Burnout & Health Alex Chapter Shirom-Melamed

48 Pages·2003·0.3 MB·English

by  Arie Shirom

Arie Shirom and Shmuel Melamed

Burnout and health: Current Knowledge and Future Research Directions

Burnout has received increased research attention in recent years. During the period
of 1995-2002, annually about 150 articles that concerned burnout have appeared in journals
covered by PsychInfo. As evident, burnout has been a major focus of researchers’ efforts. A
recent review of the area of burnout (Schuafeli & Enzmann, 1998) found about 5,500 entries
with burnout as a key word between 1975 and 1995. Notwithstanding this large number of
studies, the relationships between burnout and physical health, including physiological risk
factors and physical disease states, have hardly been explored. The literature on burnout and
well being or mental health is substantial, but has not been reviewed with sufficient attention
to the instruments used to gauge burnout and their respective construct validity. The
objectives of this chapter are to review current knowledge on the above issues and to provide
a perspective on future directions of research into burnout – health linkages.
We start out by discussing the conceptual meaning of burnout. Burnout is viewed as
an affective reaction to ongoing stress. We contend that core content of this affective reaction
is the gradual depletion over time of individuals’ intrinsic energetic resources, leading to
feelings of emotional exhaustion, physical fatigue, and cognitive weariness (Shirom, 1989).
Given the multidimensionality of the construct and the controversy over its operational
definition (Maslach, Schaufeli, & Leiter, 2001), this conceptual analysis is essential for
understanding the possible health consequences of burnout. We seek in this chapter to
propose mechanisms that link burnout and health (cf. Schaufeli & Greenglass, 2001). The
following sections cover the empirical literature on burnout’s linkages with mental and
physical health, respectively.
Typically, empirical studies on the health consequences of burnout are based on a
cross-sectional study design and measure burnout, and also mental health, by asking
respondents to complete a self-report questionnaire. In this review, the emphasis is on
longitudinal studies on burnout’s impact on health since they provide more credence to cause
and effect statements. The voluminous empirical research on burnout has already been
reviewed by several by meta-analytic studies (Collins, 1999; Lee & Ashforth, 1996; Schaufeli
& Enzmann, 1998). Most of this research has measured burnout by the Maslach Burnout
Inventory (MBI). In references made to this body of studies, we will focus on results reported
for the emotional exhaustion scale.
This review covers burnout of employees in work organizations, excluding research
that deals exclusively with non-employment settings (e.g., athletes’ burnout: Dale &
Weinberg, 1990). Also excluded is research that deals with burnout in life domains other
than work, like crossover of burnout among marital partners (e.g., Pines, 1996; Westman &
Etzion, 1995).
The Conceptual Basis of Burnout
During the 1980s and early 1990s, research on burnout, regardless of the conceptual
approach employed, dealt almost exclusively with people-oriented professionals (e.g.,
teachers, nurses, doctors, social workers, and policepersons). People-oriented professionals
often enter their mostly public sector profession with service-oriented idealistic goals. They
typically work under norms that expect them to continuously invest emotional, cognitive and
even physical energy in service recipients. In most of today’s advanced market economies,
the public sector has to adjust to consumers’ growing demands for quality service,
downsizing, and budgetary retrenchments. Inevitably, such a context of overloading and
conflicting demands is a fertile ground for creating a process of emotional exhaustion, mental
weariness and physical fatigue that Freudenberger, who pioneered in scientifically
investigating this phenomenon, labeled as burnout.
Freudenberger (1974, 1980) pioneering clinically oriented work on burnout inspired
three different conceptual approaches to burnout, each with its distinct measure. We refer to
the conceptual schemes and measures of Maslach and her colleagues (Maslach, 1982;
Maslach & Leiter, 1997), of Pines and her colleagues (Pines & Aronson, 1988; Pines,
Aronson & Kafry, 1981) and of Shirom and Melamed (Shirom, 1989; Hobfoll & Shirom,
1993, 2000; Melamed, Kushnir & Shirom, 1992). In this review, we will emphasize issues
related to the validity of the first conceptual approach toward burnout, including the
measurement instrument constructed by Maslach and her colleagues, the MBI (Maslach,
Jackson, & Leiter, 1996). The reason for this focus is that the MBI was one of the very first
scientifically validated burnout measurement instruments, and it has been the most widely
used in scholarly research (Schaufeli & Enzmann, 1998). The first version of the MBI
reflected the field’s preoccupation with professionals in people-oriented occupations.
Subsequently, the construction of newer versions of the popular MBI, applicable to other
