Walden University Burnout in the Workplace Discussion Wellness Strategies for Burnout Prevention Burnout is one of the most significant threats to the ability of human services professionals in effectively helping clients cope with crisis. It is a pernicious and rampant force within all helping professions, and the human services field—especially the specialties of crisis and intervention—is no exception. Crisis intervention work is intrinsically stressful. In the course of their crisis work, human services professionals inevitably encounter situations and circumstances that are shocking, horrific, heartbreaking, and/or tragic. Although human services professionals are trained to deal with these events, they nevertheless take a toll—sometimes an extreme one. Compounding the difficulties of the profession are organizational issues. Human services professionals often work within larger agencies and infrastructures. Issues such as bureaucracy, poor leadership, inadequate compensation, and lack of community or fairness can cause frustration, dissatisfaction, and apathy—all contributing factors to burnout. As a result, it is essential that human services professionals working in crisis and intervention are proactive in burnout prevention. Wellness strategies are methods, practices, or processes that human services professionals can implement to make it more likely that they will maintain their mental and physical health while working in challenging situations. By developing and implementing wellness strategies, human services professionals can help reduce the risk of burnout. The bottom line is this: in order to effectively take care of others, human services professionals also must take care of themselves. To prepare for this Discussion:
· Crisis Intervention Strategies, focusing on the contributing factors to burnout within the human services profession. Also pay particular attention to the various intervention strategies, often referred to as wellness strategies, which are outlined.
· Review the article, “The Contribution of the Psychosocial Work Environment to Sickness Absence in Human Service Workers: Results of a 3-Year Follow-Up Study,” focusing on how certain psychosocial work characteristics could be adjusted to minimize the incidence of burnout, given the results of the study.
· Review the article, “Burnout Among Employees in Human Service Work: Design and Baseline Findings of the PUMA Study,” paying particular attention to the contributors to burnout identified in the theoretical framework of the PUMA study.
· Review the article, “Emotional Exhaustion and Turnover Intention in Human Service Occupations: The Protective Role of Coworker Support,” noting the benefits of coworker support and how they reduce the risk of burnout within the human services workplace.
· Consider the factors that might contribute to burnout when doing crisis and intervention work. Then, reflect on the wellness (intervention) strategies a human services professional might implement to maintain his or her wellness and reduce the risk of burnout.
With these thoughts in mind: Post a brief description of at least three specific factors that might lead to burnout when doing work in crisis and intervention. Then, describe at least three wellness (intervention) strategies human services professionals and/or the organizations for which they work might implement to prevent burnout. Explain why these strategies might be effective. Be specific. ORIGINAL ARTICLE
Burnout among employees in human service work: design and baseline findings of the PUMA study
MARIANNE BORRITZ1,2, REINER RUGULIES1, JAKOB B. BJORNER1,3, EBBE VILLADSEN1, OLE A.
MIKKELSEN1 & TAGE S. KRISTENSEN1
1National Institute of Occupational Health, Denmark, 2Department of Occupational Medicine,
Bispebjerg Hospital, Copenhagen, Denmark, and 3Quality Metric Incorporated, Lincoln, RI, USA
Abstract Aim: To present the theoretical framework, design, methods, and baseline findings of the first
Danish study on determinants and consequences of burnout, and the impact of workplace interventions
in human service work organizations. Method: A 5-year prospective intervention study comprising 2,391
employees from different organizations in the human service sector: social security offices, psychiatric
prison, institutions for severely disabled, hospitals, and homecare services. Data were collected at
baseline and at two follow-ups. The authors developed a new burnout tool (the Copenhagen Burnout
Inventory) covering workrelated, client-related, and personal burnout. The study includes potential
determinants of burnout (e.g. the psychosocial work environment, social relations outside work, lifestyle
factors, and personality aspects) and consequences of burnout (e.g. poor health, low job satisfaction,
turnover, and absenteeism). Here, the focus is on the description of the study population at baseline,
workburnoutwithpsychosocialworkenvironmentscalesandabsence.Results:Response rate atbaseline was
80.1%. Midwives and homecare workers had high levels on both work- and client-related burnout.
Prison officers had the highest level on client-related burnout. Supervisors and office assistants had low
levels on both scales. Work burnout showed the highest correlations with job satisfaction (r520.51),
quantitative demands (r50.48), role-conflicts (r50.44), and emotional demands (r50.42). Sickness
absence was 13.9 vs 6.0 days among participants in the highest and lowest work burnout quartile,
respectively. Conclusion: Thefindings indicate thatstudy design and methodsare adequate for the
upcoming prospective analyses of aetiology and consequences of burnout and of the impact of
Key Words: Burnout, Copenhagen Burnout Inventory, exhaustion, human service work, intervention
study, occupational health, prospective study, psychosocial factors
During the mid-1990s Danish unions in the human service sector recognized that an increasing number
of their members took long-term sick leave, or applied for retraining or early retirement, because of
burnout symptoms. Although Denmark has one of the largest numbers of employees working in the
human service sector in the Western world no major study on burnout had been conducted in Denmark.
