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Burnout prevention: A review of intervention programs
Patient Education and Counseling 78 (2010) 184–190
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Burnout
Burnout prevention: A review of intervention programs Wendy L. Awa *, Martina Plaumann, Ulla Walter Hannover Medical School, Institute for Epidemiology, Social Medicine and Health System Research, Endowed Chair Prevention and Rehabilitation in Health System and Health Services Research, Hannover, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 November 2008 Received in revised form 10 April 2009 Accepted 16 April 2009
Objective: To evaluate the effectiveness of intervention programs at the workplace or elsewhere aimed at preventing 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 hand search. Results: A total of 25 primary intervention studies were reviewed. Seventeen (68%) were persondirected interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of both interventions types. Eighty percent of all programs led to a reduction in burnout. Person-directed interventions reduced burnout in the short term (6 months or less), while a combination of both personand organization-directed interventions had longer lasting positive effects (12 months and over). In all cases, positive intervention effects diminished in the course of time. Conclusion: Intervention programs against burnout are beneficial and can be enhanced with refresher courses. Better implemented programs including both person- and organization-directed measures should 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 intervention programs available to employees. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Burnout Worksite mental health Prevention Empowerment Review
1. Introduction 1.1. Background Burnout is a work related mental health impairment comprising three dimensions: emotional exhaustion, depersonalisation and reduced personal accomplishment. Emotional exhaustion is the state of being depleted of one’s emotional resources, depersonalisation refers to a negative, cynical and detached approach to people under ones care and reduced personal accomplishment refers to a sense of low self-efficacy and negative feelings towards one’s self.
Abbreviations: EE, emotional exhaustion; DP, depersonalisation; PA, personal accomplishment; LOE, level of evidence; BBI, Bergen burnout indicator; CBI, Copenhagen burnout inventory; MBI, Maslach burnout inventory; UBOS, Utecht burnout scale; MBI-NL, Maslach burnout inventory-Netherlands; EVL-Burnout, burnout assessment questionnaire; RCT, randomised controlled trials. * Corresponding author at: Endowed Chair Prevention and Rehabilitation in Health System Research, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany. Tel.: +49 05 11 532 4455; fax: +49 05 11 532 5347. E-mail address: [email protected] (W.L. Awa). 0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.04.008
The presence of these three components alongside one another differentiates burnout from stress and other psychological conditions with which it shares similar symptoms like depression, fatigue, anxiety or lack of motivation. Burnout further differs from stress in that its victims have experienced prolonged symptoms. Burnout results from stress that comes about through the social relationship between a helper and a help recipient, usually found in asymmetrical professional relationships, whereby the victim is the ‘‘giver’’ and the client(s) the ‘‘receiver’’. This is usually the case with professionals like physicians, nurses, teachers or social workers [1]. For example an estimated 22% of physicians in the USA, 27% of physicians in Great Britain [2] and 20% of physicians in Germany suffer burnout [3]. Similarly, about 30% of teachers are affected [4,5] and some studies report up to 40% [6]. However, burnout can manifest in any person and the number of individuals suffering burnout are continuously on the rise [7]. An imbalance between job demands and job skills, a lack of job control, effort reward imbalance (discrepancy which exists between resources, expectations and job reality) and prolonged work stress, are some of the leading risk factors for the development of burnout or other work related mental health
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impairment [8,9]. Some consequences of burnout are absenteeism, sick leave job turnover as well as physical health impediments [10–12]. The health report of one German employee insurance company Deutsche Angestellten-Krankenkasse (DAK) for 2005 for instance, showed a continuous increase in the rate of sick leave days for the diagnosis group psychological sickness among members. Cases of illness and the total number of days off work due to mental health problems increased approximately by 70% between 1997 and 2004, while total sick leave increased by 5% in the same period [13]. Poor work related mental health is associated with enormous economic costs. The European Agency for Safety and Health at Work estimated that the annual economic cost of work related stress disorders in the EU was about 20 billion Euros (about USD 25 billion) in 2002. Similar losses have been estimated for other western countries [14–16]. A favourable psychological working environment is therefore in the interest of both employers and employees. This has not only been recognized by health promotion policy makers as a means of reducing health inequalities today, but also is being practiced by certain institutions with different degrees of success. Intervention programs for preventing burnout can either be person-directed (individual/groups), organization-directed or a combination of both person- and organization-directed aspects. Person-directed interventions programs are usually cognitive behavioural measures aimed at enhancing job competence and personal coping skills, social support or different kinds of relaxation exercises. Organization-directed interventions on the other hand are usually changes in work procedures like task restructuring, work evaluation and supervision aimed at decreasing job demand, increasing job control or the level of participation in decision making. These measures empower individuals and reduce their experience of stressors. In the absence of effective burnout prevention, employees are likely to suffer poor work related mental health where risk factors prevail. People who take part in stress intervention programs usually experience less stress symptoms than those who do not [17]. We therefore expect that intervention programs against burnout will reduce symptoms and positively influence risk factors for poor work related mental health. For person-directed interventions we hypothesise a short term reduction in burnout. Secondly, we hypothesise that organization-directed interventions will result in longer lasting positive effects on burnout and worksite mental health than person-directed interventions, since they address major risk factors like work overload and effort reward imbalance. Thirdly, we hypothesise that a combination of both person- and organization-directed interventions will lead to better results on burnout and worksite mental health than either person- or organization-directed interventions independently. The aim of this review is to analyze the effectiveness of different intervention programs in reducing burnout. The objectives of this literature review are: 1. To evaluate the effectiveness of person-and organizationdirected intervention programs intended to prevent burnout in any target group and 2. to compare the effectiveness of these different intervention types in reducing burnout.
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search I was carried out at the end of March 2006 and covered the period from January 1995 to March 2006. Literature search II, conducted in January 2008, covered the period from April 2006 to December 2007. Languages were limited to English and German for both search phases and the search strategy was based on key words 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 management program’’, ‘‘empowerment’’, ‘‘prevention’’, ‘‘health promotion’’, ‘‘health education’’ and ‘‘early intervention’’ amongst others. Additionally, the reference lists of selected publications were hand searched in order to identify potential papers missed by the systematic search. 2.2. Paper inclusion criteria Included were primary studies with at least 1 pre- and postintervention assessment point, aimed at preventing burnout. Only studies which measured the outcome burnout or any of its core components were included. Studies which only measured risk or protective factors of burnout were excluded as well as those which assessed measures for improving worksite mental health, reducing work stress or general distress. Relevant publications were included regardless of study design or type of target group. This is due to the fact that evaluated burnout intervention studies are relatively few and their study designs are diverse. Reviews of occupational health parameters were excluded since they did not present relevant information in the desired detail for this review. Studies which analyzed participants’ reasons or motivation for seeking help in a burnout intervention program only, studies which assessed participants’ opinion about and satisfaction with a burnout intervention program as well as those which only identified sources of work stress and potential areas for burnout prevention were left out as well. 2.3. Paper selection The results of the systematic literature search I and II were stored in the literature management system Reference Manager and duplets were automatically excluded. In the next step, titles of interest were selected and their abstracts were read by two reviewers. The full texts of abstracts which met inclusion criteria were ordered and further analyzed. In cases of disagreement a consensus or third opinion was sought. A hand search of the reference lists of selected papers was also conducted to identify studies missed by the systematic search. 2.4. Data extraction and management Data extraction and critical appraisal of selected intervention studies were carried according to existing guideline for qualitative reviews [18] and levels of evidence were attributed to intervention programs in line with the guidelines of the U.S. Preventive Task Force [19]. Strong evidence was attributed to outcomes where a significant positive or negative intervention effect was measured (p 0.05). Non-significant positive or negative intervention effects (p > 0.05) were regarded as limited evidence.
