The conceptualization and measurement of burnout: Questions and directions

Towards a new approach to job-related distress: A three-sample study of the Occupational Depression Inventory

The Occupational Depression Inventory (ODI) was recently developed to assess depressive symptoms that individuals specifically attribute to their work. One purpose of the ODI is to respond to limitations of current assessments of job-related distress, most notably, assessments relying on the burnout construct. In this study, we conducted a thorough examination of the psychometric and structural properties of the ODI using exploratory structural equation modelling bifactor analysis and Mokken scale analysis. The study involved three samples of employed individuals, recruited in France (N = 3454), Switzerland (N = 1971), and Australia (N = 1485). Results were consistent across the three samples. The ODI exhibited essential unidimensionality and excellent total-score reliability-as indexed by McDonald's omega, Cronbach's alpha, Guttman's lambda-2, and the Molenaar-Sijtsma statistic. We found evidence for measurement invariance across sexes, age groups, and samples. Mokken scale analysis revealed that the ODI's scalability was strong. No monotonicity violation was detected. Invariant item ordering showed sufficient accuracy. In all three samples, suicidal ideation was the least commonly endorsed item-thus acting as a sentinel item-and fatigue/loss of energy was the most commonly endorsed item. The ODI exhibits excellent psychometric and structural properties, suggesting that occupational health specialists can effectively employ the instrument.

The Mediator Role of Feelings of Guilt in the Process of Burnout and Psychosomatic Disorders: A Cross-Cultural Study

Burnout was recently declared by WHO as an “occupational phenomenon” in the International Classification of Diseases 11th revision (ICD-11), recognizing burnout as a serious health issue. Earlier studies have shown that feelings of guilt appear to be involved in the burnout process. However, the exact nature of the relationships among burnout, guilt and psychosomatic disorders remains unclear. The purpose of this study was to investigate the mediator role of feelings of guilt in the relationship between burnout and psychosomatic disorders, and perform a cross-cultural validation of the multi-dimensional model by Gil-Monte in two samples of teachers (Portuguese vs. Spanish). The study sample was composed of 1,266 teachers, 1,062 from Spain, and 204 from Portugal. Burnout was measured by the Spanish Burnout Inventory. Hypotheses were tested together in a path model. The results obtained provide empirical evidence for the mediator role of guilt in the relationship between the Burnout syndrome and psychosomatic disorders in the sample of teachers from Spain and Portugal, and they contribute to the empirical validation of the model by Gil-Monte. The results indicate that guilt should be incorporated as a symptom of burnout in order to identify individuals affected by burnout and profiles or types of burnout to differentiate it from other pathologies like depression.

Role of NR3C1 and SLC6A4 methylation in the HPA axis regulation in burnout

BACKGROUND

Work-related stress and burnout have become major occupational health concerns. Dysregulation of HPA axis is considered one of the central mechanisms and is potentially moderated through epigenetics. In the present study, we aim to investigate epigenetic regulation of the HPA axis in burnout, by focusing on salivary cortisol and cortisone and DNA methylation of the glucocorticoid receptor gene (NR3C1) and the serotonin transporter gene (SLC6A4).

METHODS

We conducted a cross-sectional study with 59 subjects with burnout and 70 healthy controls recruited from the general population. All participants underwent a clinical interview and psychological assessment. Saliva samples were collected at 0, 30 and 60 min after awakening and were used to quantify cortisol and cortisone. Pyrosequencing was performed on whole blood-derived DNA to assess DNA methylation.

RESULTS

There were no between-group differences in cortisol levels, whereas burnout participants had higher levels of cortisone. Job stress was associated with increased cortisol and cortisone. We observed both increased and decreased NR3C1 and SLC6A4 methylation in the burnout group compared to the control group. Some of these methylation changes correlated with burnout symptoms dimensionally. Increased methylation in a specific CpG in the SLC6A4 promoter region moderated the association between job stress and burnout. DNA methylation in this CpG was also associated with increased cortisol. In addition, average methylation of NR3C1 was negatively associated with cortisone levels.

