C H A P T E R
43
Burnout
C. Maslach1, M.P. Leiter2
1
University of California, Berkeley, CA, USA
2
Acadia University, Wolfville, NS, Canada
O U T L I N E
Definition and Assessment 351
Assessment 352
Engagement 353
Psychosocial Factors 353
A Mediation Model of Burnout 354
Job Characteristics: Six Areas of Worklife 354
Personal Characteristics 355
Abstract
Burnout is a prolonged response to chronic emotional and inter-
personal stressors on the job. It is defined by the three dimensions
of exhaustion, cynicism, and professional inefficacy. As a reliably
identifiable job stress syndrome, burnout clearly places the indi-
vidual stress experience within a larger organizational context of
people's relation to their work. Burnout impairs both personal
and social functioning. This decline in the quality of work and
in both physical and psychological health can be costly—not just
for the individual worker, but for everyone affected by that per-
son. Interventions to alleviate burnout and to promote its oppo-
site, engagement with work can occur at both organizational and
personal levels. The social focus of burnout, the solid research
basis concerning the syndrome, and its specific ties to the work
domain make a distinct and valuable contribution to people's
health and well-being.
DEFINITION AND ASSESSMENT
The relationship that people have with their work, and
the difficulties that can arise when that relationship goes
awry, have long been recognized as a significant phe-
nomenon in people's lives. However, the identification
of the name, “burnout” occurred in the 1970s, first in a
volume of articles about free clinics,1 and then in an arti-
cle about workers in health care and human service occu-
pations.2 In both instances, burnout was rooted within
caregiving and service occupations, in which the core
Stress: Concepts, Cognition, Emotion, and Behavior 351
http://dx.doi.org/10.1016/B978-0-12-800951-2.00044-3
Implications for Interventions 355
Using the Mediation Model in Interventions 355
Future Work on Intervention 356
References 356
of the job is the relationship between provider and recip-
ient. This interpersonal context of the job meant that, from
the beginning, burnout was studied not simply as an indi-
vidual stress response, but in terms of an individual's
relational transactions in the workplace. Moreover, this
interpersonal context focused attention on the individ-
ual's emotions, and on the motives and values underlying
his or her work with other people. Job burnout has
remained an active research focus across a wide range
of academic and professional disciplines in the decades
since its introduction in the 1970s, inspiring the develop-
ment of theoretical constructs and practical methods for
alleviating the syndrome.
Burnout is predominantly defined by its three main
components: exhaustion, cynicism, and professional inef-
ficacy. Exhaustion refers to feelings of being overex-
tended and depleted of one's emotional and physical
resources. Workers feel drained and used up, without
any source of replenishment. They lack enough energy
to face another day or another person in need. The
exhaustion component represents the basic individual
stress dimension of burnout. Cynicism refers to a nega-
tive, hostile, or an excessively detached response to the
job, which often includes a loss of idealism. It usually
develops in response to the overload of emotional
exhaustion, and is self-protective at first—an emotional
Copyright © 2016 Elsevier Inc. All rights reserved.
352 43. BURNOUT
buffer of “detached concern.” But the risk is that the
detachment can turn into dehumanization. The cynicism
component represents the interpersonal dimension of
burnout. Professional inefficacy refers to a decline in feel-
ings of competence and productivity at work. People
experience a growing sense of inadequacy about their
ability to do the job well, and this may result in a self-
imposed verdict of failure. The inefficacy component rep-
resents the self-evaluation dimension of burnout.
What has been distinctive about burnout is the inter-
personal framework of the phenomenon. The centrality
of relationships at work—whether it's relationships with
clients, colleagues, or supervisors—has always been at
the heart of descriptions of burnout. These relationships
are the source of both emotional strains and rewards,
they can be a resource for coping with job stress, and they
often bear the brunt of the negative effects of burnout.
Thus, if one were to look at burnout out of context, and
simply focus on the individual exhaustion component,
one would lose sight of the phenomenon entirely.
KEY PO INTS
• Burnout, as an enduring response to poor person/
job or person/organization fit, is experienced as a
syndrome of exhaustion, cynicism, and
professional inefficacy.
• Since its introduction to psychological research in
the 1970s, people have worked to understand the
dynamics of the syndrome, its causes, and its
consequences.
• Burnout has also inspired conceptual work,
considering its place in a broad range of
psychological connections with work,
such as work engagement and chronic
fatigue.