2. Methods 3. Results 2.1. Literature search 3.1. Search results This review is based on a systematic search of burnout intervention studies in the electronic databases Medline, PsycINFO and PSYNDEX. The search was conducted in two phases: Literature
The systematic literature search I and II resulted in a total of 535 publications. Based on their titles, 258 relevant abstracts were
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Table 1 Details of studies reviewed: person-directed interventions (in ascending order of publication year). Level of evidence [19]
Participants
Intervention content
Duration
Instrument
Post-tests
Outcome: burnout, post-test: end of intervention—6 months
Post-test > 6 months < 1 year
Post-test >1 year
Palsson et al. [20], SE
II-1
33 district nurses from 10 primary health care districts
Professional skill training, clinical supervision
4 weeks
1.5 and 2.4 years
_
Burnout: $
Burnout: $
van Dierendonck et al. [21], NL Ossenbaad [22], NL
II-1
149 mental health professionals
5 weeks
6 and 12 months
_
Burnout: #*
EE/Equity: "PA: $
II-1
Rowe [23], US
II-1
Te Brake et al. [24], NL
II-1
Cognitive behavioural training, counselling Relaxation using brain machines Adaptive coping, refresher courses Cognitive behavioural training, counselling Cognitive behavioural training, counselling Psycho-social skill training
Burnout measure (Schaufeli and Enzmann, 1993) MBI
Gorter et al. [25], NL
II-1
Ewers et al. [26], GB
Ia
Brittman et al. [27], US
Ia a
Lange et al. [28], NL
I
Salmmela-aro et al. [29], FI Cohen Katz [30], US
Ia Ia
Cohen et al. [31], IL
II-2
Van Rhenen et al. [32], NL
Ia
Zolnierezyk-Zreda [33], PL
Ia a
42 addiction care employees (185 controls) 113 health care professions 171 dentist with high burnout scores 19 dentists with high burnout scores 33 forensic mental nurses
112 interdisciplinary care workers 133 news paper announcement respondents 62 employees suffering burnout 25 (nurses in pastoral care, respiratory therapy and social work) 25 social workers of a medical centre 130 employees with high stress levels (telecommunication company) 59 teachers
van Dierendonck et al. [34], NL Kanji et al. [35], GB
I
Ia
38 individuals from engineering background 93 nursing students
Margalit et al. [36], IL
Ia
102 general practitioners
*
8 weeks
MBI,
2 and 10 weeks
EE: # , EE: $
_
_
–
MBI MBI-NL
EE: #*, DP: #*, PA: "* _
EE: #*, DP:#*, PA: "* Burnout: #*
EE: #*, DPz, PA: "*
1 month
2, 6, 12, 24 and 30 months 12 months
*
_
–
MBI-NL
6 months
Burnout: #
_
_
20 days
MBI
6 months
_
_
Recreational music making (RMM) Online counselling and supervision ‘interapy’ Analytic and experimental psychotherapy Cognitive behavioural training, counselling
6 weeks
MBI,
1 day, 6 and 12 weeks 6 weeks
Burnout: #* (EE: d = 0.59; DP: d = 0.29; PA: d = 1.2) Burnout: #*
_
_
_
_
5 and 6 months
Burnout: # (d = 0.54) Burnout: #*
_
_
Psychosocial skill and communication training Relaxation training
10 weeks
UBOS, EVL-Burnout BBI
8 weeks
MBI
Several months later
Burnout: #*
_
_
8 weeks
MBI
1 and 2 months
_
_
8 weeks
UBOS
10 weeks, 6 months
EE: #z, DP: #*, PA: "* Burnout: #*
_
_
Adaptive coping/communication, relaxation Psychosynthesis
2 days
MBI
1 month
_
_
10 days
MBI
3 and 9 months
EE: #*; DP: $; PA: "z Burnout: #
–
–
Autogenic training, laughter therapy Bio-psychological approach [49], didactic/interactive teaching
8 weeks
MBI
Burnout: $
–
_
12 weeks
[48], open questions
5, 8, 11 and 14 months 6 months
Burnout: "*
_
_
Increase/improvement: ". Decrease/reduction: #. No changes: $. d (effect size: Cohen’s d). a RCT. * Significant change (p < 0.005). z Non-significant change (p > 0.005).
7 weeks
*
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Paper/Country
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Table 2 Details of studies reviewed: organization-directed interventions (in ascending order of publication year). Paper/Country
Level of evidence [19]
Participants
Intervention content
Duration
Instrument
Post-tests
Outcome: burnout, post-test: end of intervention—6 months
Post-tests > 6 months < 1 year
Post-tests >1 year
Boumans et al. [37], NL Halbesleben et al. [38], US
Ia
248 professional care giver 65 federal military fire department workers
Primary nursing, personal care giving Cognitive behavioural and, management skill training, social support
–
MBI
1 year
_
EE: $
_
90 days (200 h)
MBI-GS
1 year
_
EE: #*, DP: #*
_
II-3
Increase/improvement: ". Decrease/reduction: #. No changes: $. d (effect size: Cohen’s d). a RCT. * Significant change (p < 0.005).
