Occupational Medicine 2018;68:246–254

Advance Access publication 26 March 2018 doi:10.1093/occmed/kqy033

Age, burnout and physical and psychological work

ability among nurses
D. J. Hatch1, G. Freude2, P. Martus3, U. Rose2, G. Müller2 and G. G. Potter1
1
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA, 2Federal
Institute for Occupational Safety and Health, Berlin, D-10317, Germany, 3Institute for Clinical Epidemiology and Applied

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Biostatistics, University Tübingen, Tübingen, 72074, Germany.
Correspondence to: D. J. Hatch, Bryan Alzheimer’s Disease Research Center, 2200 West Main St., Suite A200, Box 3503,
Durham, NC 27705, USA. Tel: +1 919-668-2157; fax: +1 919 668–0828; e-mail: daniel.hatch@duke.edu

Background The ageing of the US labour force highlights the need to examine older adults’ physical and psycho-
logical ability to work, under varying levels of occupational burnout.
Aims To examine how age and burnout interact in predicting physical and psychological work ability.
Methods Using a cohort of actively working nurses, we assessed factors on the Work Ability Index at 12-month
follow-up and determined how these were related to age and exhaustion-related burnout at baseline.
Results The study group consisted of 402 nurses aged 25–67 (mean = 41.7). Results indicated age by burn-
out interactions in which decrements in physical work ability with greater age were observed at all
but the lowest level of burnout (1.5 SD below mean: β = −0.14, 95% CI −0.36, 0.07; 1 SD below:
β = −0.23, 95% CI −0.39, −0.06; mean: β = −0.39, 95% CI −0.50, −0.29; 1 SD above: β = −0.56,
95% CI −0.70, −0.42; 1.5 SD above: β = −0.64, 95% CI −0.83, −0.46). In contrast, we observed
decrements in psychological work ability with age at higher levels of burnout only (1 SD above:
β = −0.20, 95% CI −0.35, −0.05; 1.5 SD above: β = −0.30, 95% CI −0.49, −0.11); at lower levels
of burnout, older age was associated with improvements in this (1 SD below: β = 0.19, 95% CI 0.03,
0.35; 1.5 SD below: β = 0.29, 95% CI 0.08, 0.50).
Conclusions Findings indicated physical and psychological dimensions of work ability that differed by age and
occupational burnout. This emphasizes the need for interventions to reduce burnout and to address
age-related strengths and vulnerabilities relating to physical and psychological work ability.
Key words Burnout; older workers; work ability.

Introduction psychosocial and health outcomes in ageing, including

A range of demographic and social factors are leading to a
‘greying’ labour force in many countries. Factors includ-
ing better health, increased life expectancy and lower
birth rates over time have led to higher age-dependency
ratios, and resulting increases in the age of entitlement
to retirement benefits [1]. Consequently, labour force
participation after age 65 continues to rise in developed
economies including Europe and the USA [2]. Given the
prospective need for older adults in many labour markets
to work longer, it is important to understand how to help
individuals maintain work ability as they age.
Much of the research on promoting work ability in
ageing uses the Work Ability Index (WAI). This ques-
tionnaire assesses workers’ perceived performance of
their job relative to its mental and physical demands
[3]. Studies have found the WAI to predict multiple
increased health care utilization [4], retirement due to
disability [5] and function and well-being in retirement
[6]. Research across countries and occupations has gen-
erally found work ability to decline with age [7] due to
greater physical decrements and chronic medical con-
ditions [8]. However, evidence also indicates age-asso-
ciated gains in cognitive function, including indicators
of crystallized intelligence such as vocabulary, skills and
work-related knowledge, and the ability to maintain psy-
chological and emotional health [9,10]. This suggests the
need to better understand the effect of age by type of
work ability.
Clinicians generally assess the WAI as a total score
and researchers have generally considered this measure
to be a uni-dimensional scale; however, research sug-
gests that the WAI consists of more than one dimension.
In one such study [11], researchers examined a sample