• Although some connections have been made of
burnout with personality or demographic
characteristics, the evidence consistently points
toward workplace variables as the primary drivers
of burnout.
• Important workplace factors influencing burnout
include workload, control, reward, community,
fairness, and value congruence.
• Burnout has close associations with workplace
outcomes, including health problems, and
performance deficits.
• Interventions have explored various forms of
programs to ameliorate or prevent burnout.
Initiatives to enhance the quality of workplace
social environments have shown encouraging
results.
2. COGNITION, EMOTION, AND BEHAVIOR
Assessment
The three dimensions of burnout are assessed by the
Maslach Burnout Inventory (MBI), which has been trans-
lated and validated in many languages.3 Recently, an
alternative burnout questionnaire has been proposed—
the Oldenburg Burnout Inventory—that assesses the
two dimensions of exhaustion and disengagement from
work, and has shown high convergent validity with the
MBI.4 Other conceptualizations of burnout have con-
sidered exhaustion to be the sole defining criterion.5,6
Although more recent theories make distinctions bet-
ween various aspects of exhaustion—e.g., physical
fatigue, emotional exhaustion, and cognitive weariness7
or physical and psychological exhaustion8—their mea-
sures inevitably produce a single overriding factor of
exhaustion. However, the fact that exhaustion is a neces-
sary criterion for burnout does not mean it is sufficient.
Exhaustion is not something that is simply experi-
enced—rather, it prompts actions to distance oneself emo-
tionally and cognitively from one's work, presumably as a
way to cope with the work overload. Distancing is such an
immediate reaction to exhaustion that a strong relation-
ship from exhaustion to cynicism is found consistently
in burnout research, across a wide range of organizational
and occupational settings. The inclusion of distancing
(cynicism) and discouragement (inefficacy) draws an
important distinction between burnout and chronic
exhaustion. People experiencing burnout are not simply
fatigued or overwhelmed by their workload. They also
have lost a psychological connection with their work that
has implications for their motivation and their identity.
If the only issue were exhaustion, the term “burnout”
would add nothing beyond what is already and more
straightforwardly captured by the term chronic fatigue.
Instead, the concept and operationalization of burnout
through the MBI captures a disaffection with work, as well
as a crisis in work-based efficacy expectations.
Research has established that, without definitive
changes in work settings, burnout remains fairly constant
for long periods.9 Recently, longitudinal analyses of
burnout have developed approaches that concentrate on
subgroups with a greater probability of change. In one
study, employees who had inconsistent scores on exhaus-
tion and cynicism (high scores on one; low scores on the
other) were more likely to change over time than were
their colleagues with consistent scores. The direction of
the subsequent change was associated with employees'
sense of fairness: those who found their workplace to be
fair tended to change in the positive direction of low scores
on both exhaustion and cynicism.10 This same pattern of
inconsistent scores and change was replicated among
another group of employees, but the positive change
toward lower burnout scores was associated with their
access to work-relevant information control in their job.11
 PSYCHOSOCIAL FACTORS
Engagement
An important development has been that researchers
have turned their attention to the positive antithesis of
burnout, which has been defined as “engagement.”
Although there is general agreement that engagement
with work represents a productive and fulfilling state
within the occupational domain, there are some differences
in its definition. From the point of view of burnout
researchers, engagement is considered to be the opposite
of burnout and is defined in terms of the same three dimen-
sions as burnout, but the positive end of those dimensions
rather than the negative. Thus, engagement consists of a
state of high energy, strong involvement, and a sense of
efficacy.12 An alternative view is that work engagement
is an independent, distinct concept, which is not the oppo-
site of burnout, although it is negatively related to it. In this
model, engagement is defined as a positive state of mind
characterized by vigor, dedication, and absorption.13
Recent theory and research is bringing new understanding
of both the work engagement and burnout concepts.14,15
One important implication of the burnout-
engagement continuum is that strategies to promote
engagement may be just as important for burnout pre-
vention as strategies to reduce the risk of burnout. A
workplace that is designed to support the positive devel-
opment of the three core qualities of energy, involvement,
and effectiveness should be successful in promoting the
well-being and productivity of its employees, and thus
the health of the entire organization.
PSYCHOSOCIAL FACTORS
Once burnout had been defined, and measures
had been created to capture its complexity, it became a
topic for theory development and empirical research.