selected and read while 277 were excluded. Twenty of these met the inclusion criteria and their full texts were further analyzed. The hand search resulted in 5 additional studies. Thus, a total of total 25 studies made up the basis of this review. Twelve of the 25 selected studies (48%) were conducted in the Netherlands and constituted the majority. Four (16%) were conducted in the USA, 2 (8%) in Great Britain and Israel, as well as 1 each in Canada, Finland, Norway, Sweden and Poland (Tables 1–3). Fourteen of the selected studies were randomised control trials or randomised experiments. There were 9 quasi-experimental studies, 5 of which were either non-randomised or provided no information on the randomisation of participants. Two studies had no control groups. 3.1.1. Types of participants Participants either actively or passively sought help in a burnout intervention program. In 21 (84%) studies the participants were current employees, in 2 (8%) employees on sick leave or rehabilitation, in another (4%) they were people who responded to media announcements of the intervention program, and in yet another (4%) participants were nursing students. Participants’ profession ranged from health care professionals, dentists, interdisciplinary care workers, social workers, police officers, company managers to federal military force department employees amongst others. Some studies only included participants which had been assessed to have very high burnout scores [29,30]. 3.1.2. Types and duration of interventions In 17 (68%) studies the interventions were person-directed. These included measures like cognitive behavioural training, psychotherapy, counselling, adaptive skill training, communication skills training, social support, relaxation exercises or recreational music making amongst others [20–36] (Table 1). There were 2 (8%) organization-directed interventions, where measures like work process restructuring, work performance appraisals, work shift readjustments and job evaluation were offered for instance [37,38] (Table 2). A combination of aspects of both person- and organization-directed interventions measures was offered in 6 (24%) of the intervention studies analyzed [39–44] (Table 3). In about 68% of all studies, the intervention periods were less than 6 months, in 1 case it lasted 6 months (4%) while about 24% of studies did not state the intervention duration. Study periods (pretest, intervention, and post-tests) ranged from a minimum of 1 month to a maximum of 2.5 years. Four study periods were less than 6 months, 11 stretched between 6 months and 1 year, while in 10 cases the study periods lasted more than 1 year. Among these, there were three long term studies lasting over 2 years. Post-test assessments were carried out at least once and at most five times in the studies analyzed. The first post-test was conducted between the end of the intervention and 6 months afterwards in 17 (68%) studies, in 8 (32%) studies between 6 months and 1 year after the
intervention ended. The last post-test was done 6 months after the intervention ended in 14 (56%) studies, between 6 months and 1 year after the intervention in 7 (28%) cases and in 4 (16%) cases, more than 1 year after end of intervention. 3.1.3. Effect size For inter- and intra-group comparisons, the means of dependent variables were usually compared and/or repeated ANOVA or MANOVA/MANCOVA conducted. Effect sizes were stated only in a few studies (Tables 1–3). In these studies, positive results usually remained significant and stable, i.e. despite high dropout levels no significant difference emerged between groups, suggesting that attrition was not selective. However in 1 study [44] there were significant differences between groups at different post-test measurement points. The intervention group had higher mean scores for quantitative job demands (d = 0.12) and significantly lower scores for emotional demand (d = 0.41) than controls at T1, even though these differences did not exist at baseline. Nevertheless this study reports that absolute differences between measurements points in terms of d values were small. 3.1.4. Assessed parameters Person- and organization-oriented outcomes were measured using standard validated or self-report questionnaires. The effect of intervention programs on burnout was assessed as well as other person-oriented outcomes like state anxiety, psychological distress, depression, moods, fear, perceived stress, self-esteem, feelings of guilt, feeling of deprivation, effort reward imbalance, and emotional job demands amongst others. These outcomes were measured in about 50% of all studies. Protective factors like social support from supervisors/peers, emotional intelligence or selfesteem were analyzed in about 16% of studies. General health, sleeping problems, blood pressure and other physical health outcomes were additionally investigated in 12% of all studies. Organization- and work related outcomes like quantitative job demands, job control, job performance, personal skills, intellectual job demands, participation in decision making as well as job satisfaction and turnover intension were assessed in about 24% of studies which met the inclusion criteria. 3.2. Outcomes 3.2.1. Burnout Burnout or its core components was assessed in all studies. Intervention periods ranged from 2 days to 10 months where mentioned. In 21 (84%) of these studies, a reduction in burnout or some core component(s) was registered and in 17 (90%) cases positive changes were significant. In 3 (12%) intervention studies (2 person- and 1 organization-directed), there were no positive changes in burnout [20,35,37] and an unexpected significant increase in burnout was registered in 1 person-directed interven-
Burnout: #*
EE: #*, DP: $
EE: #*, DP: #z
_
EE. #*, DP: #*
EE: #*, DP: #* (d = 0.41);
_
_
_ EE: #*
_
_ Exhaustion: # _
Burnout: $
tion study [36]. One of 2 organization-directed interventions led to a significant positive change in burnout while the other had no effect (Table 2). All combined (person-and organization-directed) interventions led to significant positive changes in burnout (Table 3). Reductions in burnout or its subscale scores usually lasted between 6 months and 1 year. The burnout component emotional exhaustion was best influenced: in 1 long term study, positive changes in emotional exhaustion lasted up to 2.5 years after the intervention. However, this study included refresher sessions at intervals after the intervention ended [23]. Positive changes in the other burnout core components (depersonalisation and reduced personal accomplishment) usually did not last over 6 months except in the case where refresher sessions were offered. The durations of organization-directed and combined intervention program (2–6 months) were usually longer than those of person-directed interventions (2 days to 3 months). A comparison between the duration of significant positive changes in burnout from the different intervention programs shows that while positive changes in burnout after person-directed intervention usually only lasted up to 6 months; those resulting from organization-directed and combined interventions usually lasted up to 1 year (Tables 1–3). Nevertheless, in 3 out of 4 persondirected interventions significant positive effects lasted up to 1 year after the intervention program were measured. The trend of results from all intervention types are thus similar, i.e. are inclined towards a reduction in positive effects over time in the absence of refresher sessions.
10 months
End of each work shift, 6 months
1 year
4 and 10 months
6 months, 1 year
MBI-GS
MBI,
CBI
MBI-NL
MBI
–
3 month
2 months
–
6 months
Work schedule reorganization, lectures
Work shift evaluation, reorganization, communication, feedback, supervision Changes made to reduce adverse job psychosocial factors Extensive cognitive behavioural therapy (CBT) Participatory action research (PAR) communication, social support, coping skills
112 staff working with the intellectually disabled All 61 staff of a paediatric intensive care unit II-2
II-I
Ia
Ia
Sluiter et al. [41], NL
Bourbonnais et al. [42], CA
Blonk et al. [43], NL
Le Blanc et al. [44], NL
II-1
674 hospital care personnel and 894 controls 122 self-employed on sick leave 664 staff of 29 oncology wards in 18 general hospitals
– Professional supervision 161 psychiatric nurses Ia
Melchoir et al. [39], NL Innstrand et al. [40], NO
Increase/improvement: ". Decrease/reduction: #. No changes: $. d (effect size: Cohen’s d). a RCT. * Significant change (p < 0.005). z Non-significant change (p > 0.005).
*
Burnout: #* 1 and 2.5 years MBI
_
Post-tests Instrument Duration Intervention content Participants Level of evidence [19] Paper/Country
Table 3 Details of studies reviewed: combined (person- and organization-directed) interventions (in ascending order of publication year).
Outcome: burnout, post-test: end of intervention—6 months
Post-test >1 year
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Post-test > 6 months < 1 year
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3.2.2. Burnout risk and protective factors Psychological outcomes like state anxiety, moods, fear, depression, psychological distress, fatigue, negative emotions, and emotional job demands, which when experienced over prolonged periods represent risk factors for burnout, were usually assessed alongside burnout and usually improved or depreciated in a similar fashion as burnout. However, positive changes in these parameters usually did not last over 6 months. This was also the case for outcomes like general health condition and sleeping problems which also improved or depreciated with corresponding changes in burnout. Long term measurements over 1 year were not available for these secondary outcomes. Supervisor, peer and/or co-worker support which are known to be protective factors of burnout also significantly improved with significant improvements in burnout, and lasted up to 1 year after the intervention ended. This was also the case for work related stressor like high job demand, low job control, lack of skills or effort reward imbalance, whereby positive changes in these risk factors went alongside positive changes in burnout and psychological outcomes like depression, anxiety distress in these outcomes lasting 1 year. 3.3. Analysis of randomised control trials Due to the fact that the intervention programs reviewed used several different types of study designs, participants and settings, we compared the effects of RCTs with those of other study designs, in order to find out if any discrepancies exist between the results. Fourteen studies used were classified as RCTs. Ten (71%) of these were person-directed interventions, 1 (4%) was an organizationdirected intervention study and 3 (12%) were combined interventions. Their intervention periods ranged from 20 days to 6 months and were comparable to the intervention periods of other study designs, i.e. 2 days to 6 months. Burnout significantly reduced in 7 (70%) out of the 10 person-directed intervention RCTs. There was a non-significant decrease in 1 study [34], no change in another [35] and self-reported increase in burnout was found in the third [36].