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 D. J. HATCH ET AL.: AGE, BURNOUT, AND WORK ABILITY  247

of German workers from different occupational groups
and found marked improvement in a bi-dimensional
solution consisting of items assessing health-related
work ability, including number of injuries or diseases
diagnosed by a physician, sick leave taken and an esti-
mate of work impairment due to disease, and items
relating to subjective work ability, including psycho-
logical resources, subjective estimates of current work
ability and perceived prognosis of work ability. Similar
dimensionality was reported in the European Nurses’
Early Exit (NEXT) Study [12], in 8 out of 10 European
countries studied. These studies suggest a psycho-
on the severity of burnout symptoms. In this study, we
examined the association of physical and psychological
work ability with age, and moderation of these associa-
tions by burnout. In doing so, we sought to confirm a
bi-dimensional WAI model [11] in an independent, sin-
gle-occupation sample of working nurses. This sample
fits our study objectives well, as nurses are particularly
vulnerable to burnout [18], based on exposure to a high
level of both physical and psychological stressors [19].
Methods

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logical dimension to work ability that includes a sub-
jective appraisal of work ability and mental resources,
and a physical dimension of work ability that includes
an objective characterization of health based on accu-
mulated medical conditions and injuries.
One condition that may adversely influence both
physical and psychological dimensions of work ability is
burnout. In the current study, we defined the core feature
of burnout as the presence of emotional, physical and
cognitive exhaustion due to job stressors [13]. Burnout
is important to the work ability of older adults, given
that they appear to need more job controls to buffer the
effects of job-related stressors [14], recover from stress
less quickly [15] and are more sensitive to the effects of
job-related stress and burnout on self-efficacy [16] and
age-related cognitive decline [17]. This suggests that
older workers may be sensitive to burnout symptoms,
and the effects of these on work ability.
This research on the interaction between work ability,
age and burnout suggests that an individual’s capacity to
maintain work ability with age may differ across physical
and psychological dimensions, and that it may depend
We recruited individuals actively working in the nursing
field from a health care system in the southeast USA.
Health system administration provided e-mail addresses
of nurses employed across all departments. We targeted
recruitment for 400 persons to achieve a sample size
adequate to detect statistically significant differences.
Eligible individuals were required to be actively working
in the nursing field (not on medical leave, disability leave
or family leave), to have at least 2  years’ experience in
the nursing field and be at least 25 years old. In addition,
because we conducted cognitive testing as part of our
broader project, we excluded individuals with possible
confounding neurological conditions (seizures, severe
brain trauma and stroke). Race and sex ratios approxi-
mated the US nursing population as a whole [20], with
the exception that it over-represented Black/African
Americans [14%, compared to 5% in US registered
nurses (RN), see Table  1]. Participants gave informed
consent. This research was approved by the Institutional
Review Board of Duke University.
This study was based on a prospective cohort design,
including assessment of burnout at baseline and of work

Table 1.  Bivariate relationships between age and other demographic characteristics, total work ability at month 12 and OLBI exhaustion

Study variables Total WAI OLBI Ex

Test value 95% CI P value Test value 95% CI P value

Age r(347) = −0.17 −0.27, −0.06 <0.01 r(347) = −0.13 −0.23, −0.03 <0.01

Sex t(350) = −1.27 NS t(350) = 3.32 <0.001
 Female 38.49, 39.66 2.57, 2.67
 Male 38.43, 42.46 2.13, 2.51
Education F(3,341) = 1.64 NS F(3,341) = 2.24 NS
  High school 35.59, 41.87 2.29, 2.84
 Associates 37.48, 39.66 2.47, 2.66
 Bachelors 38.98, 40.44 2.52, 2.65
  Masters or doctorate 36.42, 39.80 2.64, 2.93
Nurse type t(350) = 0.55 NS t(350) = 0.50 NS
 RN 38.64, 39.81 2.55, 2.66
 Non-RN 36.40, 40.83 2.37, 2.75
OLBI Ex r(350) = −0.39 −0.48, −0.30 <0.001 – – –