LIMITATIONS

This is a cross-sectional study and therefore no conclusions on causality could be made.

CONCLUSIONS

We provide first evidence of changes in DNA methylation of NR3C1 and SLC6A4 in burnout, which were further associated with cortisol and cortisone. Further, increased cortisol and cortisone seemed to reflect job stress rather than burnout itself.

Burnout: Redefining its key symptoms

Burnout is currently operationalised as comprising of exhaustion, depersonalization and reduced personal accomplishment. However, questions have been raised as to whether this three-factor model accurately characterises the syndrome. We therefore sought to re-examine burnout's key symptoms and to develop a new model of the syndrome. 622 participants who self-identified as experiencing burnout completed a questionnaire covering a large item set of candidate burnout symptoms. Bifactor modelling identified a 34-item general factor that was dominated by items capturing exhaustion and cognitive dysfunction, but which also included items indicative of decreased work performance, insularity and a depressed mood. Five specific factors capturing additional data variance were identified and were interpreted as representing cognitive impairment, empathy loss, exhaustion, compromised work performance, and social withdrawal. Reliability indices indicated that the general factor alone accounted for most of the variance in observed scale scores for each specific factor, except for the loss of empathy specific factor. We concluded that burnout may therefore potentially be modelled as a unidimensional construct comprising exhaustion, cognitive impairment, compromised work performance, empathy loss and social withdrawal. Further, while those with burnout are likely to experience depressive symptoms, their presence is not of necessity indicative of clinical depression.

The influence of maladaptive coping modes, resilience, and job demands on emotional exhaustion in psychologists

Although it is well established that emotion-focused coping is associated with burnout, the schema therapy model may improve the prediction of who is most vulnerable to using emotion-focused coping and what kinds of emotion-focused coping carry the greatest risk of burnout. It is also unknown the extent to which resilience might buffer against maladaptive coping in protecting against burnout. The present study investigated whether maladaptive coping modes would incrementally predict emotional exhaustion (EE) adjusting for resilience and whether resilience might moderate the effect of maladaptive coping on EE. The possible role of maladaptive coping as a mediator of job demands on EE was also explored. Four hundred and forty-three clinical and counselling psychologists completed online measures of job demands, EE, resilience, and maladaptive coping modes. The Detached Protector mode was associated with greater EE after adjusting for resilience. Bully and Attack mode was associated with greater EE when considered separately from other coping modes but associated with decreased EE when considered together. Resilience did not moderate the effect of job demands on EE, or the effect of coping modes on EE, except for Compliant Surrenderer. Coping modes only partially mediated the effect of job demands on EE accounting for 20% or less of its effect. Maladaptive coping modes appear to make independent contributions to the risk of EE and efforts to reduce burnout in psychologists should focus dually on increasing resilience-building practices and decreasing maladaptive coping.

A Qualitative Reexamination of the Key Features of Burnout

Burnout is generally defined as a triad of emotional exhaustion, lack of empathy, and reduced professional accomplishment constructs. We sought to determine in an exploratory, qualitative study whether these three constructs adequately represent burnout. Participants who self-identified as experiencing burnout completed a questionnaire that asked about their experiences of the condition. A qualitative thematic analysis was undertaken to determine the primary symptom constructs nominated by participants. The thematic analysis resulted in 12 symptom clusters or "themes" being identified as putative burnout features, with several of these themes overlapping with features identified in our independent quantitative analysis. Although we found emotional exhaustion, lack of empathy, and reduced professional accomplishment to be commonly nominated symptoms of burnout, the distinctive presence of several additional themes suggests that the burnout syndrome comprises a broader set of symptom constructs than those currently accepted as the defining features of the condition.