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There was also no improvement in burnout in the only organization-directed RCT [37]. However, in all 3 combined interventions- RCTs, burnout reduced significantly [39,43,44]. These results indicate that the intervention effects of studies which used other study designs did not markedly differ from those of RCTs. 4. Discussion and conclusion 4.1. Discussion Preventing and reducing work related burnout is of great importance not only with regard to the quality of life of those affected or endangered, but also for preventing the economic losses which come about as a result of absenteeism and job turnover. The intervention programs analyzed in this review were generally helpful in reducing burnout or any of its core components. About 80% of all studies led to positive effects on burnout, while in about 20% there were either no positive effects or depreciation in burnout or some core component(s) was registered. However, the contents, design, and target groups of these intervention programs were diverse and direct comparisons were infeasible. Therefore, in assessing the effectiveness of intervention programs three categories were distinguished: person-directed, organization-directed and combined (personand organization-directed) interventions which were independently assessed. We found that about 82% of all person-directed interventions led to a significant reduction in burnout or positive changes in its risk factors, lasting up to 6 months after the intervention. This confirms hypothesis 1, which predicts short term positive intervention effects on worksite site mental health. In 2 cases, however, positive effects on burnout lasted up to 1 year and over [21,23]. In the latter, refresher sessions were offered after the intervention ended. About 60% of all person-directed interventions had the highest level of evidence [19]. One organization-directed intervention led to a significant reduction in burnout lasting up to 1 year [38]. The second hypothesis stating that organization-directed interventions will result in longer lasting positive effects could not be confirmed with certainty because even though we found positive intervention effects lasting up to 1 year, only 2 strictly organizationdirected intervention were analyzed and the designs used in 1 was non-randomised [38], and thus classified as having lower evidence [19]. Similar to one review which assessed the prevention of occupational stress as well as the outcome ‘burnout’ [45], our results are inconclusive with regard to organizationdirected interventions. However, due to the fact that the positive effects lasted up to 1 year after an intervention [38] similar results may be reckoned with from well implemented organizationdirected interventions. All 6 combined interventions led to positive effects on burnout and all positive changes in burnout were significant, 80% lasting up to 1 year. This confirmed the third hypothesis which predicts better results for combined interventions than either person- or organization-directed interventions independently. Furthermore, 50% of all combined interventions had the highest level of evidence [19]. Where assessed, psychological health improved and risk factors for poor worksite mental health reduced alongside positive changes in burnout. We further found out that intervention programs which include refresher courses resulted in longer lasting positive effects on burnout [23]. For example a reduction in the burnout component emotional exhaustion lasted over 2 years. However, more long term studies need to be conducted and evaluated in
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order to arrive at more reliable conclusions with regard to refresher courses. Compared to other study designs, the results of randomised control trials did not differ with regard to the duration of positive intervention effects. In all cases, positive intervention effects followed the general trend of reduction over time in the absence of refresher courses. Despite their lower design quality, the results of non-RCTs had followed trends similar to those of RCTS. Effect sizes were stated only in about 20% of all studies. Positive intervention effects still remained significant and stable despite drop outs and group differences did not influence significant results. Thus attrition, though high in some cases, was not selective. Nevertheless, it would have been useful if more studies provided information on effect size for better comparisons. 4.2. Limitations of this review This review was subject to a number of limitations; the search strategy was limited to publications in English and German, thus, potentially relevant studies in other languages were excluded. Only 3 data bases were sought between 1995 and 2007. This meant that relevant studies available elsewhere and published outside this time frame could also have been left out. Furthermore, the hand search of reference lists was unsystematic; as a result, relevant studies could also have been overseen. Additionally, our criteria for selecting studies for this review allowed for the inclusion of a wide range of study designs and thus limiting the direct comparability of results. Some of the studies analyzed also did not provide relevant information about study design, intervention duration, or post-test intervals. Moreover, an evaluation of the quality of individual study methodology was also not conducted. We compared the results of burnout intervention studies which used different types of participants, settings, intervention durations and ingredients; using the outcome ‘burnout’ as a common denominator. Therefore our results suggest trends and identify potential areas for further research. 4.3. Implications for further research and practice This review shows that burnout intervention programs are beneficial. People who take part in burnout intervention program(s) generally experience less burnout than their counterparts who do not. Therefore properly planned intervention programs, which include aspects of both person- and organization-directed prevention measures, are expected to positively influence burnout and worksite mental health. Positive effects can be enhanced by refresher courses at appropriate intervals after the end of the program. Even though many studies have examined risk factors for burnout, only relatively few prevention programs have been conducted and even fewer have been evaluated. This may partly be due to the difficulties associated with implementing such programs, especially organization-directed interventions [46,47]. Therefore better designed and evaluated controlled trials (RCT or CTs), with comparable participants, appropriate baseline and at least two post-intervention measurements points (preferably up to 1 year) are needed in order that more reliable conclusions can be arrived at. Many of the studies analyzed in this review had small sample sizes, high dropout rates as well as short intervention and follow-up durations. Future interventions should work against such limiting factors in order to improve on the integrity of results and conclusions. It was also apparent that intervention programs could be counterproductive [36]. To avoid this, program design and implementation should take specific needs of participants into consideration.
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[26] Ewers P, Bradshaw T, McGovern J, Ewers B. Does training in psychosocial interventions reduce burnout rates in forensic nurses. J Adv Nurs 2002;27:470–6. [27] Bittman B, Bruhn KT, Stevens C, Westengard J, Umbach PO. Recreational music-making: a cost-effective group interdisciplinary strategy for reducing burnout and improving mood states in long-term care workers. Adv Mind Body Med 2003;19:4–15. [28] Lange A, Ven JP, van de Schrieken B, Smit M. ‘Interapy’ Burn-out: Pra¨vention und Behandlung von Burn-out u¨ber das Internet. Verhaltenstherapie 2004;14:190–9. [29] Salmela-Aro K, Nataanen P, Nurmi JE. The role of work-related personal projects during two burnout interventions: a longitudinal study. Work Stress 2004;18:208–30. [30] Cohen-Katz J, Wiley S, Capuano T. The effects of mindfulness-based stress reduction on nurse stress and burnout: a qualitative and quantitative study. Part III. Holist Nurs Pract 2005;19:78–86. [31] Cohen M, Gagin R. Can skill-development training alleviate burnout in hospital social workers? Soc Work Health Care 2005;40:83–97. [32] Van Rhenen W, Blonk RWB, Van der Klink JJL, Van Dijk FJH, Schaufeli WB. The effect of a cognitive and a physical stress-reducing programme on psychological complaints. Int Arch Occup Environ Health 2005;78:139–48. [33] Z˙ołnierczyk-Zreda D. An intervention to reduce work- related burnout in teachers. Int J Occup Saf Ergon 2005;11:423–30. [34] Van Dierendonck D, Garssen B, Visser A. Burnout prevention through personal growth. Int J Stress Manage 2005;12:62–77. [35] Kanji N, White AR, Ernst E. Autogenic training to reduce anxiety in nursing students: randomized controlled trial. J Adv Nurs 2006;53:729–35. [36] Margalit AP, Glick SM, Benbassat J, Cohen A, Kats M. Promoting a biopsychosocial orientation in family practice: effect of two teaching programs on the knowledge and attitudes of practising primary care physicians. Med Teach 2005;27:613–8. [37] Boumans NPG, Landeweerd JA. A Dutch study of the effects of primary nursing on job characteristics and organizational processes. J Adv Nurs 1996;24:16– 23. [38] Halbesleben JRB, Osburn HK, Mumford MD. Action research