For these reasons, we designed the study on Burnout, Motivation and Job satisfaction (Danish acronym:
PUMA), a five-year prospective intervention
study on burnout in the human service sector. The study has four aims: (1) to map the extent of burnout
among different occupational groups in the human service sector in Denmark; (2) to identify individual
and workplace factors that increase the risk of burnout; (3) to analyse the impact of burnout on job
satisfaction, job turnover, absenteeism, early retirement, morbidity, and mortality; and (4) to evaluate
whether workplace interventions that aim to improve the psychosocial work environment can reduce
burnout and its repercussions. Burnout is a concept developed in practice. It first emerged in the United
States in the mid-1970s when
Correspondence: Marianne Borritz, National Institute of Occupational Health, Denmark, Lersø Parkalle´
105, DK-2100 Copenhagen Ø, Denmark. Tel: +45 39 16 52 87. Fax: +45 39 16 52 01. E-mail: firstname.lastname@example.org
(Accepted 17 February 2005)
Scandinavian Journal of Public Health, 2006; 34: 49–58
ISSN 1403-4948 print/ISSN 1651-1905 online/06/010049-10 # 2006 Taylor & Francis DOI:
two researchers, Herbert Freudenberger and Christina Maslach, independently described burnout as a
negative consequence of human service work, characterized by emotional exhaustion, loss of energy,
and withdrawal from work [1–11]. In the pilot phase of the PUMA study we tested the Maslach Burnout
Inventory (MBI) but did not find it satisfactory . First, the respondents strongly criticized a number of
the questions. Hence, we did not find the questionnaire usable in the Danish context. Second, the
questionnaire is restricted to use among employees working with recipients (clients). Third, the burnout
concept of the MBI consists of three parts of which one can be regarded as a coping strategy
(depersonalization) and another as a consequence of burnout (reduced personal accomplishment).
Fourth, the MBI defines burnout as a reaction that only takes place among people who do ‘‘people
work’’, which leads to a circular argument. In the PUMA study we wanted to focus on exhaustion as the
core element of burnout. In order to do this, we developed our own instrument, the Copenhagen
Burnout Inventory (CBI), that focuses on exhaustion. We distinguish between three different types of
exhaustion: personal burnout, work-related burnout, and client-related burnout. A detailed description
of the CBI is given in the method section of this paper, and a manuscript with a detailed comparison of
the CBI burnout concept with the burnout concept of other researchers is in preparation. In PUMA, we
are focusing on the specific type of human service work called ‘‘client work’’. In our basic understanding
of working with humans we distinguish between three categories: clients, customers, and colleagues.
Clients can be social service recipients, patients, elderly citizens, pupils, or inmates. The basic relation to
the client is professional, and the employee is acting on behalf of society in order to bring about a
change in the client (to become healthy, more educated, less criminal, etc.) . Customers are buying a
commodity on the market. Relations with customers are commercial and usually much shorter and less
emotionally involving for the employee. Finally, we use the term colleagues to describe all employees at
the worksite with whom the person has interaction (including supervisors and subordinates). Relations
with colleagues can be emotionally involving and long lasting but also superficial and short.
Unfortunately, the international literature on burnout rarely distinguishes between clients and
customers [8,13]. Since the 1980s, more than 5,500 studies on burnout have been published . Most
studies indicate that burnout is a serious problem. In
Sweden and Finland population-based studies found severe burnout in 5–7% of the workforce [14,15].
In the Netherlands researchers estimated that 3–16% of Dutch human service work professionals have
severe burnout . Research indicates that work-related factors such as high demands and low
influence, low social support, and low role-clarity increase the risk of burnout . Factors outside work
that need to be considered are social relations and personality . However, knowledge about causality
is still limited, because most studies are cross-sectional and therefore do not allow causal inference. The
relatively few prospective studies often involved participants from only one occupational group, which
results in low variation of exposure and therefore limits the ability to analyse causal associations.
Moreover, most prospective studies covered only one year or less of follow-up, included few
participants, or had low response rates [4,8]. Burnout, however, is associated with risk of absenteeism,
sick leave and disability claims, as well as low job satisfaction, and high job turnover [8,14]. Figure 1
shows the theoretical framework of PUMA regarding the determinants and consequences of burnout.
