of the unfavourable work conditions, on the other. This discrepancy progresses towards burnout via dysfunctional ways of coping. These elements, the discrepancy, its personal meaning, and coping, are also basic elements of the traditional stress theory. They highlight the development of stress as a result of the interaction between the individual and his or her environment.
Work factors and burnout
With regard to unfavourable work conditions it has been suggested that, occupational burnout can result from a combination of high demands and low resources at work. Job demands refer to the physical, psychological, social, and organisational aspects of the work that require sustained effort. Excessive job demands and sustained effort over a prolonged period of time have been found to be associated with physiological and psychological costs for the individual. Job resources refer to those beneficial aspects of the job that help individuals achieve work goals, reduce the associated costs, and to stimulate learning and professional development. According to longitudinal studies, the psychosocial work characteristics which typically precede burnout are high quantitative and qualitative work load, role conflict and ambiguity, low predictability, experienced unfairness, and lack of participation and social support.
Other environmental factors and burnout
The importance of environmental influence in the development of burnout has also been supported in studies among twins and their siblings. Correlation of burnout scores among family members due to similar environment was found among. Common environmental factors explained 22% of the burnout scores. On the other hand, similar genetic factors between identical twins did not seem to be of importance for their burnout scores. In addition, a significant correlation of burnout between spouses supported the conclusion that a common environment does play a role in the development of burnout.
Individual factors and burnout
The vulnerability to burnout may also emerge from individual differences. The dimensions of the five-factor model of personality have been found to be associated with burnout. This model describes salient aspects of individual's personality according to the traits of neuroticism, extraversion, agreeableness, conscientiousness, and openness. Workers who show higher scores in neuroticism and lower scores in extraversion, agreeableness, and conscientiousness have been reported to be more prone to experience burnout. In addition, alexithymia (i.e., individual difficulty in identifying and describing feelings) and a low sense of coherence (sense of coherence, according to Antonovsky’s concept (1979), describes an individual characteristic to perceive the world as understandable, meaningful, and manageable) have been found to be associated with burnout. Rather than causing burnout directly, it has been proposed that individual factors interact with situational factors resulting in either acceleration or a buffer against the development of burnout.
Socio-demographic factors and burnout
With regard to socio-demographic factors, burnout has been claimed to be more frequent among women than men. In population-based studies, the level of burnout has been noted to increase with age. Although in human service samples, an opposite trend has been detected. However, detailed analyses of samples which represent different jobs and sectors nationwide revealed that age was differentially related to burnout in separate age groups of men and women. The level of burnout increased with age among middle-aged men and older women and decreased with age among younger women. There is no clear consensus about the association of burnout with education, occupational grade, and marital status.
Consequences of burnout
Burnout and work performance
According to a summary based on several studies, severe burnout is moderately related to low rated work performance. Interestingly, the relationship between burnout and work performance was consistently stronger when performance was rated by others, rather than by the employee in question. This indicates that those who suffer from burnout may not be fully aware of the extent to which burnout affects their work behaviour. In addition, the association of burnout with performance related to general contextual activities at work, which may be discretionary, was stronger than the association between burnout and performance related to the main task-related duties. This indicates that employees with burnout try to the bitter end to maintain focus on taking care of their core tasks.
Burnout and cognition
Female patients, who had been assessed to suffer from chronic burnout by a physician, displayed cognitive impairment in attention and non-verbal memory. However, no deficits were found in verbal ability or verbal memory. Conversely, in a population-based sample of young working adults, the level of burnout was found not to be related to cognitive functioning. Rather the authors found that a high burnout score was related to slightly better performance in neuropsychological tests of verbal working memory and general intelligence. No difference emerged in tests of visual short-term memory, verbal long-term memory, attention, psychomotor processing speed, or executive function between young employees with or without burnout.
Burnout and health
Burnout has also been found to be related to mental disorders. In a population-based sample, 45% of employees with severe burnout fulfilled the criteria for a depressive disorder, 21% for an anxiety disorder, and 10% for alcohol dependence. In a longitudinal design monitoring dentists, burnout predicted depressive symptoms during a three-year-follow-up. Burnout has also predicted new cases of insomnia during an 18-month follow-up of employed adults.
Burnout also has a relationship with physical illnesses. In a population-based Finnish sample, 47% of employees with severe burnout suffered a musculoskeletal disorder and 28% had a cardiovascular disease. After adjustments, musculoskeletal disorders were related to burnout among women, while cardiovascular diseases were related to burnout among men. In longitudinal designs, burnout has predicted type 2 diabetes as well as gastroenteritis and common colds.
Only 10% of employeed adults who experienced weekly symptoms of burnout were healthy (i.e., free from a physical illness or common mental disorder). Consequently there seems to be a major overlap between a severe-level of burnout and ill health. Burnout may also lead to critical health problems. In a sample of pulp and paper industry workers, burnout predicted hospitalisation due to mental disorders and cardiovascular diseases during a 10-year follow-up. In addition, burnout predicted early death among pulp and paper industry workers younger than 45 years of age at the beginning of the study. During the 10-year follow-up period, the level of burnout was positively related to the risk of all-cause mortality among younger workers, but not among those over 45 years of age at the beginning of the study.