Frenetic, under-Challenged, and Worn-out Burnout Subtypes among Brazilian Primary Care Personnel: Validation of the Brazilian "Burnout Clinical Subtype Questionnaire" (BCSQ-36/BCSQ-12)

Primary healthcare personnel show high levels of burnout. A new model of burnout has been developed to distinguish three subtypes: frenetic, under-challenged, and worn-out, which are characterized as overwhelmed, under-stimulated, and disengaged at work, respectively. The aim of this study was to assess the psychometric properties of the long/short Brazilian versions of the "Burnout Clinical Subtypes Questionnaire" (BCSQ-36/BCSQ-12) among Brazilian primary healthcare staff and its possible associations with other psychological health-related outcomes. An online cross-sectional study conducted among 407 Brazilian primary healthcare personnel was developed. Participants answered a Brazil-specific survey including the BCSQ-36/BCSQ-12, "Maslach Burnout Inventory-General Survey", "Utrecht Work Engagement Scale", "Hospital Anxiety/Depression Scale", "Positive-Negative Affect Schedule", and a Visual Analogue Scale of guilt at work. The bifactor was the model with the best fit to the data using the BCSQ-36, which allowed a general factor for each subtype. The three-correlated factors model fit better to the BCSQ-12. Internal consistence was appropriate, and the convergence between the long-short versions was high. The pattern of relationships between the burnout subtypes and the psychological outcomes suggested a progressive deterioration from the frenetic to the under-challenged and worn-out. In sum, the Brazilian BCSQ-36/BCSQ-12 showed appropriate psychometrics to be used in primary healthcare personnel.

A five-sample confirmatory factor analytic study of burnout-depression overlap

OBJECTIVE

It has been asserted that burnout-a condition ascribed to unresolvable job stress-should not be mistaken for a depressive syndrome. In this confirmatory factor analytic study, the validity of this assertion was examined.

METHODS

Five samples of employed individuals, recruited in Switzerland and France, were mobilized for this study (N = 3,113). Burnout symptoms were assessed with the Shirom-Melamed Burnout Measure, the Maslach Burnout Inventory (MBI)-General Survey, and the MBI for Educators. Depressive symptoms were measured with the PHQ-9.

RESULTS

In all five samples, the latent factors pertaining to burnout's components correlated on average more highly with the latent Depression factor than with each other, even with fatigue-related items removed from the PHQ-9. Second-order factor analyses indicated that the latent Depression factor and the latent factors pertaining to burnout's components were reflective of the same overarching factor.

CONCLUSIONS

This study suggests that the burnout-depression distinction is artificial.

Psychophysiological concomitants of burnout: Evidence for different subtypes

BACKGROUND

There is evidence that chronic stress and emotional exhaustion are related to physiological dysregulations, which could negatively impact physical and mental health. This study aimed to identify the specific physiological clusters which are most reliable and prominently associated with burnout. Emphasis was placed on variables of the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Burnout was assessed using the Emotional Exhaustion subscale of the German version of the Maslach Burnout Inventory (MBI-GS).

METHODS

A sample of 105 individuals aged between 28 and 60 years (M = 42.7, SD = 7.75) and working under highly demanding conditions participated in this study. 46 participants reported a low risk of burnout, and 58 participants a high risk. They underwent 24 h of ECG monitoring, had cortisol awakening response collected, and had blood pressure measured two times within a week.

RESULTS

Compromised HRV, higher cortisol values, and higher blood pressure were found in individuals with high burnout symptoms. Furthermore, a discriminant function analysis on cardiac and neuroendocrine variables suggested two subgroups within the high burnout individuals, with only one group showing evidence for autonomic dysfunction as indicated by lower vagal efference.

CONCLUSIONS

Results suggest that burnout might not necessarily imply physiological disturbances, thus calling for a more differentiated and individualized view of burnout.

[Oldenburg Burnout Inventory - validation of a new way to measure Burnout in Brazil]

This study sought to validate the Oldenburg Burnout Inventory (OLBI) measurement scale in Brazil. The methodology included data collection through a quantitative survey with 273 people. Structural equation modeling was used for data analysis. The scale was validated after being subjected to all statistical assumptions, reducing the original 16 to 13 variables resulting in an enhanced measurement capacity of the Burnout syndrome than the original scale. This study contributes a scale adapted to Brazil to study the health of the worker, since it provides a way to measure a syndrome responsible for problems of various types, with impacts both inside and outside organizations.