as a burnout intervention: reducing burnout in the Federal Fire Service. J Appl Behav 2006;42:244–66. [39] Melchior MEW, Philipsen H, Abu-Saad HH, Halfens RJG, van de Berg AA, Gassman P. The effectiveness of primary nursing on burnout among psychiatric nurses in long-stay settings. J Adv Nurs 1996;24:694–702. [40] Innstrand ST, Espnes GA, Mykletun R. Job stress, burnout and job satisfaction: an intervention study for staff working with people with intellectual disabilities. J Appl Res Int Dis 2004;17:119–26. [41] Sluiter JK, Bos AP, Tol D. Is staff well-being and communication enhanced by multidisciplinary work shift evaluations? Intens Care Med 2005;31:1409–14. [42] Bourbonnais R, Brisson C, Vinet A, Ve´zina M, Abdous B, Gaudet M. Effectiveness of a participative intervention on psychosocial work factors to prevent mental health problems in a hospital setting. Occup Environ Med 2006;63:335–42. [43] Blonk RW, Brenninkmeijer V, Lagerveld SE, Houtman ILD. Return to work: a comparison of two cognitive behavioural interventions in cases of workrelated psychological complaints among the self-employed. Work Stress 2006;20:129–44. [44] Le Blanc PM, Hox JJ, Schallfeli WB. Take care! The evaluation of a team-based burnout intervention program for oncology care providers. J Appl Psychol 2007;92:213–27. [45] Marine A, Ruotsalainen JH, Serra C, Verbeek JH. Preventing occupational stress in healthcare workers. Cochrane Database of Syst Rev 2006; 4 Art. No. CD002892, doi:10.1002/14651858.CD002892.pub2. [46] Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organisational-level interventions that aim to increase employee control. J Epidemiol Commun Health 2007;61:945–54. [47] Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Commun Health 2007;61:1028–37. [48] Schaufeli WB, Enzmann D, Girault N. Measurement of burnout: A review. In: Schaufeli WB, Maslach C, Marek T, editors. Professional burnout: Recent developments in theory and research. Washington, DC: Taylor & Francis; 1993. p. 199–215. [49] Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Burnout
Burnout prevention: A review of intervention programs Wendy L. Awa *, Martina Plaumann, Ulla Walter Hannover Medical School, Institute for Epidemiology, Social Medicine and Health System Research, Endowed Chair Prevention and Rehabilitation in Health System and Health Services Research, Hannover, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 November 2008 Received in revised form 10 April 2009 Accepted 16 April 2009
Objective: To evaluate the effectiveness of intervention programs at the workplace or elsewhere aimed at preventing 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 hand search. Results: A total of 25 primary intervention studies were reviewed. Seventeen (68%) were persondirected interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of both interventions types. Eighty percent of all programs led to a reduction in burnout. Person-directed interventions reduced burnout in the short term (6 months or less), while a combination of both personand organization-directed interventions had longer lasting positive effects (12 months and over). In all cases, positive intervention effects diminished in the course of time. Conclusion: Intervention programs against burnout are beneficial and can be enhanced with refresher courses. Better implemented programs including both person- and organization-directed measures should 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 intervention programs available to employees. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Burnout Worksite mental health Prevention Empowerment Review
1. Introduction 1.1. Background Burnout is a work related mental health impairment comprising three dimensions: emotional exhaustion, depersonalisation and reduced personal accomplishment. Emotional exhaustion is the state of being depleted of one’s emotional resources, depersonalisation refers to a negative, cynical and detached approach to people under ones care and reduced personal accomplishment refers to a sense of low self-efficacy and negative feelings towards one’s self.
Abbreviations: EE, emotional exhaustion; DP, depersonalisation; PA, personal accomplishment; LOE, level of evidence; BBI, Bergen burnout indicator; CBI, Copenhagen burnout inventory; MBI, Maslach burnout inventory; UBOS, Utecht burnout scale; MBI-NL, Maslach burnout inventory-Netherlands; EVL-Burnout, burnout assessment questionnaire; RCT, randomised controlled trials. * Corresponding author at: Endowed Chair Prevention and Rehabilitation in Health System Research, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany. Tel.: +49 05 11 532 4455; fax: +49 05 11 532 5347. E-mail address: [email protected] (W.L. Awa). 0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.04.008
The presence of these three components alongside one another differentiates burnout from stress and other psychological conditions with which it shares similar symptoms like depression, fatigue, anxiety or lack of motivation. Burnout further differs from stress in that its victims have experienced prolonged symptoms. Burnout results from stress that comes about through the social relationship between a helper and a help recipient, usually found in asymmetrical professional relationships, whereby the victim is the ‘‘giver’’ and the client(s) the ‘‘receiver’’. This is usually the case with professionals like physicians, nurses, teachers or social workers [1]. For example an estimated 22% of physicians in the USA, 27% of physicians in Great Britain [2] and 20% of physicians in Germany suffer burnout [3]. Similarly, about 30% of teachers are affected [4,5] and some studies report up to 40% [6]. However, burnout can manifest in any person and the number of individuals suffering burnout are continuously on the rise [7]. An imbalance between job demands and job skills, a lack of job control, effort reward imbalance (discrepancy which exists between resources, expectations and job reality) and prolonged work stress, are some of the leading risk factors for the development of burnout or other work related mental health
W.L. Awa et al. / Patient Education and Counseling 78 (2010) 184–190
impairment [8,9]. Some consequences of burnout are absenteeism, sick leave job turnover as well as physical health impediments [10–12]. The health report of one German employee insurance company Deutsche Angestellten-Krankenkasse (DAK) for 2005 for instance, showed a continuous increase in the rate of sick leave days for the diagnosis group psychological sickness among members. Cases of illness and the total number of days off work due to mental health problems increased approximately by 70% between 1997 and 2004, while total sick leave increased by 5% in the same period [13]. Poor work related mental health is associated with enormous economic costs. The European Agency for Safety and Health at Work estimated that the annual economic cost of work related stress disorders in the EU was about 20 billion Euros (about USD 25 billion) in 2002. Similar losses have been estimated for other western countries [14–16]. A favourable psychological working environment is therefore in the interest of both employers and employees. This has not only been recognized by health promotion policy makers as a means of reducing health inequalities today, but also is being practiced by certain institutions with different degrees of success. Intervention programs for preventing burnout can either be person-directed (individual/groups), organization-directed or a combination of both person- and organization-directed aspects. Person-directed interventions programs are usually cognitive behavioural measures aimed at enhancing job competence and personal coping skills, social support or different kinds of relaxation exercises. Organization-directed interventions on the other hand are usually changes in work procedures like task restructuring, work evaluation and supervision aimed at decreasing job demand, increasing job control or the level of participation in decision making. These measures empower individuals and reduce their experience of stressors. In the absence of effective burnout prevention, employees are likely to suffer poor work related mental health where risk factors prevail. People who take part in stress intervention programs usually experience less stress symptoms than those who do not [17]. We therefore expect that intervention programs against burnout will reduce symptoms and positively influence risk factors for poor work related mental health. For person-directed interventions we hypothesise a short term reduction in burnout. Secondly, we hypothesise that organization-directed interventions will result in longer lasting positive effects on burnout and worksite mental health than person-directed interventions, since they address major risk factors like work overload and effort reward imbalance. Thirdly, we hypothesise that a combination of both person- and organization-directed interventions will lead to better results on burnout and worksite mental health than either person- or organization-directed interventions independently. The aim of this review is to analyze the effectiveness of different intervention programs in reducing burnout. The objectives of this literature review are: 1. To evaluate the effectiveness of person-and organizationdirected intervention programs intended to prevent burnout in any target group and 2. to compare the effectiveness of these different intervention types in reducing burnout.