The mechanism affecting the association between work stress and health problems can be direct (i.e., stress predisposes individuals to illness, or accelerates the disease process in its subclinical phase), indirect (i.e., stress increases individuals' unfavourable health behaviour), or even reversed (i.e., coping with illness further increases stress). Since it seems to reflect the accumulated exposure to work stress, burnout may be a phase in the process between adverse psychosocial work environment and ill health. However, it is equally possible that the early phases of illness reduce the possibility of reaching one's goals at work, eventually leading to burnout. In the three years' longitudinal study of dentists, a reciprocal relationship was established between burnout and depression. Burnout predisposed individuals’ to depression and depression predisposed individuals’ to burnout. However, the relationship between job strain and depression was fully mediated by burnout, while the relationship between job strain and burnout was only partially mediated by depression.
Burnout and work ability
Both temporary work disability (indicated by sickness absence) and chronic work disability (indicated by disability pension) may follow burnout. Burnout has been shown to predict sickness absences. A higher level of burnout was related to a greater number of medically certified absence spells during a three-year follow-up in a multi-national pulp and paper industry organization. Additionally, burnout was related to longer company-registered absence duration during a one-year follow-up in a nutrition production organization. In the former study, burnout increased future absences, which were granted for mental disorders and diseases of the musculoskeletal and circulatory systems. A significant association has also been found between a high level of burnout and self-certified sickness absence during a three-year follow-up period among human service workers.
In a Finnish population level study, burnout was associated with medically certified sickness absence independent of prevalent mental disorders and physical illnesses. The duration of absence over two years was an excess of 55 sickness absence days in men, and 41 days in women. Burnout also predicted chronic work disability over four years in the same population-based sample. This association was independent of the employees' health status at the beginning of the study. The disability pension granted to those with burnout was most often awarded on the basis of mental and behavioural disorders, and diseases of the musculoskeletal system in this Finnish sample.
Managing and preventing burnout
Various interventions to tackle burnout (presented in Table 2) may be grouped according to either their purpose (i.e., ranging from the recognition and prevention of burnout to its treatment and rehabilitation) or their focus (i.e., the individual, the organization, or the interface between the individual and the organization). This schema replicates that widely used to described intervention for work stress. Primary prevention is aimed at all employees, while secondary prevention is aimed at those known or identified to be at risk for burnout. Individually focussed interventions aim at strengthening the individual's resources by providing better coping skills, while organisation-focussed interventions aim at changing the situation at work. Those interventions, which focus on the individual-organisational interface, concentrate on tackling the interrelationship between the employee and his or her work situation.
The approaches to alleviating burnout deal with the same issues as those measures aimed at its prevention. In guidelines for occupational health practitioners, treatment suggestions for stress-related conditions have included a change or a reorganization of the work situation, in combination with rehabilitation and retraining, psychotherapy and other forms of counselling, as well as pharmacological treatment depending on the type and severity of the symptoms. It is noteworthy that mere individually focused help is not considered sufficient. A change in the working conditions, where burnout had developed, was also included in the successful process of recovery from burnout discovered in a qualitative study of 20 employees who had suffered from severe burnout.
This recovery process included six phases as follows:
- admitting the problem,
- distancing from work,
- restoring health (both tension reduction and enjoyment),
- questioning values (both giving up the old and obtaining new ones),
- exploring work possibilities, and
- effecting a change.
The phase number four, questioning values, was described as being the most difficult while phase five, exploring work possibilities, lasted the longest.
Work-focused burnout workshops, in which employees discuss their work conditions in a group and together plan ways to resolve work-related challenges or to develop their work, have proven to be efficient ways for reducing burnout. During a rehabilitation process, those clients who benefited most in terms of a reduction in their burnout scores experienced an increase in their job resources and a decrease in their job demands. Participatory programs, which included co-operation with workplace representatives, were especially helpful for white-collar women. With the help of such programs, employees gained a sense of increased control in their jobs.
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Link for future reading
Leiter, M. P. & Maslach, C., Banishing burnout. Six strategies for improving your relationship with work. San Francisco: Jossey-Bass, 2005.
Maslach, C., Schaufeli, W. B. & Leiter, M. P., ‘Burnout: A perspective from social comparisons theory’. In W.B. Schaufeli, C. Maslach, & T. Marek (Eds.) Professional burnout: Recent developments in theory and research. New York: Hemisphere, 1993, pp. 53-69.
Schaufeli, W. & Enzmann, D., The burnout companion to study and practice: A critical analysis, London: Taylor & Francis, 1998.
Shirom, A., 'Job-related burnout: A review of major research foci and challenges'. In J. C. Quick & L. E. Tetrick (Eds.) Handbook of Occupational Health Psychology, 2. Ed. Washington: American Psychological Association, 2011.