New Perspectives on Burnout: A Controlled Study on Movement Analysis of Burnout Patients

Introduction: Despite extensive research on burnout, there has been to date no systematic movement analysis of burnout patients, although it is well known that psychiatric diseases express themselves through movements, such as psychomotor retardation or agitation. Since the movement expression of burnout patients has not been systematically investigated so far, the aim of this study is to close this knowledge gap in order to obtain a new perspective on burnout. Methods: Hospitalized burnout patients (n = 22; age 47.2 ± 9.1 years) and health controls (n = 20; age 41.5 ± 15.0 years) participated in a standardized movement sequence with verbal instructions. The objective Burnout Inventory Scale and diagnostics by psychiatrists were used for diagnosis. Two certified movement-analysts independently rated each participant via video by using the Effort System of Laban Movement Analysis as an instrument of dance therapy and behavior observation. Cohen's Kappa was used to test the inter-rater reliability of the movement analysts and non-parametric Mann-Whitney U tests were undertaken to assess the differences between the two groups. Results: The rater-agreement Kappa ranges from 0.66 to 0.92 (p < 0.001) with the Confidence Interval (95%) from 0.46 to 1.1. Results of the Mann-Whitney U tests indicate that burnout patients show significantly less frequent movements for the following Effort elements: Bound U(n1 = 22, n2 = 20) = 112.5, p = 0.001; Indirect U(n1 = 22, n2 = 20) = 114.5, p = 0.001; Light U(n1 = 22, n2 = 20) = 115, p = 0.001 and Sustained U(n1 = 22, n2 = 20) = 130, p = 0.01. Discussion: Burnout patients have significant deficits in all four Effort elements of the Laban Movement Analysis (Flow, Space, Time, Weight) and therefore have deficits regarding their body movement. The findings presented here provide an additional perspective on burnout.

Burnout and Depression: Two Entities or One?

OBJECTIVES

The purpose of this study was to examine the overlap in burnout and depression.

METHOD

The sample comprised 1,386 schoolteachers (mean [M]age = 43; Myears taught = 15; 77% women) from 18 different U.S. states. We assessed burnout, using the Shirom-Melamed Burnout Measure, and depression, using the depression module of the Patient Health Questionnaire.

RESULTS

Treated dimensionally, burnout and depressive symptoms were strongly correlated (.77; disattenuated correlation, .84). Burnout and depressive symptoms were similarly correlated with each of 3 stress-related factors, stressful life events, job adversity, and workplace support. In categorical analyses, 86% of the teachers identified as burned out met criteria for a provisional diagnosis of depression. Exploratory analyses revealed a link between burnout and anxiety.

CONCLUSIONS

This study provides evidence that past research has underestimated burnout-depression overlap. The state of burnout is likely to be a form of depression. Given the magnitude of burnout-depression overlap, treatments for depression may help workers identified as "burned out."

Is it Time to Consider the "Burnout Syndrome" A Distinct Illness?

The "burnout syndrome" has been defined as a combination of emotional exhaustion, depersonalization, and reduced personal accomplishment caused by chronic occupational stress. Although there has been increasing medical interest in burnout over the last decades, it is argued in this paper that the syndrome cannot be elevated to the status of diagnostic category, based on (1) an analysis of the genesis of the burnout construct, (2) a review of the latest literature on burnout-depression overlap, (3) a questioning of the three-dimensional structure of the burnout syndrome, and (4) a critical examination of the notion that burnout is singularized by its job-related character. It turns out that the burnout construct is built on a fragile foundation, both from a clinical and a theoretical standpoint. The current state of science suggests that burnout is a form of depression rather than a differentiated type of pathology. The inclusion of burnout in future disorder classifications is therefore unwarranted. The focus of public health policies dedicated to the management of "burnout" should not be narrowed to the three definitional components of the syndrome but consider its depressive core.

Is burnout separable from depression in cluster analysis? A longitudinal study

PURPOSE

Whether burnout and depression represent distinct pathologies is unclear. The aim of this study was to examine whether burnout and depressive symptoms manifest themselves separately from each other or are so closely intertwined as to reflect the same phenomenon.