Sample restricted to those who completed follow-up at month 12. 95% CI, 95% confidence intervals for Pearson correlations based on Fisher’s z transformation;
non-RN, non-RN nursing professional: certified nursing assistant, licensed practical nurse and medical assistants; OLBI Ex, Oldenburg Burnout Inventory,
Exhaustion subscale; RN, registered nurse; total WAI, Work Ability Index total score at follow-up month 12.
248  OCCUPATIONAL MEDICINE
ability at 12-month follow-up. The current study used
data collected from a broader project on work stress
and mental health among nurses. We collected base-
line data by self-reported questionnaires, including
demographic information and assessment of burnout.
A  trained research technician was present during com-
pletion of baseline questionnaires to provide assistance
but was positioned so as not to be able to view partici-
pant responses. After baseline, we sent follow-up ques-
tionnaires monthly via e-mail with a link to a confidential
survey, which concluded at month 12 in February of
2016. Although data on burnout were collected monthly,
in this study, we used burnout at baseline only, to predict
WAI at 12-month follow-up.
We used factors derived from the 12-month follow-up
assessment of the WAI [3] as the dependent measures in
this study. The WAI consists of items related to p ­ hysical
health, including number of injuries or physician-­
diagnosed diseases endorsed by the participant, out of a
list of 49 injuries and diseases (item 3), number of sick
leave days (item 5) and an estimate of work impairment
due to illness (item 4). Other items assess psychological
resources (enjoyment of daily a­ctivities, alertness and
hopefulness for the future; item 7), s­ ubjective estimates
of current ability to work compared with lifetime best
(item 1), ability to work in relation to job demands (item
2)  and perceived prognosis of work ability in 2  years
(item 6).
We assessed burnout at baseline with the exhaustion
subscale of the Oldenburg Burnout Inventory (OLBI;
[13]). This subscale is composed of eight items, includ-
ing, ‘I can tolerate the pressure of my work very well’ and
‘during my work, I often feel emotionally drained’. Items
are assessed on a four point scale, ranging from ‘strongly
agree’ to ‘strongly disagree’. We reverse-coded the four
negatively worded items before calculating the mean of
all eight items, yielding total scores ranging from 1 to
4. We found the internal consistency of these items to be
acceptable in our sample (α = 0.81). In a recent study
[21], researchers found that 40–45% of the variance in
overall OLBI burnout at three waves across 3 years can
be accounted for by a stable trait component, suggesting
stability as well as change in burnout over time.
We selected baseline age, sex, educational level and
nursing certification status as covariates based on their
associations with work ability in previous studies. We
categorized education as: high school equivalent, asso-
ciate’s degree, bachelors’ degree and master’s degree/
PhD, and nursing certification as RNs versus other
certification types.
To confirm the factor structure of the WAI and to
test the association of age and burnout to work abil-
ity at the 12-month follow-up, we used confirmatory
factor analysis (CFA) with covariates models [22]. This
method consists of two steps. In the first, the adequacy
of a measurement model is tested. In the second, factors
from this model are linearly regressed with covariates,
to identify differences in factor means by covariates.
In accordance with Martus et  al. [11], we tested the
adequacy of four CFA measurement models. In model
A, we tested a one-factor solution, with all seven WAI
items included. For models B and C, we entered items
1, 2 and 7, along with items 4 and 6, to reflect psycho-
logical work ability, and items 3 and 5 to reflect physical
work ability. To test the assumption of factor orthogo-
nality, we constrained the covariance between factors in
model B to zero. However, this made the model under-
justified. To address this, we constrained the factor
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loadings in this model to equality, so as to have fewer
parameters to estimate. In model C, we tested the same
item structure as in model B, but freely estimated the
covariance between factors. We expanded this in model
D, in which we cross-loaded items 4 and 6.  This was
done because these items assess both psychological and
physical work ability, in that they assess the partici-
pants’ subjective estimation of ability in regards to the
participants’ health. In step 2, we linearly regressed fac-
tors from the best-fitting model on covariates, includ-
ing centred burnout and centred age at baseline (model
1); demographic covariates (sex, education and nurse
type; model 2); and the interaction between burnout
and age (model 3), controlling for any covariates found
to be significant in model 2. For all models, we reported
standardized factor loadings, factor covariances and
predictor coefficients where applicable, along with 95%
confidence intervals (CIs) and fit statistics [23]. We
conducted descriptive statistics with SAS version 9.3
[24], and CFA models with Mplus version 7 [25].
Results
The study population was 402 individuals, which
included 372 RNs and 28 other nursing workers
(licensed practical nurses, certified nursing assistants
and medical assistants). Mean age (SD) at baseline
among the 352 participants who completed follow-up
at month 12 was 42.1 (11.4), with 20% being age 55
or older (n  =  70). Most were female (n  =  325, 92%)
and had an RN certification (n = 326, 93%) with either
an associate or bachelor’s degree (n  =  91, 26% and
n = 205, 59%). The completion rate at follow-up month
12 was 88% (n = 352). We found that loss to follow-up
was not significantly related to age [t(397)  =  −1.52],
burnout [t(400)  =  1.18], sex [χ2(1)  =  0.88], education
[χ2(1) = 0.98], nurse type [χ2(1) = 0.02] or total WAI at
baseline [t(400) = −0.40], suggesting that loss to follow-
up was not biased on these variables.
Table 1 contains zero-order correlations between age
and other demographic characteristics, total work abil-
ity at month 12 and burnout. These indicated lower
work ability based on WAI total score at month 12 to
be associated with higher severity of burnout symptoms
 D. J. HATCH ET AL.: AGE, BURNOUT, AND WORK ABILITY  249