185
search I was carried out at the end of March 2006 and covered the period from January 1995 to March 2006. Literature search II, conducted in January 2008, covered the period from April 2006 to December 2007. Languages were limited to English and German for both search phases and the search strategy was based on key words 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 management program’’, ‘‘empowerment’’, ‘‘prevention’’, ‘‘health promotion’’, ‘‘health education’’ and ‘‘early intervention’’ amongst others. Additionally, the reference lists of selected publications were hand searched in order to identify potential papers missed by the systematic search. 2.2. Paper inclusion criteria Included were primary studies with at least 1 pre- and postintervention assessment point, aimed at preventing burnout. Only studies which measured the outcome burnout or any of its core components were included. Studies which only measured risk or protective factors of burnout were excluded as well as those which assessed measures for improving worksite mental health, reducing work stress or general distress. Relevant publications were included regardless of study design or type of target group. This is due to the fact that evaluated burnout intervention studies are relatively few and their study designs are diverse. Reviews of occupational health parameters were excluded since they did not present relevant information in the desired detail for this review. Studies which analyzed participants’ reasons or motivation for seeking help in a burnout intervention program only, studies which assessed participants’ opinion about and satisfaction with a burnout intervention program as well as those which only identified sources of work stress and potential areas for burnout prevention were left out as well. 2.3. Paper selection The results of the systematic literature search I and II were stored in the literature management system Reference Manager and duplets were automatically excluded. In the next step, titles of interest were selected and their abstracts were read by two reviewers. The full texts of abstracts which met inclusion criteria were ordered and further analyzed. In cases of disagreement a consensus or third opinion was sought. A hand search of the reference lists of selected papers was also conducted to identify studies missed by the systematic search. 2.4. Data extraction and management Data extraction and critical appraisal of selected intervention studies were carried according to existing guideline for qualitative reviews [18] and levels of evidence were attributed to intervention programs in line with the guidelines of the U.S. Preventive Task Force [19]. Strong evidence was attributed to outcomes where a significant positive or negative intervention effect was measured (p 0.05). Non-significant positive or negative intervention effects (p > 0.05) were regarded as limited evidence.
2. Methods 3. Results 2.1. Literature search 3.1. Search results This review is based on a systematic search of burnout intervention studies in the electronic databases Medline, PsycINFO and PSYNDEX. The search was conducted in two phases: Literature
The systematic literature search I and II resulted in a total of 535 publications. Based on their titles, 258 relevant abstracts were
186
Table 1 Details of studies reviewed: person-directed interventions (in ascending order of publication year). Level of evidence [19]
Participants
Intervention content
Duration
Instrument
Post-tests
Outcome: burnout, post-test: end of intervention—6 months
Post-test > 6 months < 1 year
Post-test >1 year
Palsson et al. [20], SE
II-1
33 district nurses from 10 primary health care districts
Professional skill training, clinical supervision
4 weeks
1.5 and 2.4 years
_
Burnout: $
Burnout: $
van Dierendonck et al. [21], NL Ossenbaad [22], NL
II-1
149 mental health professionals
5 weeks
6 and 12 months
_
Burnout: #*
EE/Equity: "PA: $
II-1
Rowe [23], US
II-1
Te Brake et al. [24], NL
II-1
Cognitive behavioural training, counselling Relaxation using brain machines Adaptive coping, refresher courses Cognitive behavioural training, counselling Cognitive behavioural training, counselling Psycho-social skill training
Burnout measure (Schaufeli and Enzmann, 1993) MBI
Gorter et al. [25], NL
II-1
Ewers et al. [26], GB
Ia
Brittman et al. [27], US
Ia a
Lange et al. [28], NL
I
Salmmela-aro et al. [29], FI Cohen Katz [30], US
Ia Ia
Cohen et al. [31], IL
II-2
Van Rhenen et al. [32], NL
Ia
Zolnierezyk-Zreda [33], PL
Ia a
42 addiction care employees (185 controls) 113 health care professions 171 dentist with high burnout scores 19 dentists with high burnout scores 33 forensic mental nurses
112 interdisciplinary care workers 133 news paper announcement respondents 62 employees suffering burnout 25 (nurses in pastoral care, respiratory therapy and social work) 25 social workers of a medical centre 130 employees with high stress levels (telecommunication company) 59 teachers
van Dierendonck et al. [34], NL Kanji et al. [35], GB
I
Ia
38 individuals from engineering background 93 nursing students
Margalit et al. [36], IL
Ia
102 general practitioners
*
8 weeks
MBI,
2 and 10 weeks
EE: # , EE: $
_
_
–
MBI MBI-NL
EE: #*, DP: #*, PA: "* _
EE: #*, DP:#*, PA: "* Burnout: #*
EE: #*, DPz, PA: "*
1 month
2, 6, 12, 24 and 30 months 12 months
*
_
–
MBI-NL
6 months
Burnout: #
_
_
20 days
MBI
6 months
_
_
Recreational music making (RMM) Online counselling and supervision ‘interapy’ Analytic and experimental psychotherapy Cognitive behavioural training, counselling
6 weeks
MBI,
1 day, 6 and 12 weeks 6 weeks
Burnout: #* (EE: d = 0.59; DP: d = 0.29; PA: d = 1.2) Burnout: #*
_
_
_
_
5 and 6 months
Burnout: # (d = 0.54) Burnout: #*
_
_
Psychosocial skill and communication training Relaxation training
10 weeks
UBOS, EVL-Burnout BBI
8 weeks
MBI
Several months later
Burnout: #*
_
_
8 weeks
MBI
1 and 2 months
_
_
8 weeks
UBOS
10 weeks, 6 months
EE: #z, DP: #*, PA: "* Burnout: #*
_
_
Adaptive coping/communication, relaxation Psychosynthesis
2 days
MBI
1 month
_
_
10 days
MBI
3 and 9 months
EE: #*; DP: $; PA: "z Burnout: #
–
–
Autogenic training, laughter therapy Bio-psychological approach [49], didactic/interactive teaching
8 weeks
MBI
Burnout: $
–
_
12 weeks
[48], open questions
5, 8, 11 and 14 months 6 months
Burnout: "*
_
_
Increase/improvement: ". Decrease/reduction: #. No changes: $. d (effect size: Cohen’s d). a RCT. * Significant change (p < 0.005). z Non-significant change (p > 0.005).