The framework is based on both extensive reviews of the literature and on discussions with focus
groups, employers, and employees’ representatives. We hypothesize that the psychosocial work
environment plays a major role in the onset of burnout (see Figure 1). Because working with clients is a
core characteristic of human service work [12,13], we differentiate the psychosocial work environment
in client-related and nonclient-related factors. Client-related factors include emotional demands and
demands for hiding emotions at work. This also covers situations where focus is solely on helping the
client and when focus is on both help and control, e.g. in a psychiatric hospital . Non-client-related
factors are psychosocial exposures often measured in work and health research, such as quantitative
demands, influence in the workplace, or social support from supervisors and colleagues .
Interestingly, although the relation of burnout to client work is widely acknowledged, most burnout
studies have focused on these general psychosocial exposures, whereas only a few studies have
explicitly addressed client-related factors . In addition to psychosocial work environment factors,
sociodemographic characteristics of the employees (e.g. age, sex, and cohabitant status), social relations
outside the workplace, lifestyle (e.g. smoking and alcohol consumption), and personality aspects may
influence the risk of burnout. These
50 M. Borritz et al.
factors could act independently, but could also interact or mediate each other’s effect. Potential
consequences of burnout (Arrow B) are job dissatisfaction, job turnover, absenteeism, and early
retirement, and possibly morbidity and mortality. As with the determinants, the consequences might be
interrelated. For example, poor health will probably increase absenteeism from work and early
retirement. Whereas the main interest of PUMA is to analyse the determinants and consequences of
burnout, we acknowledge that not all causal associations in the figure are uni-directional. It is possible
that burnout influences some of the variables we plan to analyse as determinants (Arrow C). For
example, high levels of burnout may lead to changes in workplace characteristics, such as an increase in
part-time employment or a decrease in the amount of time working with clients. Conversely, some
consequences might also influence burnout (Arrow D). For example, quitting a highly demanding job and
getting a less demanding job (job turnover) could result in a decreasing level of burnout. These issues of
bidirectionality and reciprocal effects need to be addressed in the data analyses. We are able to do this
because PUMA is a prospective study with a full-panel design, including three measurement times
(baseline, three-year follow-up, five-year follow-up) at which both potential predictors and potential
consequences of burnout are measured. This will enable us to disentangle uni-directional and bidirectional (reciprocal) effects of the variables we regard as potential ‘‘determinants’’ and ‘‘outcomes’’.
In this first paper, we describe the design and methods of PUMA and present selected baseline findings
regarding psychosocial work environment, sickness absence, and burnout.
Material and methods
PUMA is designed as a five-year prospective intervention study in different organizations in the human
service sector. All organizations were selfselected to the study after meetings between representatives
from employers’ and employees’ organizations and the PUMA project group. Criteria for inclusion were
(1) the organizations should represent different areas within the human service sector; (2) the size of
the organization should be between 200 and 500 employees; (3) all occupational groups within each
organization should be willing to participate; (4) the organizations should commit themselves to the
entire five-year study period and (5) personal registration numbers (national identity numbers) of the
employees could be collected and used in later record linkages by the Danish Institute of Occupational
Health, including linkages to Danish registries for hospitalization and mortality
(Hospitalsindlæggelsesregisteret, Dødsa˚rsagsregisteret). Initially, we also had the criterion that the
organizations should agree to implement interventions after the collection of baseline data, but neither
employers nor employees were willing to commit themselves in advance. However, it was agreed that
the organizations should receive the survey results after each round and establish project committees to
review and discuss the findings. Based on the survey results and the work in the committees, the
organizations could develop and implement interventions. PUMA therefore is a quasi-experimental
study, in which the feedback of the survey results could initiate ad-hoc interventions. Type,
implementation, and conduct of these interventions will be
Figure 1. Theoretical framework of the PUMA study.
Burnout among employees in human service work 51
evaluated through separate telephone interviews with key informants and questionnaires to all
participants at later stages of the PUMA study. The impact of the interventions on working conditions,
burnout, and health outcomes will be analysed both at the individual level and at the workplace level.
Seven different organizations within the human service sector participated in the study: (1) 10 social
security offices in an urban area; (2) a state psychiatric prison; (3) 16 county institutions for severely
disabled people; (4) three somatic wards (surgical, medical, gynaecological-obstetric) from two county
hospitals; (5) one psychiatric ward from a psychiatric hospital; (6) one homecare service in a rural area;
and (7) one homecare service in an urban area. All occupational groups in each organization were
invited to join the study, resulting in 2,391 eligible employees. At baseline, 1,914 employees participated
in the survey, yielding a response rate of 80.1%. The Danish Data Protection Agency (Datatilsynet) and
Scientific Ethical Committees (Videnskabsetisk Komite´) in the respective counties have given approval
for the PUMA study.