METHODS

A two-wave longitudinal study involving 627 French schoolteachers (73 % female) was conducted. Burnout was assessed with the Maslach Burnout Inventory and depression with the 9-item depression module of the Patient Health Questionnaire.

RESULTS

Burnout and depressive symptoms clustered both at baseline and follow-up. Cluster membership at time 1 (T1) predicted cases of burnout and depression at time 2 (T2), controlling for gender, age, length of employment, lifetime history of depression, and antidepressant intake. Changes in burnout and depressive symptoms from T1 to T2 were found to overlap. Teachers with increasing burnout experienced increases in depression and teachers with decreasing burnout experienced decreases in depression. In addition, emotional exhaustion, the core of burnout, was more strongly associated with depression than with depersonalization, the second dimension of burnout, underlining an inconsistency in the conceptualization of the burnout syndrome.

CONCLUSIONS

Our results are consistent with recent findings showing qualitative and quantitative symptom overlap of burnout with depression. The close interconnection of burnout and depression questions the relevance of a nosological distinction between the two entities. Emotional exhaustion and depersonalization, the two main dimensions of burnout, may be better conceptualized as depressive responses to adverse occupational environments than as components of a separate entity.

Burnout-depression overlap: a review

Whether burnout is a form of depression or a distinct phenomenon is an object of controversy. The aim of the present article was to provide an up-to-date review of the literature dedicated to the question of burnout-depression overlap. A systematic literature search was carried out in PubMed, PsycINFO, and IngentaConnect. A total of 92 studies were identified as informing the issue of burnout-depression overlap. The current state of the art suggests that the distinction between burnout and depression is conceptually fragile. It is notably unclear how the state of burnout (i.e., the end stage of the burnout process) is conceived to differ from clinical depression. Empirically, evidence for the distinctiveness of the burnout phenomenon has been inconsistent, with the most recent studies casting doubt on that distinctiveness. The absence of consensual diagnostic criteria for burnout and burnout research's insufficient consideration of the heterogeneity of depressive disorders constitute major obstacles to the resolution of the raised issue. In conclusion, the epistemic status of the seminal, field-dominating definition of burnout is questioned. It is suggested that systematic clinical observation should be given a central place in future research on burnout-depression overlap.

Is burnout solely job-related? A critical comment

Within the field-dominating, multidimensional theory of burnout, burnout is viewed as a work-specific condition. As a consequence, the burnout syndrome cannot be investigated outside of the occupational domain. In the present paper, this restrictive view of burnout's scope is criticized and a rationale to decide between a work-specific and a generic approach to burnout is presented. First, the idea that a multidimensional conception of burnout implies a work-restricted scope is deconstructed. Second, it is shown that the burnout phenomenon cannot be confined to work because chronic, unresolvable stress - the putative cause of burnout - is not limited to work. In support of an integrative view of health, it is concluded that the field-dominating, multidimensional theory of burnout should abandon as groundless the idea that burnout is a specifically job-related phenomenon and define burnout as a multi-domain syndrome. The shift from a work-specific to a generic approach would allow both finer analysis and wider synthesis in research on chronic stress and burnout.

Operationalizing burnout in the Maslach Burnout Inventory–Student Survey: personal efficacy versus personal inefficacy

Burnout is conceptualized and measured as a three-dimensional construct consisting of emotional exhaustion, cynicism, and personal efficacy. Research suggests that the personal efficacy scale be replaced by a personal inefficacy scale. The purpose of this study was to explore (a) differences in the general factor saturation of the Maslach Burnout Inventory–Student Survey when efficacy or inefficacy items are included, (b) the strength of the correlations of the efficacy versus inefficacy scales with emotional exhaustion and depersonalization, and (c) the reliabilities of the different subscales. Two unrestricted maximum likelihood item factor analyses with bifactor rotations were conducted on data collected from 522 South African university students. The results indicate that the inefficacy scale loads more strongly on a general burnout factor than does the efficacy scale, the inefficacy scale correlates more strongly with the exhaustion and cynicism scales, and the inefficacy scale is more reliable than the efficacy scale. Jointly this implies that the inefficacy scale, rather than the efficacy scale, should be used in the measurement of burnout.

