Burnout

Burnout prevention: A review of intervention programs

Wendy L. Awa*, Martina Plaumann, Ulla Walter

HannoverMedicalSchool,InstituteforEpidemiology,SocialMedicineandHealthSystemResearch,EndowedChairPreventionandRehabilitationinHealthSystemandHealthServicesResearch, Hannover, Germany

1. Introduction

1.1. Background

Burnout is a work related mental health impairment compris-ing three dimensions: emotional exhaustion, depersonalisationand reduced personal accomplishment. Emotional exhaustion isthe state of being depleted of one’s emotional resources,depersonalisation refers to a negative, cynical and detachedapproach to people under ones care and reduced personalaccomplishment refers to a sense of low self-efﬁcacy and negativefeelings towards one’s self.The presence of these three components alongside oneanother differentiates burnout from stress and other psycholo-gical conditions with which it shares similar symptoms likedepression, fatigue, anxiety or lack of motivation. Burnoutfurther differs from stress in that its victims have experiencedprolonged symptoms. Burnout results from stress that comesabout through the social relationship between a helper and ahelp recipient, usually found in asymmetrical professionalrelationships, whereby the victim is the ‘‘giver’’ and the client(s)the ‘‘receiver’’. This is usually the case with professionals likephysicians, nurses, teachers or social workers[1]. For examplean estimated 22% of physicians in the USA, 27% of physicians inGreat Britain[2]and 20% of physicians in Germany sufferburnout[3]. Similarly, about 30% of teachers are affected[4,5] and some studies report up to 40%[6]. However, burnout canmanifest in any person and the number of individuals sufferingburnout are continuously on the rise[7].An imbalance between job demands and job skills, a lack of jobcontrol, effort reward imbalance (discrepancy which existsbetween resources, expectations and job reality) and prolongedwork stress, are some of the leading risk factors for thedevelopment of burnout or other work related mental health

Patient Education and Counseling 78 (2010) 184–190

A R T I C L E I N F O

Article history:

Received 17 November 2008

Received in revised form 10 April 2009

Accepted 16 April 2009

Keywords:

BurnoutWorksite mental healthPreventionEmpowermentReview

A B S T R A C T

Objective:

Toevaluatetheeffectivenessofinterventionprogramsattheworkplaceorelsewhereaimedatpreventing burnout, a leading cause of work related mental health impairment.

Methods:

A systematic search of burnout intervention studies was conducted in the databases Medline,PsycINFO and PSYNDEX from 1995 to 2007. Data was also extracted from papers found through a handsearch.

Results:

A total of 25 primary intervention studies were reviewed. Seventeen (68%) were person-directed interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of bothinterventions types. Eighty percent of all programs led to a reduction in burnout. Person-directedinterventionsreducedburnoutintheshortterm(6monthsorless),whileacombinationofbothperson-and organization-directed interventions had longer lasting positive effects (12 months and over). In allcases, positive intervention effects diminished in the course of time.

Conclusion:

Intervention programs against burnout are beneﬁcial and can be enhanced with refreshercourses. Better implemented programs including both person- and organization-directed measuresshould be offered and evaluated.

Practice implications:

A combination of both intervention types should be further investigated,optimized and practiced. Institutions should recognize the need for and make burnout interventionprograms available to employees.

Abbreviations:

EE, emotional exhaustion; DP, depersonalisation; PA, personalaccomplishment; LOE, level of evidence; BBI, Bergen burnout indicator; CBI,Copenhagen burnout inventory; MBI, Maslach burnout inventory; UBOS, Utechtburnout scale; MBI-NL, Maslach burnout inventory-Netherlands; EVL-Burnout,burnout assessment questionnaire; RCT, randomised controlled trials.* Corresponding author at: Endowed Chair Prevention and Rehabilitation inHealth System Research, Hannover Medical School, Carl-Neuberg-Straße 1, 30625Hannover, Germany. Tel.: +49 05 11 532 4455; fax: +49 05 11 532 5347.

E-mail address:

Walter.Ulla@mh-hannover.de(W.L. Awa).