at baseline, r(350) = −0.40, P < 0.001, and greater age
and female sex to be associated with lower burnout
[r(347) = −0.13, P < 0.05 and t(350) = 3.32, P < 0.01].
Tables 2 and 3 report correlation coefficients of study
variables, and results of CFA models. Findings for CFA
model A indicated that although all item loadings were
significant, a one-factor solution did not adequately fit
observed data [χ2(14)  =  121.9, P  <  0.001; standard-
ized root mean square residual (SRMR)  =  0.09; root
mean square error of approximation (RMSEA) = 0.15;
comparative fit index (CFI)  =  0.74; Akaike informa-
tion criterion (AIC)  =  6866]. Findings for model B
psychological work ability (β = −0.25, 95% CI −0.36,
−0.13 and β = −0.55, 95% CI −0.65, −0.46), while older
age was associated with diminished physical work abil-
ity only (β = −0.41, 95% CI −0.51, −0.31). Fit statistics
for this model indicated acceptable fit [χ2(21)  =  52.1,
P < 0.001; SRMR = 0.04; RMSEA = 0.07; CFI = 0.94].
Findings did not change markedly with inclusion of
covariates (model 2), though the effect for nurse certifi-
cation was significant, in that nurses with certifications
other than RN exhibited diminished psychological work
ability (β  =  −0.17, 95% CI −0.32, −0.03). Because
nurse certification was significant, it was retained in

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also exhibited poor fit [χ2(18)  =  140.2, P  <  0.001;
SRMR = 0.16; RMSEA = 0.14; AIC = 6877]. Findings
for model C appeared to exhibit better absolute fit
[χ2(13) = 96, P < 0.001; SRMR = 0.08; AIC = 6842],
though fit adjusted for model parsimony was poor
(RMSEA  =  0.14), as was fit compared to that of the
null model (CFI  =  0.80). In contrast, model D, the
two-factor non-orthogonal solution with items 4 and 6
cross-loaded onto both factors, demonstrated good fit
on all indices [χ2(11) = 15.4, P = 0.17; SRMR = 0.03;
RMSEA = 0.03; CFI = 0.99], and comparatively greater
fit than other models (AIC = 6766), including model C
[likelihood ratio test: χ2(2) = 80.4, P < 0.001]. Because
this measurement structure demonstrated good fit in this
study and in Martus et  al. [11], we used this measure-
ment model for subsequent models of age and modera-
tion by burnout.
Table  4 reports findings from CFA with covariates
models regressing WAI physical and WAI psychologi-
cal on age, burnout, demographic covariates and the
interaction between age and baseline burnout. Greater
burnout was associated with diminished physical and
model 3, which tested the interaction between age and
burnout.
In model 3, we found significant interactions between
age and baseline burnout for both physical work ability
(β = −0.16, 95% CI −0.27, −0.05) and psychological work
ability (β = −0.19, 95% CI −0.29, −0.08), with fit statis-
tics indicating acceptable fit [χ2(31) = 66.0, P < 0.001;
SRMR  =  0.04; RMSEA  =  0.057, 95% CI 0.04–0.08;
CFI = 0.94]. To interpret the interactions, we tested and
plotted simple slopes for age in predicting work ability
outcomes at different conditional values of burnout (the
mean, and 1.0 and 1.5 SDs below and above the mean).
As shown in Figure 1, findings revealed that at low lev-
els of burnout (1 SD below mean), and at  mean and
high (1.5 SDs above mean) levels of burnout, older age
predicted diminished physical work ability (1 SD below:
β = −0.23, 95% CI −0.39, −0.06; mean: β = −0.39, 95%
CI −0.50, −0.29; 1 SD above: β = −0.56, 95% CI −0.70,
−0.42; 1.5 SD above: β = −0.64, 95% CI −0.83, −0.46),
while at very low levels of burnout (1.5 SD below mean),
age was unrelated to physical work ability (β  =  −0.14,
95% CI −0.36, 0.07). With respect to psychological work