7 weeks
*
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Paper/Country
W.L. Awa et al. / Patient Education and Counseling 78 (2010) 184–190
187
Table 2 Details of studies reviewed: organization-directed interventions (in ascending order of publication year). Paper/Country
Level of evidence [19]
Participants
Intervention content
Duration
Instrument
Post-tests
Outcome: burnout, post-test: end of intervention—6 months
Post-tests > 6 months < 1 year
Post-tests >1 year
Boumans et al. [37], NL Halbesleben et al. [38], US
Ia
248 professional care giver 65 federal military fire department workers
Primary nursing, personal care giving Cognitive behavioural and, management skill training, social support
–
MBI
1 year
_
EE: $
_
90 days (200 h)
MBI-GS
1 year
_
EE: #*, DP: #*
_
II-3
Increase/improvement: ". Decrease/reduction: #. No changes: $. d (effect size: Cohen’s d). a RCT. * Significant change (p < 0.005).
selected and read while 277 were excluded. Twenty of these met the inclusion criteria and their full texts were further analyzed. The hand search resulted in 5 additional studies. Thus, a total of total 25 studies made up the basis of this review. Twelve of the 25 selected studies (48%) were conducted in the Netherlands and constituted the majority. Four (16%) were conducted in the USA, 2 (8%) in Great Britain and Israel, as well as 1 each in Canada, Finland, Norway, Sweden and Poland (Tables 1–3). Fourteen of the selected studies were randomised control trials or randomised experiments. There were 9 quasi-experimental studies, 5 of which were either non-randomised or provided no information on the randomisation of participants. Two studies had no control groups. 3.1.1. Types of participants Participants either actively or passively sought help in a burnout intervention program. In 21 (84%) studies the participants were current employees, in 2 (8%) employees on sick leave or rehabilitation, in another (4%) they were people who responded to media announcements of the intervention program, and in yet another (4%) participants were nursing students. Participants’ profession ranged from health care professionals, dentists, interdisciplinary care workers, social workers, police officers, company managers to federal military force department employees amongst others. Some studies only included participants which had been assessed to have very high burnout scores [29,30]. 3.1.2. Types and duration of interventions In 17 (68%) studies the interventions were person-directed. These included measures like cognitive behavioural training, psychotherapy, counselling, adaptive skill training, communication skills training, social support, relaxation exercises or recreational music making amongst others [20–36] (Table 1). There were 2 (8%) organization-directed interventions, where measures like work process restructuring, work performance appraisals, work shift readjustments and job evaluation were offered for instance [37,38] (Table 2). A combination of aspects of both person- and organization-directed interventions measures was offered in 6 (24%) of the intervention studies analyzed [39–44] (Table 3). In about 68% of all studies, the intervention periods were less than 6 months, in 1 case it lasted 6 months (4%) while about 24% of studies did not state the intervention duration. Study periods (pretest, intervention, and post-tests) ranged from a minimum of 1 month to a maximum of 2.5 years. Four study periods were less than 6 months, 11 stretched between 6 months and 1 year, while in 10 cases the study periods lasted more than 1 year. Among these, there were three long term studies lasting over 2 years. Post-test assessments were carried out at least once and at most five times in the studies analyzed. The first post-test was conducted between the end of the intervention and 6 months afterwards in 17 (68%) studies, in 8 (32%) studies between 6 months and 1 year after the
intervention ended. The last post-test was done 6 months after the intervention ended in 14 (56%) studies, between 6 months and 1 year after the intervention in 7 (28%) cases and in 4 (16%) cases, more than 1 year after end of intervention. 3.1.3. Effect size For inter- and intra-group comparisons, the means of dependent variables were usually compared and/or repeated ANOVA or MANOVA/MANCOVA conducted. Effect sizes were stated only in a few studies (Tables 1–3). In these studies, positive results usually remained significant and stable, i.e. despite high dropout levels no significant difference emerged between groups, suggesting that attrition was not selective. However in 1 study [44] there were significant differences between groups at different post-test measurement points. The intervention group had higher mean scores for quantitative job demands (d = 0.12) and significantly lower scores for emotional demand (d = 0.41) than controls at T1, even though these differences did not exist at baseline. Nevertheless this study reports that absolute differences between measurements points in terms of d values were small. 3.1.4. Assessed parameters Person- and organization-oriented outcomes were measured using standard validated or self-report questionnaires. The effect of intervention programs on burnout was assessed as well as other person-oriented outcomes like state anxiety, psychological distress, depression, moods, fear, perceived stress, self-esteem, feelings of guilt, feeling of deprivation, effort reward imbalance, and emotional job demands amongst others. These outcomes were measured in about 50% of all studies. Protective factors like social support from supervisors/peers, emotional intelligence or selfesteem were analyzed in about 16% of studies. General health, sleeping problems, blood pressure and other physical health outcomes were additionally investigated in 12% of all studies. Organization- and work related outcomes like quantitative job demands, job control, job performance, personal skills, intellectual job demands, participation in decision making as well as job satisfaction and turnover intension were assessed in about 24% of studies which met the inclusion criteria. 3.2. Outcomes 3.2.1. Burnout Burnout or its core components was assessed in all studies. Intervention periods ranged from 2 days to 10 months where mentioned. In 21 (84%) of these studies, a reduction in burnout or some core component(s) was registered and in 17 (90%) cases positive changes were significant. In 3 (12%) intervention studies (2 person- and 1 organization-directed), there were no positive changes in burnout [20,35,37] and an unexpected significant increase in burnout was registered in 1 person-directed interven-
Burnout: #*
EE: #*, DP: $
EE: #*, DP: #z
_
EE. #*, DP: #*
EE: #*, DP: #* (d = 0.41);
_
_
_ EE: #*
_
_ Exhaustion: # _
Burnout: $
tion study [36]. One of 2 organization-directed interventions led to a significant positive change in burnout while the other had no effect (Table 2). All combined (person-and organization-directed) interventions led to significant positive changes in burnout (Table 3). Reductions in burnout or its subscale scores usually lasted between 6 months and 1 year. The burnout component emotional exhaustion was best influenced: in 1 long term study, positive changes in emotional exhaustion lasted up to 2.5 years after the intervention. However, this study included refresher sessions at intervals after the intervention ended [23]. Positive changes in the other burnout core components (depersonalisation and reduced personal accomplishment) usually did not last over 6 months except in the case where refresher sessions were offered. The durations of organization-directed and combined intervention program (2–6 months) were usually longer than those of person-directed interventions (2 days to 3 months). A comparison between the duration of significant positive changes in burnout from the different intervention programs shows that while positive changes in burnout after person-directed intervention usually only lasted up to 6 months; those resulting from organization-directed and combined interventions usually lasted up to 1 year (Tables 1–3). Nevertheless, in 3 out of 4 persondirected interventions significant positive effects lasted up to 1 year after the intervention program were measured. The trend of results from all intervention types are thus similar, i.e. are inclined towards a reduction in positive effects over time in the absence of refresher sessions.
10 months
End of each work shift, 6 months
1 year
4 and 10 months
6 months, 1 year
MBI-GS
MBI,
CBI
MBI-NL
MBI
–
3 month
2 months
–
6 months
Work schedule reorganization, lectures
Work shift evaluation, reorganization, communication, feedback, supervision Changes made to reduce adverse job psychosocial factors Extensive cognitive behavioural therapy (CBT) Participatory action research (PAR) communication, social support, coping skills
112 staff working with the intellectually disabled All 61 staff of a paediatric intensive care unit II-2
II-I
Ia
Ia
Sluiter et al. [41], NL
Bourbonnais et al. [42], CA
Blonk et al. [43], NL
Le Blanc et al. [44], NL
II-1
674 hospital care personnel and 894 controls 122 self-employed on sick leave 664 staff of 29 oncology wards in 18 general hospitals
– Professional supervision 161 psychiatric nurses Ia
Melchoir et al. [39], NL Innstrand et al. [40], NO
Increase/improvement: ". Decrease/reduction: #. No changes: $. d (effect size: Cohen’s d). a RCT. * Significant change (p < 0.005). z Non-significant change (p > 0.005).