Although initially identified within North America,
burnout was soon being studied in many different coun-
tries, and it is now recognized as a global construct. From
the beginning, the burnout syndrome has been primarily
attributed to work environments, where employees expe-
rience a breadth of emotional, physical, and psychologi-
cal demands. Researchers have now begun to expand
their scope of what leads to burnout, and what are its
effects. In particular, two main developmental models
have emerged: the job demands-resources model (JD-R)
and the conservation of resources model (COR). The
JD-R model focuses on the notion that burnout arises
when individuals experience incessant job demands
and have inadequate resources available to address and
to reduce those demands.16,17 The COR model follows
a basic motivational theory following the idea that burn-
out arises as a result of persistent threats to available
resources.18 When individuals perceive that the resources
2. COGNITION, EMOTION, AND BEHAVIOR
353
they value are threatened, they strive to maintain those
resources. The loss of resources or even the impending
loss of resources may aggravate burnout. Both the JD-R
and the COR theory of burnout development have
received confirmation in research studies.
Unlike acute stress reactions, which develop in
response to specific critical incidents, burnout is a cumu-
lative stress reaction to ongoing occupational stressors.
With burnout, the emphasis has been more on the process
of psychological erosion, and the psychological and social
outcomes of this chronic exposure, rather than just the
physical ones. Because burnout is a prolonged response
to chronic interpersonal stressors on the job, it tends to
be fairly stable over time.
Of the three burnout dimensions, exhaustion is the
closest to an orthodox stress variable, and therefore is
more predictive of stress-related health outcomes than
the other two dimensions. Exhaustion is typically corre-
lated with such stress symptoms as: headaches, chronic
fatigue, gastrointestinal disorders, muscle tension,
hypertension, cold/flu episodes, and sleep disturbances.
These physiological correlates mirror those found with
other indices of prolonged stress. Similarly parallel find-
ings have been found for the link between burnout and
various forms of substance abuse. A 10-year follow-up
study of Finnish industrial workers found burnout to
predict subsequent hospital admissions for cardiovas-
cular problems.19 Other Finnish research found that a
one-unit increase in burnout score related to a 1.4 unit
increase in risk for hospital admission for mental health
problems, as well as a one-unit increase in risk for hospital
admissions for cardiovascular problems. Both the exhaus-
tion and cynicism dimensions of burnout were closely
related to mental and cardiovascular problems, with little
connection to the efficacy dimension of burnout.20 Other
research has provided a more detailed examination of
the link between burnout and cardiovascular disease,
noting the role of high-sensitivity C-reactive protein and
fibrinogen concentrations in the link.21
In terms of mental, as opposed to physical, health, the
link with burnout is more complex. It has been assumed
that burnout may result in subsequent mental disabilities,
and there is some evidence to link burnout with greater
anxiety, irritability, and depression. However, an alterna-
tive argument is that burnout is itself a form of mental ill-
ness, rather than a cause of it. Much of this discussion has
focused on depression, and whether or not burnout is a
different phenomenon. Research has demonstrated that
the two constructs are indeed distinct: burnout is job-
related and situation-specific, as opposed to depression,
which is general and context-free. A recent study found
a reciprocal relationship between burnout and depres-
sion with each predicting subsequent developments in
the other. It was noteworthy that burnout fully mediated
the relationship of workplace strains with depression:
354 43. BURNOUT
when problems at work contribute to depression,
experiencing burnout is a step in the process.22
Burnout has also been associated with various forms of
job withdrawal—absenteeism, intention to leave the job,
and actual turnover. For example, cynicism has been
found to be the pivotal aspect of burnout to predict turn-
over,23 and burnout mediates the relationship between
being bullied in the workplace and the intention to quit
the job.24 However, for people who stay on the job, burn-
out leads to lower productivity and effectiveness at work.
To the extent that burnout diminishes opportunities for
satisfying experiences at work, it is associated with
decreased job satisfaction and a reduced commitment
to the job or the organization.
People who are experiencing burnout can also have a
negative impact on their colleagues, both by causing
greater personal conflict and by disrupting job tasks.