Table 2.  Pearson correlations between variables entered into confirmatory factor analyses

Study variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

WAI item
  1: Current work ability – – – – – – – – – – – – – – –
  2: Work ability–demands 0.53 – – – – – – – – – – – – – –
  3: Diseases 0.09 0.16 – – – – – – – – – – – – –
  4: Disease impairment 0.21 0.27 0.46 – – – – - – – – – – – –
  5: Sick leave 0.14 0.12 0.32 0.28 – – – – – – – – – – –
  6: Work ability prognosis 0.21 0.28 0.14 0.31 0.10 – – – – – – – – – –
  7: Mental resources 0.42 0.41 0.07 0.21 0.09 0.27 – – – – – – – – –
8. Age 0.06 −0.01 −0.35 −0.07 −0.08 −0.10 0.03 – – – – – – – –
9. Male sex 0.06 0.13 0.03 0.09 0.10 0.00 0.06 0.01 – – – – – – –
Educationa 10: High school 0.00 −0.05 0.00 0.07 0.05 0.00 0.03 0.03 0.26 – – – – – –
  11: Associates 0.00 −0.02 −0.13 −0.06 0.00 −0.11 0.00 0.16 0.00 −0.11 – – – – –
  12: Bachelors 0.01 0.08 0.18 0.06 0.03 0.10 0.04 −0.26 −0.04 −0.21 −0.70 – – – –
  13: Masters/PhD −0.01 −0.04 −0.08 −0.04 −0.01 0.02 −0.06 0.11 −0.07 −0.06 −0.21 −0.42 – – –
14. Nurse type: non-RN −0.03 −0.11 −0.01 0.09 0.06 −0.07 −0.03 −0.01 0.18 0.66 −0.03 −0.18 −0.02 – –
15. OLBI Ex −0.32 −0.35 −0.15 −0.31 −0.09 −0.20 −0.43 −0.13 −0.17 −0.01 −0.04 −0.05 0.14 −0.05 –

Non-RN, non-registered nursing professional: certified nursing assistant, licensed practical nurse and medical assistants; OLBI Ex: Oldenburg Burnout Inventory,
Exhaustion subscale; WAI, Work Ability Index at follow-up month 12.
a
Each category of education tested as a dummy-coded variable.
250  OCCUPATIONAL MEDICINE

Table 3.  Confirmatory factor analysis of WAI

Model Aa Model Bb Model Cc Model Dd

Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI

WAI item factor loadings

  1: Current work ability 0.67 0.58, 0.75 0.69 0.60, 0.78 0.68 0.59, 0.76 0.70 0.62, 0.79
  2: Work ability–demands 0.71 0.63, 0.80 0.62 0.56, 0.69 0.73 0.64, 0.81 0.74 0.65, 0.82
  7: Mental resources 0.57 0.48, 0.66 0.60 0.54, 0.66 0.58 0.48, 0.67 0.58 0.49, 0.68
  4: Disease impairment 0.45 0.34, 0.56 0.54 0.48, 0.59 0.42 0.31, 0.53 0.18 0.03, 0.32
  6: Work ability prognosis 0.42 0.31, 0.53 0.34 0.30, 0.39 0.41 0.30, 0.52 0.32 0.20, 0.45