Causes of discomfort in the academic workplace and their associations with the different burnout types: a mixed-methodology study

BACKGROUND

Burnout is the result of prolonged workplace exposure to chronic stress factors and may present itself in one of the following subtypes: "frenetic", "under-challenged" and "worn-out". The aims of the present study were to identify the causes of workplace discomfort that affect employees in large organizations and to determine the predictive power of these causes with regard to the burnout subtypes.

METHOD

We employed a qualitative and quantitative analysis (QQA), using a cross-sectional design with an online survey administered to a randomly selected sample of University workers (n = 409). To determine the causes of discomfort, we raised the following open question: "What aspects of your work generate discomfort for you?". The responses were subjected to content analysis and categorized by three independent referees. The concordance between the responses was estimated with the kappa coefficient (k). Subtype classification was assessed according to the "Burnout Clinical Subtype Questionnaire" (BCSQ-36). The degree of association between the motives for the complaint and the burnout profiles was evaluated using adjusted odds ratio (OR), which was based on multivariate logistic regression models.

RESULTS

The causes of discomfort included: physical environment (setting aspects, material conditions, journey/access), organization (schedules, structure, functions, interpersonal relations) and individual conditions (workload, powerlessness, rewards, negligence). The concordance index between the referees was k = 0.80. Employees who were upset with the hierarchical structure were more likely to be classified as frenetic (OR = 4.32; 95% CI = 1.43-13.06; p = 0.010); those who complained of routine duties were more likely to be classified as under-challenged (OR = 5.33; 95% CI = 1.84-15.40; p = 0.002); those whose discomfort was caused by structure control systems were more likely to be classified as worn-out (OR = 6.13; 95% CI = 1.57-23.91; p = 0.009).

CONCLUSIONS

The causes of discomfort among the different burnout subtypes are primarily attributable to the organization itself, in response to the structure and functions. The associations observed between the different subtypes and motives for complaint are consistent with the clinical profile-based syndrome definition, which suggests that interventions should be case-specific.

Comparative symptomatology of burnout and depression

The link between burnout and depression remains unclear. In this study, we compared depressive symptoms in 46 burned-out workers, 46 outpatients experiencing a major depressive episode, and 453 burnout-free workers to test the distinctiveness of burnout as a clinical entity. Participants with burnout and major depressive episode reported similar, severe levels of overall depressive symptoms. The between-syndrome overlap was further verified for eight of the nine major depressive episode diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Our findings do not support the view hypothesizing that burnout and depression are separate entities and question the nosological added value of the burnout construct.

Defining the student burnout construct: a structural analysis from three burnout inventories

College student burnout has been assessed mainly with the Maslach burnout inventory (MBI). However, the construct's definition and measurement with MBI has drawn several criticisms and new inventories have been suggested for the evaluation of the syndrome. A redefinition of the construct of student burnout is proposed by means of a structural equation model, reflecting burnout as a second order factor defined by factors from the MBI-student survey (MBI-SS); the Copenhagen burnout inventory-student survey (CBI-SS) and the Oldenburg burnout inventory-student survey (OLBI-SS). Standardized regression weights from Burnout to Exhaustion and Cynicism from the MBI-SS scale, personal burnout and studies related burnout from the CBI, and exhaustion and disengagement from OLBI, show that these factors are strong manifestations of students' burnout. For college students, the burnout construct is best defined by two dimensions described as "physical and psychological exhaustion" and "cynicism and disengagement".

The effects of midwives' job satisfaction on burnout, intention to quit and turnover: a longitudinal study in Senegal

BACKGROUND

Despite working in a challenging environment plagued by persistent personnel shortages, public sector midwives in Senegal play a key role in tackling maternal mortality. A better understanding of how they are experiencing their work and how it is affecting them is needed in order to better address their needs and incite them to remain in their posts. This study aims to explore their job satisfaction and its effects on their burnout, intention to quit and professional mobility.