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impairment[8,9].Someconsequencesofburnoutareabsenteeism,sick leave job turnover as well as physical health impediments[10–12]. The health report of one German employee insurancecompany Deutsche Angestellten-Krankenkasse (DAK) for 2005 forinstance, showed a continuous increase in the rate of sick leavedays for the diagnosis group psychological sickness amongmembers. Cases of illness and the total number of days off workdue to mental health problems increased approximately by 70%between 1997 and 2004, while total sick leave increased by 5% inthe same period[13].Poor work related mental health is associated with enormouseconomic costs. The European Agency for Safety and Health atWork estimated that the annual economic cost of work relatedstressdisordersintheEUwasabout20billionEuros(aboutUSD25billion) in 2002. Similar losses have been estimated for otherwestern countries[14–16]. A favourable psychological workingenvironment is therefore in the interest of both employers andemployees.Thishasnotonlybeenrecognizedbyhealthpromotionpolicymakersasameansofreducinghealthinequalitiestoday,butalso is being practiced by certain institutions with differentdegrees of success.Intervention programs for preventing burnout can either beperson-directed (individual/groups), organization-directed or acombination of both person- and organization-directed aspects.Person-directed interventions programs are usually cognitivebehavioural measures aimed at enhancing job competence andpersonal coping skills, social support or different kinds of relaxation exercises. Organization-directed interventions on theother hand are usually changes in work procedures like taskrestructuring, work evaluation and supervision aimed at decreas-ing job demand, increasing job control or the level of participationin decision making. These measures empower individuals andreduce their experience of stressors. In the absence of effectiveburnout prevention, employees are likely to suffer poor workrelated mental health where risk factors prevail.People who take part in stress intervention programs usuallyexperience less stress symptoms than those who do not[17]. Wetherefore expect that intervention programs against burnout willreduce symptoms and positively inﬂuence risk factors for poorwork related mental health. For person-directed interventions wehypothesise a short term reduction in burnout. Secondly, wehypothesise that organization-directed interventions will result inlonger lasting positive effects on burnout and worksite mentalhealth than person-directed interventions, since they addressmajor risk factors like work overload and effort reward imbalance.Thirdly, we hypothesise that a combination of both person- andorganization-directed interventions will lead to better results onburnout and worksite mental health than either person- ororganization-directed interventions independently.Theaimofthisreviewistoanalyzetheeffectivenessofdifferentintervention programs in reducing burnout.The objectives of this literature review are:

To evaluate the effectiveness of person-and organization-directed intervention programs intended to prevent burnoutin any target group and

to compare the effectiveness of these different interventiontypes in reducing burnout.

2. Methods

2.1. Literature search

This review is based on a systematic search of burnoutinterventionstudiesintheelectronicdatabasesMedline,PsycINFOandPSYNDEX.Thesearchwasconductedintwophases:Literaturesearch I was carried out at the end of March 2006 and covered theperiod from January 1995 to March 2006. Literature search II,conducted in January 2008, covered the period from April 2006 toDecember2007.LanguageswerelimitedtoEnglishandGermanforboth search phases and the search strategy was based on keywords related to burnout, work stress, workplace and prevention,both as free texts and MeSH terms. These included ‘‘burnout’’,‘‘emotional exhaustion’’, ‘‘cynicism’’, ‘‘depersonalisation’’,‘‘employee’’, ‘‘workplace’’, ‘‘stress’’, ‘‘workload’’, ‘‘stress manage-ment program’’, ‘‘empowerment’’, ‘‘prevention’’, ‘‘health promo-tion’’,‘‘healtheducation’’and ‘‘earlyintervention’’amongstothers.Additionally,the referencelists ofselected publicationswerehandsearched in order to identify potential papers missed by thesystematic search.

2.2. Paper inclusion criteria

Included were primary studies with at least 1 pre- and post-intervention assessment point, aimed at preventing burnout. Onlystudies which measured the outcome burnout or any of its corecomponents were included. Studies which only measured risk orprotectivefactorsofburnoutwereexcludedaswellasthosewhichassessedmeasuresforimprovingworksitementalhealth,reducingwork stress or general distress. Relevant publications wereincluded regardless of study design or type of target group. Thisis due to the fact that evaluated burnout intervention studies arerelatively few and their study designs are diverse. Reviews of occupational health parameters were excluded since they did notpresent relevant information in the desired detail for this review.Studies which analyzed participants’ reasons or motivation forseeking help in a burnout intervention program only, studieswhich assessed participants’ opinion about and satisfaction with aburnout intervention program as well as those which onlyidentiﬁed sources of work stress and potential areas for burnoutprevention were left out as well.

2.3. Paper selection

The results of the systematic literature search I and II werestored in the literature management system Reference Managerand duplets wereautomaticallyexcluded. In the next step,titlesof interest were selected and their abstracts were read by tworeviewers. The full texts of abstracts which met inclusion criteriawere ordered and further analyzed. In cases of disagreement aconsensus or third opinion was sought. A hand search of thereference lists of selected papers was also conducted to identifystudies missed by the systematic search.

2.4. Data extraction and management

Data extraction and critical appraisal of selected interventionstudies were carried according to existing guideline for qualitativereviews[18]andlevelsofevidencewereattributedtointerventionprograms in line with the guidelines of the U.S. Preventive TaskForce[19].Strongevidencewasattributedtooutcomeswhereasigniﬁcantpositive or negative intervention effect was measured (



0.05).Non-signiﬁcant positive or negative intervention effects (

0.05)were regarded as limited evidence.

3. Results

3.1. Search results