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  3: Diseases 0.30 0.18, 0.42 0.44 0.36, 0.52 0.62 0.42, 0.83 0.68 0.55, 0.82
  5: Sick leave 0.25 0.13, 0.37 0.72 0.58, 0.85 0.51 0.33, 0.68 0.43 0.31, 0.54

  4: Disease impairment – – – 0.64 0.49, 0.80

  6: Work ability prognosis – – – 0.20 0.06, 0.33
Factor covariance – 0 – 0.42 0.25, 0.59 0.27 0.10, 0.45

Fit statistics
  χ , df, P value
2
121.9, 14, <0.001 140.2, 18, <0.001 95.8, 13, <0.001 15.4, 11, 0.17
 SRMR 0.09 0.16 0.08 0.03
  RMSEA, 95% CI 0.15, 0.12–0.17 0.14, 0.12–0.16 0.14, 0.11–0.16 0.03, 0.00–0.07
 CFI 0.74 0.70 0.80 0.99
 AIC 6866 6877 6842 6766

Parameter estimate (est.) and 95% CI reported for each factor loading. AIC, Akaike information criterion; CFI, comparative fit index; RMSEA, root mean square
error of approximation; SRMR, standardized root mean square residual; WAI, Work Ability Index at follow-up month 12.
a
Model A: one-factor solution.
b
Model B: two-factor solution, 4 and 6 on WAI psychological, factor covariance constrained to 0.
c
Model C: two-factor solution, 4 and 6 on WAI psychological, factor covariance freely estimated.
d
Model D: two-factor solution, 4 and 6 on both factors, factor covariance freely estimated.

ability (see Figure 2), results indicated that at mean lev-
els of burnout, age did not predict psychological work
ability (β  =  −0.01, 95% CI −0.11, 0.10); however, at
higher levels of burnout (1 and 1.5 SDs above the mean
of OLBI Ex), older age predicted diminished psychologi-
cal work ability (1 SD above: β = −0.20, 95% CI −0.35,
−0.05; 1.5 SD above: β = −0.30, 95% CI −0.49, −0.11),
while at lower levels of burnout (1 and 1.5 SDs below the
mean), older age predicted increased psychological work
ability (1 SD below: β =  0.19, 95% CI 0.03, 0.35; 1.5
SD below: β = 0.29, 95% CI 0.08, 0.50).
Discussion
The current study confirmed a bi-dimensional factor
structure for the WAI representing physical and psy-
chological dimensions and extended this with two novel
findings. Firstly, we found differences in physical and
psychological dimensions for age and burnout, with
older age being associated with lower physical work abil-
ity only, and greater burnout being associated with lower
physical and psychological work ability. Secondly, we
found that age and burnout interact. In the psychologi-
cal dimension, older age predicted lower work ability at
high levels of burnout, whereas at low levels of burnout,
older age predicted higher work ability. In the physical
dimension, older age generally predicted lower work
ability, with the exception of no association at very low
levels of burnout symptoms.
The study has both strengths and limitations. We
conducted assessments on a large cohort of actively
working health professionals at baseline and 12-month
follow-up. With a mean age of 42  years, many of the
older workers in our sample are closer to midlife than
later life; however, this is consistent with evidence link-
ing reduced work ability and burnout in mid-career to
higher risk for early retirement [7], and with approaches
emphasizing interventions in midlife to maintain health
and ability in late life [26]. We were limited in our use
of convenience sampling of individuals who responded
promptly to recruiting e-mails. This may have intro-
duced unintended bias toward healthy, non-burned-out
workers, but our descriptive data indicate an adequate
range of burnout scores comparable to a sample of
Norwegian nurses [27], and a demographic composi-
tion consistent with that of the nursing workforce in
general. We note this study uses only the exhaustion
component of burnout. Although exhaustion is theo-
rized to be the core component of burnout, in the sense
that it precedes other aspects of burnout [28], future
studies would benefit from examining other compo-
nents of burnout such as disengagement or personal
 D. J. HATCH ET AL.: AGE, BURNOUT, AND WORK ABILITY  251

Table 4.  Confirmatory factor analysis of WAI psychological and WAI physical on OLBI exhaustion, age, demographics and OLBI
exhaustion by age interaction