Thus, burnout can be “contagious” and perpetuate itself
through informal interactions on the job.25,26 There is also
some evidence that burnout has a negative “spillover”
effect on people's home life. The critical importance of
social relationships for burnout is underscored by studies
that show that burnout increases in work environments
characterized by interpersonal aggression.27,28 In con-
trast, when there is greater social support and trust
among coworkers, burnout is lessened.29,30
A MEDIATION MODEL OF BURNOUT
Inherent to the fundamental concept of stress is the
problematic relationship between the individual and
the situation. Thus, prior research has tried to identify
both the key personal and job characteristics that put
Areas of worklife
Manageable workload
Control
Reward
Community
Fairness
Values
FIGURE 1 The mediation model of burnout.
2. COGNITION, EMOTION, AND BEHAVIOR
individuals at risk for burnout. In general, far more evi-
dence has been found for the impact of job variables than
for personal ones. These job factors fall into six key
domains within the workplace: workload, control,
reward, community, fairness, and values.
However, more recent theorizing has argued that per-
sonal and job characteristics need to be considered jointly
within the context of the organizational environment. The
degree of fit, or match, between the person and the job
within the six areas of worklife will determine the extent
to which the person experiences engagement or burnout,
which in turn will determine various outcomes, such as
personal health, work behaviors, and organizational
measures.31 In other words, the burnout-engagement
continuum (with its three dimensions) mediates the
impact of the six areas of worklife on important personal
and organizational outcomes (see Figure 1).
Job Characteristics: Six Areas of Worklife
An analysis of the research literature on organizational
risk factors for burnout has led to the identification of six
major domains. Both workload and control are reflected
in the demand-control model of job stress, and reward
refers to the power of reinforcements to shape behavior.
Community captures all of the work on social support
and interpersonal conflict, while fairness emerges from
the literature on equity and social justice. Finally, the area
of values picks up the cognitive-emotional power of job
goals and expectations.
Workload. Both qualitative and quantitative work over-
load contribute to burnout by depleting the capacity of
people to meet the demands of the job. When this kind
of overload is a chronic job condition, there is little
Burnout Outcomes
Exhaustion
Health
Cynicism productivity
well-being
Inefficacy
 IMPLICATIONS FOR INTERVENTIONS 355
opportunity to rest, recover, and restore balance. A sus- type-A behavior (which tends to predict coronary heart
tainable and manageable workload, in contrast, provides disease) are more prone to the exhaustion dimension of
opportunities to use and refine existing skills as well as to burnout.
become effective in new areas of activity. There are few consistent relationships of burnout with
Control. Research has identified a clear link between a demographic characteristics. Although higher age seems
lack of control and high levels of stress and burnout. to be associated with lower burnout, it is confounded
However, when employees have the perceived capacity with both years of experience and with survival bias
to influence decisions that affect their work, to exercise (i.e., those who “survive” early job stressors and do not
professional autonomy, and to gain access to the quit). Thus it is difficult to derive a clear explanation
resources necessary to do an effective job, they are more for this age pattern. The only consistent gender difference
likely to experience job engagement. is a tendency for men to score slightly higher on cynicism.
Reward. Insufficient recognition and reward (whether These weak demographic relationships are congruent
financial, institutional, or social) increases people's vul- with the view that the work environment is of greater sig-
nerability to burnout, because it devalues both the work nificance than personal characteristics in the develop-
and the workers, and is closely associated with feelings of ment of burnout.
inefficacy. In contrast, consistency in the reward dimen-
sion between the person and the job means that there
are both material rewards and opportunities for intrinsic
IMPLICATIONS FOR INTERVENTIONS
satisfaction.
Community. Community has to do with the ongoing
The personal and organizational costs of burnout have
relationships that employees have with other people on
led to proposals for various intervention strategies. Some
the job. When these relationships are characterized by a
try to treat burnout after it has occurred, while others
lack of support and trust, and by unresolved conflict, then
focus on how to prevent burnout by promoting engage-
there is a greater risk of burnout. However, when these
ment. Intervention may occur on the level of the individ-
job-related relationships are working well, there is a great
ual, workgroup, or an entire organization. In general, the
deal of social support, employees have effective means of
primary emphasis has been on individual strategies,
working out disagreements, and they are more likely to
rather than social or organizational ones, despite the
experience job engagement.
research evidence for the primary role of situational fac-
Fairness. Fairness is the extent to which decisions at
tors. Many of these individual strategies have been
work are perceived as being fair and equitable. People
adapted from other work done on stress, coping, and
use the quality of the procedures, and their own treatment
health, rather than on studies of burnout.