METHODS

A cohort of 226 midwives from 22 hospitals across Senegal participated in this longitudinal study. Their job satisfaction was measured from December 2007 to February 2008 using a multifaceted instrument developed in West Africa. Three expected effects were measured two years later: burnout, intention to quit and turnover. Descriptive statistics were reported for the midwives who stayed and left their posts during the study period. A series of multiple regressions investigated the correlations between the nine facets of job satisfaction and each effect variable, while controlling for individual and institutional characteristics.

RESULTS

Despite nearly two thirds (58.9%) of midwives reporting the intention to quit within a year (mainly to pursue new professional training), only 9% annual turnover was found in the study (41/226 over 2 years). Departures were largely voluntary (92%) and entirely domestic. Overall the midwives reported themselves moderately satisfied; least contented with their "remuneration" and "work environment" and most satisfied with the "morale" and "job security" facets of their work. On the three dimensions of the Maslach Burnout Inventory, very high levels of emotional exhaustion (80.0%) and depersonalization (57.8%) were reported, while levels of diminished personal accomplishment were low (12.4%). Burnout was identified in more than half of the sample (55%). Experiencing emotional exhaustion was inversely associated with "remuneration" and "task" satisfaction, actively job searching was associated with being dissatisfied with job "security" and voluntary quitting was associated with dissatisfaction with "continuing education".

CONCLUSIONS

This study found that although midwives seem to be experiencing burnout and unhappiness with their working conditions, they retain a strong sense of confidence and accomplishment in their work. It also suggests that strategies to retain them in their positions and in the profession should emphasize continuing education.

Conceito(s) de burnout: questões atuais da pesquisa e a contribuição da clínica

Considerando o crescente interesse científico no fenômeno burnout, apresentamos uma amostra da diversidade teórica que forma o campo de pesquisa neste tema a partir de algumas questões atuais de discussão sobre o seu conceito. Discutimos aparentes limitações da abordagem empírica à compreensão da natureza conceitual do burnout, apontando uma possível contribuição da clínica (dentro do campo da Psiquiatria) a este debate.

Construção e validação fatorial da Escala de Caracterização do Burnout (ECB)

Este artigo descreve o desenvolvimento da Escala de Caracterização do Burnout (ECB). No primeiro estudo, 375 trabalhadores de enfermagem e do ensino responderam a primeira versão da ECB com 77 itens. Análises fatoriais revelaram os fatores Exaustão Emocional (Alfa = 0,94); Desumanização (Alfa = 0,88), Realização Pessoal (Alfa = 0,76) e Decepção no Trabalho (Alfa = 0,80). No segundo estudo, 787 membros da Policia Civil responderam a segunda versão da ECB com 46 itens. Os resultados de novas análises fatoriais evidenciaram os mesmos três fatores do estudo 1: Exaustão Emocional (Alfa = 0,93); Desumanização (Alfa = 0,84) e Decepção no Trabalho (Alfa = 0,90). Os itens do fator Realização Pessoal, observado no estudo 1, foram incorporados ao fator Decepção no Trabalho. A versão final da ECB apresentou 35 itens. O fator Exaustão Emocional evidenciou a maior consistência interna. Os níveis de consistência interna dos outros dois fatores superaram índices apresentados por outras medidas de burnout.

Association between burnout and circulating levels of pro- and anti-inflammatory cytokines in schoolteachers

OBJECTIVE

The burnout syndrome has been associated with an increased risk of cardiovascular disease. The physiological mechanisms potentially involved in this link are underexplored. Knowing that a chronic low-grade systemic inflammatory state contributes to atherosclerosis, we investigated circulating cytokine levels in relation to burnout symptoms.