Model 1 Model 2 Model 3

Est. 95% CI Est. 95% CI Est. 95% CI

Coefficients
  WAI psychological on
  OLBI Ex −0.55 −0.65, −0.46 −0.56 −0.66, −0.46 −0.56 −0.65, −0.46
  Age −0.02 −0.14, 0.09 −0.02 −0.13, 0.10 −0.01 −0.11, 0.10
   OLBI Ex × age − − − −0.19 −0.29, −0.08
  Sex − − 0.03 −0.08, 0.14 – –

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  Educationa
   High school − − 0.17 −0.04, 0.37 − −
   Associates − − 0.14 −0.23, 0.52 − −
   Bachelors − − 0.21 −0.21, 0.62 − −
   Masters/PhD − − 0.16 −0.12, 0.44 − −
   Nurse type (non-RN) − − −0.17 −0.32, −0.03 −0.10 −0.21, 0.01
R2 0.30 0.32 0.35
  WAI physical on
  OLBI Ex −0.25 −0.36, −0.13 −0.24 −0.36, −0.12 −0.25 −0.37, −0.13
  Age −0.41 −0.51, −0.31 −0.39 −0.49, −0.28 −0.39 −0.50, −0.29
   OLBI Ex × age − − − −0.16 −0.27, −0.05
  Sex − − 0.01 −0.11, 0.12 − −
  Educationa
   High school − − 0.08 −0.13, 0.29 − −
   Associates − − 0.03 −0.36, 0.41 − −
   Bachelors − − 0.14 −0.29, 0.56 − −
   Masters/PhD − − 0.06 −0.23, 0.34 − −
   Nurse type (non-RN) − − −0.03 −0.18, 0.12 0.004 −0.11, 0.12
R2 0.20 0.21 0.23
Factor covariance 0.10 −0.05, 0.26 0.09 −0.06, 0.25 0.07 −0.10, 0.23

Fit statistics
  χ , df, P value
2
52.15, 21, <0.001 84.52, 51, <0.01 65.98, 31, <0.001
 SRMR 0.04 0.03 0.04
  RMSEA (95% CI) 0.07 (0.04, 0.09) 0.04 (0.03, 0.06) 0.057 (0.04, 0.08)
 CFI 0.94 0.94 0.94
 AIC 6589.0 6602.4 6574.3

Loadings for WAI psychological and WAI physical factors available upon request. Parameter estimate (Est.) and 95% CI reported for each coefficient or estimate of
factor covariance. AIC, Akaike information criterion; CFI, comparative fit index; non-RN, non-registered nursing professional: certified nursing assistant, licensed
practical nurse and medical assistants; OLBI Ex, Oldenburg Burnout Inventory, Exhaustion subscale; RMSEA, root mean square error of approximation; SRMR,
standardized root mean square residual; WAI, Work Ability Index at follow-up month 12.
a
Each category of education tested as a dummy-coded variable.

accomplishment. Finally, our findings also highlight the
need to examine how such interventions generalize to
other human service professions.
The current study supports previous research sug-
gesting the principal metric of the WAI—the total
score—may be better represented as a bi-dimensional
measure [11,12], particularly with respect to age and
severity of burnout. This is consistent with the broader
literature suggesting overall work ability declines with
age [7,29], but it highlights important exceptions. In
line with the broader literature, physical work ability
was lower with increasing age, and this relationship
worsened with greater burnout, and, at higher levels
of burnout, psychological work ability was also lower
with increasing age. This suggests that at high burnout,
older workers may not be as able to direct adequate
physical and psychological resources toward their job
duties. This is consistent with evidence finding older
individuals need more job resources as a buffer to work
stress [14], and recover less quickly from stress [15]. In
contrast to the broader literature, at low levels of burn-
out, older workers exhibited greater psychological work
ability. This suggests that under optimal conditions,
older workers may be more able to engage cognitive,
psychological and occupational strengths that improve
with age [9,30].
Our study findings suggest that the WAI total score
provides an incomplete clinical impression of the work
252  OCCUPATIONAL MEDICINE

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Figure 1.  Physical work ability on age at conditional values of exhaustion burnout.