Data were collected in 1999–2000 (baseline) and in 2002–03 (first follow-up). A third round of data
collection is planned in 2005 (second follow-up). Therefore, PUMA consists of three cross-sectional
samples and one prospective cohort (baseline participants followed up over time). All rounds have the
same sampling procedure: we obtained the home address of all employees from the participating
workplaces and then sent an invitation letter from the organization together with a study description
and the survey questionnaire. We contacted the project committee at worksites with low response rates
to find the reasons for low participation and to help improve employers’ and employees’ commitment
to the study. Employees who left the cohort after baseline or first follow-up assessment will get a special
questionnaire in the 2004–05 follow-up to assess their current connection to the labour market.
Employees who entered the workforce in the organizations after the baseline assessment were eligible
for participation in the follow-up surveys (open cohort principle).
Measurements in PUMA were mainly based on selfreported questionnaires. In accordance with the
theoretical framework presented in Figure 1, we measured burnout, its potential determinants, and its
Burnout. Burnout was measured with the Copenhagen Burnout Inventory (CBI), an instrument
specifically developed for PUMA [18,19]. The CBI focuses on exhaustion and is divided into three scales.
Personal burnout contains six items on general symptoms of exhaustion and is applicable to every
person, regardless of whether the person is a member of the workforce or not. Work-related burnout
comprises seven items on symptoms of exhaustion related to work and applies to every person in the
workforce. Clientrelated burnout is based on six items on symptoms of exhaustion related to working
with recipients in human services and is applicable only to people who work with clients. All items have
five response categories. The responses are rescaled to a 0–100 metric (the values being 0–25–50–75–
100). Scale scores are calculated by taking the mean of the items in that scale. A full list of all burnout
items – together with the response frequencies and Cronbach’s alphas for the scales – is provided in the
Non-client-related psychosocial work environment factors. In accordance with the theoretical
framework in Figure 1, we distinguished between client-related and non-client-related psychosocial
work environment factors. Non-client-related factors were measured with scales from the Copenhagen
Psychosocial Questionnaire (COPSOQ), a comprehensive and validated instrument on work and health
[20–22]. Among other things, the COPSOQ includes scales on well-established psychosocial workplace
factors such as demands, control, and social support at work . We used a total of 16 scales: two
scales on demands (quantitative demands, cognitive demands), five scales on active and developmental
work (influence, possibilities for development, meaning of work, commitment to the workplace, and
quality of leadership), seven scales on interpersonal relations at work
(feedback,predictability,roleclarity,role conflict, social support at work, social relations, and sense of
community), one scale on job insecurity, and one scale on job satisfaction. A complete list of all scales,
including their correlations with work burnout, is presented in the results section.
52 M. Borritz et al.
Client-related psychosocial work environment factors. Client-related factors were assessed with scales
on emotional demands and demands for hiding emotions from the COPSOQ, single items with specific
questions about working with clients, and one proxy measure about types of client. The single items
were developed de novo for the PUMA study to obtain more detailed information on the daily work
with clients: (1) frequency of client contact was measured with the question ‘‘How much contact do you
have on average with clients during the working week?’’), with the four response categories ‘‘almost all
the working time’’, ‘‘more than half the working time’’, ‘‘less than half the working time’’, and
‘‘never/almost never’’; (2) demands from clients were measured with the question ‘‘The demands are
many in the xxx sector. How do you experience these demands?’’, with seven response options ranging
from ‘‘very low demands’’ to ‘‘very high demands’’; (3) increasing demands from clients was measured
with the question ‘‘Do you experience that the clients in general have become more demanding during
the last few years?’’, with five response categories ranging from ‘‘to a very high degree’’ to ‘‘to a very
low degree’’; (4) rewards from clients was measured with the question ‘‘Do you feel that your work is
appreciated by the clients?’’, with five response categories ranging from ‘‘always’’ to ‘‘never’’; and (5)
violence and threats from clients was measured by asking the participants to list the number of these
occurrences during the last 12 months. Finally, we used the type of organization (prison, hospital, social
security office etc.) as a proxy measure for the type of client that the participants are exposed to.
Other workplace characteristics. We collected data on other workplace characteristics, such as the type
of department or institution, job title, seniority, and number of working hours per week of the
participants and work shift arrangement.
Sociodemographic factors. We assessed age, sex, education, cohabitant status, number and age of
children living at home.
Social relationships outside the workplace. We measured soc…
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