METHODS

We studied 167 schoolteachers (median, 48 years; range, 23-63 years; 67% women) who completed the Maslach Burnout Inventory with its three subscales emotional exhaustion (EE), lack of accomplishment (LA), and depersonalization (DP). Levels of the proinflammatory cytokine tumor necrosis factor (TNF)-alpha and of the anti-inflammatory cytokines interleukin (IL)-4 and IL-10 were determined in fasting morning plasma samples. The TNF-alpha/IL-4 ratio and the TNF-alpha/IL-10 ratio were computed as two indices of increased inflammatory activity. Analyses were adjusted for demographic factors, medication, lifestyle factors (including sleep quality), metabolic factors, and symptoms of depression and anxiety.

RESULTS

Higher levels of total burnout symptoms aggregating the EE, LA, and DP subscales independently predicted higher TNF-alpha levels (DeltaR(2)=.024, P=.046), lower IL-4 levels (DeltaR(2)=.021, P=.061), and a higher TNF-alpha/IL-4 ratio (DeltaR(2)=.040, P=.008). Higher levels of LA predicted decreased IL-4 levels (DeltaR(2)=.041, P=.008) and a higher TNF-alpha/IL-4 ratio (DeltaR(2)=.041, P=.007). The categorical dimensions of the various burnout scales (e.g., burnout yes vs. no) showed no independent relationship with any cytokine measure.

CONCLUSION

Burnout was associated with increased systemic inflammation along a continuum of symptom severity rather than categorically. Given that low-grade systemic inflammation promotes atherosclerosis, our findings may provide one explanation for the increased cardiovascular risk previously observed in burned-out individuals.

Job strain, burnout, and depressive symptoms: a prospective study among dentists

BACKGROUND

Burnout has been presented as an antecedent of depression, but longitudinal data are lacking. We investigated whether burnout mediates the association between job strain and depressive symptoms.

METHODS

Two surveys were conducted. In 2003, 71% of Finnish dentists were reached, and the response rate of the 3-year follow-up was 84% (n=2555). Burnout was measured with the Maslach Burnout Inventory and depressive symptoms with the Beck Depression Inventory. The sequences 'job strain-burnout-depressive symptoms' and 'job strain-depressive symptoms-burnout' were investigated with logistic regression analyses.

RESULTS

Of the burnout sufferers without depressive symptoms at baseline, 23% reported depressive symptoms at follow-up. The adjusted odds ratio of burnout for depressive symptoms was 2.6 (95% CI 2.0-3.5). The effect of job strain on depressive symptoms had an OR of 3.4 (95% CI 2.0-5.7), but it disappeared when adjusted for burnout. Of those who had depressive symptoms without burnout at baseline, 63% had burnout at follow-up. The adjusted odds ratio of depressive symptoms for burnout was 2.2 (95% CI 1.4-3.4). The effect of job strain on burnout had an OR of 27.9 (95% CI 6.5-120.2) for the men and 4.9 (95% CI 2.5-9.6) for the women. These effects remained significant after adjustment for depressive symptoms.

LIMITATIONS

The study was conducted among one occupational group.

CONCLUSIONS

There is a reciprocal relationship between burnout and depressive symptoms. Job strain predisposes to depression through burnout. In comparison, job strain predisposes to burnout directly and via depression.

Evidence that impaired sleep recovery may complicate burnout improvement independently of depressive mood

OBJECTIVE

This article examines recovery through sleep in relation to sleep quality, exhaustion, and depression in clinical burnout. We focus on actual recovery per night, given its relevance to burnout improvement.

METHODS

Sixty clinically burned-out participants and 40 healthy controls recorded symptoms with an electronic diary for 2 weeks at random times per day. Recovery through sleep was defined as the difference in fatigue between late evening and the next morning.

RESULTS

In clinical burnout, sleep quality and recovery are impaired, and depression is elevated. Poor recovery through sleep is associated with poor same-night sleep quality, clarifying the mechanisms underlying poor recovery. Individual differences in recovery though sleep were related to differences in refreshed awakening, but not to other sleep problems. Impaired recovery was also related to severity of exhaustion, but not to severity of depressive mood, indicating that, in burnout, nonprofit from sleep is a symptom of energy depletion, not a sign of depression.

CONCLUSION

Impaired recovery through sleep may hamper recovery from burnout independently of the influence of depression.