*
Burnout: #* 1 and 2.5 years MBI
_
Post-tests Instrument Duration Intervention content Participants Level of evidence [19] Paper/Country
Table 3 Details of studies reviewed: combined (person- and organization-directed) interventions (in ascending order of publication year).
Outcome: burnout, post-test: end of intervention—6 months
Post-test >1 year
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Post-test > 6 months < 1 year
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3.2.2. Burnout risk and protective factors Psychological outcomes like state anxiety, moods, fear, depression, psychological distress, fatigue, negative emotions, and emotional job demands, which when experienced over prolonged periods represent risk factors for burnout, were usually assessed alongside burnout and usually improved or depreciated in a similar fashion as burnout. However, positive changes in these parameters usually did not last over 6 months. This was also the case for outcomes like general health condition and sleeping problems which also improved or depreciated with corresponding changes in burnout. Long term measurements over 1 year were not available for these secondary outcomes. Supervisor, peer and/or co-worker support which are known to be protective factors of burnout also significantly improved with significant improvements in burnout, and lasted up to 1 year after the intervention ended. This was also the case for work related stressor like high job demand, low job control, lack of skills or effort reward imbalance, whereby positive changes in these risk factors went alongside positive changes in burnout and psychological outcomes like depression, anxiety distress in these outcomes lasting 1 year. 3.3. Analysis of randomised control trials Due to the fact that the intervention programs reviewed used several different types of study designs, participants and settings, we compared the effects of RCTs with those of other study designs, in order to find out if any discrepancies exist between the results. Fourteen studies used were classified as RCTs. Ten (71%) of these were person-directed interventions, 1 (4%) was an organizationdirected intervention study and 3 (12%) were combined interventions. Their intervention periods ranged from 20 days to 6 months and were comparable to the intervention periods of other study designs, i.e. 2 days to 6 months. Burnout significantly reduced in 7 (70%) out of the 10 person-directed intervention RCTs. There was a non-significant decrease in 1 study [34], no change in another [35] and self-reported increase in burnout was found in the third [36].
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There was also no improvement in burnout in the only organization-directed RCT [37]. However, in all 3 combined interventions- RCTs, burnout reduced significantly [39,43,44]. These results indicate that the intervention effects of studies which used other study designs did not markedly differ from those of RCTs. 4. Discussion and conclusion 4.1. Discussion Preventing and reducing work related burnout is of great importance not only with regard to the quality of life of those affected or endangered, but also for preventing the economic losses which come about as a result of absenteeism and job turnover. The intervention programs analyzed in this review were generally helpful in reducing burnout or any of its core components. About 80% of all studies led to positive effects on burnout, while in about 20% there were either no positive effects or depreciation in burnout or some core component(s) was registered. However, the contents, design, and target groups of these intervention programs were diverse and direct comparisons were infeasible. Therefore, in assessing the effectiveness of intervention programs three categories were distinguished: person-directed, organization-directed and combined (personand organization-directed) interventions which were independently assessed. We found that about 82% of all person-directed interventions led to a significant reduction in burnout or positive changes in its risk factors, lasting up to 6 months after the intervention. This confirms hypothesis 1, which predicts short term positive intervention effects on worksite site mental health. In 2 cases, however, positive effects on burnout lasted up to 1 year and over [21,23]. In the latter, refresher sessions were offered after the intervention ended. About 60% of all person-directed interventions had the highest level of evidence [19]. One organization-directed intervention led to a significant reduction in burnout lasting up to 1 year [38]. The second hypothesis stating that organization-directed interventions will result in longer lasting positive effects could not be confirmed with certainty because even though we found positive intervention effects lasting up to 1 year, only 2 strictly organizationdirected intervention were analyzed and the designs used in 1 was non-randomised [38], and thus classified as having lower evidence [19]. Similar to one review which assessed the prevention of occupational stress as well as the outcome ‘burnout’ [45], our results are inconclusive with regard to organizationdirected interventions. However, due to the fact that the positive effects lasted up to 1 year after an intervention [38] similar results may be reckoned with from well implemented organizationdirected interventions. All 6 combined interventions led to positive effects on burnout and all positive changes in burnout were significant, 80% lasting up to 1 year. This confirmed the third hypothesis which predicts better results for combined interventions than either person- or organization-directed interventions independently. Furthermore, 50% of all combined interventions had the highest level of evidence [19]. Where assessed, psychological health improved and risk factors for poor worksite mental health reduced alongside positive changes in burnout. We further found out that intervention programs which include refresher courses resulted in longer lasting positive effects on burnout [23]. For example a reduction in the burnout component emotional exhaustion lasted over 2 years. However, more long term studies need to be conducted and evaluated in
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order to arrive at more reliable conclusions with regard to refresher courses. Compared to other study designs, the results of randomised control trials did not differ with regard to the duration of positive intervention effects. In all cases, positive intervention effects followed the general trend of reduction over time in the absence of refresher courses. Despite their lower design quality, the results of non-RCTs had followed trends similar to those of RCTS. Effect sizes were stated only in about 20% of all studies. Positive intervention effects still remained significant and stable despite drop outs and group differences did not influence significant results. Thus attrition, though high in some cases, was not selective. Nevertheless, it would have been useful if more studies provided information on effect size for better comparisons. 4.2. Limitations of this review This review was subject to a number of limitations; the search strategy was limited to publications in English and German, thus, potentially relevant studies in other languages were excluded. Only 3 data bases were sought between 1995 and 2007. This meant that relevant studies available elsewhere and published outside this time frame could also have been left out. Furthermore, the hand search of reference lists was unsystematic; as a result, relevant studies could also have been overseen. Additionally, our criteria for selecting studies for this review allowed for the inclusion of a wide range of study designs and thus limiting the direct comparability of results. Some of the studies analyzed also did not provide relevant information about study design, intervention duration, or post-test intervals. Moreover, an evaluation of the quality of individual study methodology was also not conducted. We compared the results of burnout intervention studies which used different types of participants, settings, intervention durations and ingredients; using the outcome ‘burnout’ as a common denominator. Therefore our results suggest trends and identify potential areas for further research. 4.3. Implications for further research and practice This review shows that burnout intervention programs are beneficial. People who take part in burnout intervention program(s) generally experience less burnout than their counterparts who do not. Therefore properly planned intervention programs, which include aspects of both person- and organization-directed prevention measures, are expected to positively influence burnout and worksite mental health. Positive effects can be enhanced by refresher courses at appropriate intervals after the end of the program. Even though many studies have examined risk factors for burnout, only relatively few prevention programs have been conducted and even fewer have been evaluated. This may partly be due to the difficulties associated with implementing such programs, especially organization-directed interventions [46,47]. Therefore better designed and evaluated controlled trials (RCT or CTs), with comparable participants, appropriate baseline and at least two post-intervention measurements points (preferably up to 1 year) are needed in order that more reliable conclusions can be arrived at. Many of the studies analyzed in this review had small sample sizes, high dropout rates as well as short intervention and follow-up durations. Future interventions should work against such limiting factors in order to improve on the integrity of results and conclusions. It was also apparent that intervention programs could be counterproductive [36]. To avoid this, program design and implementation should take specific needs of participants into consideration.
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