Figure 2.  Psychological work ability on age at conditional values of exhaustion burnout.

ability of older individuals, who appear to have more
resilience on psychological aspects of work ability under
low-to-medium levels of burnout, but less resilience on
physical aspects overall. This suggests that deficits in
physical health are the most consistent contributors to
decline in work ability with age, and that interventions
targeting disease prevention and health maintenance
from midlife and earlier may be effective ways to main-
tain work ability with age. In addition, support for men-
tal/emotional resources in the workplace may provide an
important buffer against burnout and its effect on the
work ability of older individuals.
 D. J. HATCH ET AL.: AGE, BURNOUT, AND WORK ABILITY  253
Key points
•• This study confirmed a bi-dimensional structure
in the Work Ability Index in the form of physical
and psychological work ability.
•• It also found age relationships with these dimen-
sions that were moderated by exhaustion-related
burnout.
•• Findings emphasize the need to reduce burnout
and to address age-related strengths and vulnera-
bilities relating to physical and psychological work
ability.
Funding
This work was supported by the German Federal Institute for
Occupational Safety and Health (Bundesanstalt für Arbeitsschutz
und Arbeitsmedizin, BAuA: Project F2318). Support for Daniel
Hatch was provided by the National Institutes of Health (NIH
Grant No. T32-AG000029).
Competing interests
None declared.
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physician in the 1970s
I joined ICI’s Medical Service, as it was then called,
in 1976 after completing a three-year general practice
vocational training course. ICI offered comprehen-
sive training and it was indeed provided. At the time
ICI had many divisions and owned many companies
around the world. To name just a few, the divisions were
Mond, Organics (formerly Dyestuffs), Agriculture,
Petrochemicals, Paints, Plastics, Plant Protection,
Fibres and Pharmaceuticals. The site I  worked on in
Scotland had parts of Organics and Petrochemicals
Divisions, plus the major part of Nobel’s Explosive
Company. On-site manufacture included initiating
explosives (detonators), burning explosives (black
powder or gunpowder—the stuff which used to be
in penny bangers) and blasting explosives (dynamite,
sometimes known as gelignite). There was no manu-
facture of TNT on site.
There were 33 full-time doctors, of the medical vari-
ety, in ICI in the UK at the time; Nobel’s had many
staff with PhDs but they were known as ‘Dynamite
Doctors’! The Medical Service was charged with look-
ing after staff of which there were 60 000 in the UK
alone. ICI employed many more doctors around the
world, many nurses, physiotherapists, radiographers,
dentists and opticians-to prescribe and dispense safety
glasses.
What I hadn’t realized at the time is that the job of an
occupational physician is defined by the type of organ-
ization in which they work and also, very much, by the
local culture. Some organizations merely want to abide
by legislative requirements, whereas others realize the
importance of having a happy, healthy workforce to
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doi:10.1093/occmed/kqx189
maximize innovation, creativity and, ultimately, prod-
uctivity. Within ICI the Medical Service provided a
clinical service, information on the toxicity of the mate-
rials handled, and an industrial hygiene service with
a focus on dust, noise and fume. It also carried out
epidemiology studying the effects of work and working
practices on human health.
My time in Scotland provided a valuable introduc-
tion to occupational medicine. Accidents were fortu-
nately rare but, when they occurred often resulted in
major injury and, on one occasion, death. Accidents were
almost always the result of human error and failure to
operate ‘Safe Systems of Work’. When, after just short of
5 years, I transferred to ICIs Pharmaceuticals Division,
the problems were of an entirely different nature. Staff
were often employed for their scientific knowledge and
skills to discover and develop medicines for human use.
It was as if they were employed for what they had from
the neck upwards—their brains. It took some years for
the industry to realize that physical health, from the neck
downwards, was also important to ensure that members
of staff could maintain a high level of innovation, creativity
and productivity week after week, month after month and
year after year. The era of health and well-being, recog-
nizing the importance of having and maintaining healthy
staff with high energy levels, started in the ‘Noughties’.
Learning how to maximize and fully utilize the energy of
staff is key to having organizations which can play a full
role on the national and international stages.
Eric L. Teasdale
e-mail: drelteasdale@gmail.com