during the decision-making process, as an index of their
However, the greater challenge is that actual evalua-
place in the community. Cynicism, anger, and hostility
tion of the effectiveness of any of these interventions
are likely to arise when people feel they are not being trea-
has been relatively rare. Especially rare are studies mod-
ted with the respect that comes from being treated fairly.
eled even loosely on randomized control trials. More
Values. Values are the ideals and motivations that orig-
common are studies with a single intervention group of
inally attracted people to their job, and thus they are the
volunteer participants for whom there are rarely
motivating connection between the worker and the work-
follow-up assessments after treatment has ended.32
place, which goes beyond the utilitarian exchange of time
With these caveats, research indicates that burnout is
for money or advancement. When there is a values conflict
responsive to a diverse range of methods. For example
on the job, and thus a gap between individual and organi-
a metaanalysis confirmed evidence for a beneficial effect
zational values, employees will find themselves making a
for burnout prevention programs that were designed to
trade-off between work they want to do and work they
improve employees' coping abilities, social support,
have to do, and this can lead to greater burnout.
and confidence in their job performance, as well as job
redesign initiatives focusing on streamlined procedures
Personal Characteristics and increased job control.33 It is not yet clear whether
burnout is generally susceptible to a range of strategies
Although job variables and the organizational context
or whether it is crucial to fit the strategy to the specific
are the prime predictors of burnout and engagement, a
context of a workplace to be effective.
few personality variables have shown some consistent
correlational patterns. In general, burnout scores are
higher for people who have a less “hardy” personality,
Using the Mediation Model in Interventions
who have a more external locus of control, and who score
as “neurotic” on the five-factor model of personality. From the perspective of the mediation model, burnout
There is also some evidence that people who exhibit reflects a mismatch: workplace design is incompatible

2. COGNITION, EMOTION, AND BEHAVIOR

356
Problem situation
Weaken
Incivility team
culture
Resentment Cynicism
Emotional
withdrawal
FIGURE 2 The CREW process as a response to community mismatches in a workgroup.
with employees' preferred work patterns. Experiencing
that conflict is exhausting, prompting cynical withdrawal
and discouragement. Addressing burnout could take two
general pathways. One path is to design more employee-
friendly workplaces; the other path is to increase
employees' reliance to tolerate workplace mismatches.
Reflecting the emphasis on the exhaustion aspect of burn-
out, much of the attention for interventions have been
increasing employees' energy through healthy lifestyles
with less focus on increasing their involvement by
improving the alignment of personal and corporate
values.
An intervention with a demonstrated impact on the
cynicism aspect of burnout is CREW (civility, respect,
and engagement at work). In contrast with control groups,
workgroups participating in CREW showed an increase in
civility as well as decreases in incivility, burnout, and
absenteeism. The decreases in cynicism underscored the
importance of social relationships to this aspect of burnout.
Although the exhaustion dimension of burnout is highly
sensitive to work overload, the cynicism and efficacy
dimensions relate closely to other areas of worklife. These
studies also demonstrated the potential for workgroup-
level interventions to reduce burnout.34–36
As outlined in Figure 2, the CREW process begins and
ends with an assessment of the social dynamics of a work-
group to determine its specific challenges and the impact
of the process. The CREW process provides extensive
training and mentoring to local facilitators who lead the
CREW meetings over 6 months. The essence of the CREW
meetings is developing new behavior repertories through
role-playing, followed by assignments in which partici-
pants implement these new behaviors in their work set-
tings. It is a team-based enhancement in the community
area of worklife that has its most direct impact on the cyn-
icism dimension of burnout, increasing employees'
involvement in their work and with their coworkers.
2. COGNITION, EMOTION, AND BEHAVIOR
43. BURNOUT
CREW process
Improve Assess
team team
civility culture
Establish
Reflect and
safe group
refine
setting
Practice and
test new
behaviors
Future Work on Intervention
Burnout has been an important social issue for many
years, and there have been continuing calls for solutions
to the problems that burnout poses. Increasingly, these
calls are coming from government agencies and organi-
zations in both the public and private sectors. Many
researchers from many countries around the world have
been doing research to understand the burnout phenom-
enon, but so far this work has not included many rigorous
tests of actual interventions to ameliorate or prevent
burnout. Clearly, a serious focus on designing, imple-
menting, and evaluating the effectiveness of such inter-
vention programs is the next big challenge for
researchers and practitioners alike, working in collabora-
tion with each other.
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