occupational groups (Maslach et al., 1996) extended the study of burnout to other categories
of employees.
The Maslach Burnout Model and Inventory
According to this conceptualization (Maslach & Jackson, 1981; Maslach, 1982;
Maslach & Leiter, 1997), burnout is viewed as a syndrome that consists of three dimensions:
emotional exhaustion, depersonalization, and reduced personal accomplishment. Emotional
exhaustion, which refers to feelings of being depleted of one’s emotional resources, is
regarded as the basic individual stress component of the syndrome (Maslach, Schaufeli, &
Leiter, 2001). Depersonalization, referring to negative, cynical or excessively detached
responses to other people at work, represents the interpersonal component of burnout.
Reduced personal accomplishment, referring to feelings of decline in one’s competence and
productivity and to one’s lowered sense of self-efficacy, represents the self-evaluation
component of burnout (Maslach, 1998, p. 69). The three dimensions were not deducted
theoretically but resulted from labeling exploratory factor-analyzed items initially collected to
reflect the range of experiences associated with the phenomenon of burnout (Maslach, 1998,
p. 68; Schaufeli & Enzmann, 1998, p. 51).
Subsequently, Maslach and her colleagues modified the original definition of the
latter two dimensions (cf. Maslach et al., 2001, p. 399). Depersonalization was renamed
cynicism, though it still referred to the same cluster of symptoms involving other people at
work rather than service recipients. However, the new label for this dimension of the
syndrome poses new problems. As an emerging new concept in psychology and
organizational behavior, the term cynicism is used to refer to negative attitudes involving
frustration from, disillusionment with, and distrust of organizations, persons, groups or
objects (Andersson & Bateman, 1997; Dean, Brandes, & Dharwadkar, 1998). Abraham
(2000) has suggested that work cynicism, one of the forms of cynicism that she had identified
in her research, tends to be closely related to burnout. Garden (1987) has argued that this
dimension of the syndrome of burnout gauges several distinct attitudes, including distancing,
hostility, rejection, and unconcern. It follows that the discriminant validity of this component
of burnout, relative to the current conceptualizations of employee or work cynicism or
relative to the other distinct attitudinal concepts noted by Garden (1987) has yet to be
established.
The third dimension was re-labeled as reduced efficacy or ineffectiveness, depicted to
include the self-assessments of low self-efficacy, lack of accomplishment, lack of
productivity, and incompetence (Leiter & Maslach, 2001). Each of these concepts, namely
self-efficacy, accomplishment or achievement, personal productivity or performance, and
personal competence, represents a distinct field of research in the behavioral sciences and the
authors of the MBI have yet to clarify on what theoretical grounds they can be grouped
together to represent a single conceptual entity. Does reduced efficacy refer to one’s
confidence in one’s capability to successfully execute courses of action required to deal with
prospective tasks, as self-efficacy is customarily defined (e.g., Lee & Bobko, 1994; Stajkovic
& Luthans, 1998)? Does the third dimension of burnout reflect one’s belief in one’s
knowledge and skills, as competence is often conceptualized (Foschi, 2000; Sandberg, 2000)?
As an additional alternative, does it relate to self-assessed job performance or performance
expectations (e.g., Stajkovic & Luthans, 1998)? It appears that each of the second and third
dimensions of the MBI, as currently defined, probably represents each several multifaceted
constructs, each having different theoretical implications with regard to the emotional
exhaustion component of burnout suggested by the authors of the MBI (cf. Moore, 2000,
p.341).
Clearly, the conceptualization of burnout as tapped by the MBI relates to it as a
multidimensional construct. A construct is multidimensional when it refers to several distinct
but related dimensions that are viewed as a single theoretical construct (Law, Wong, &
Mobley, 1998). The proponents of this multidimensional view of burnout (e.g., Maslach,
1998) argue that it provides a holistic representation of a complex phenomenon, broadly
conceived as referring to the process of wear and tear or continuous encroachment upon
employees’ resources. However, they have yet to provide convincing theoretical arguments
as to why the three different clusters of symptoms that comprise their conceptualization of
burnout should “hang together” (cf. Maslach et al., 2001). They further argue that their
conceptualization allows researchers to use broadly conceived types of stress in both the
work and the family domains as potential antecedents of burnout, thus increasing its
explained variance. However, there is a paucity of evidence that there are specific antecedent
variables or mechanisms leading to all of the three clusters of symptoms included in the MBI
(Collins, 1999; Lee & Ashforth, 1996; Schaufeli & Enzmann, 1998). A case in point is the
phase model of burnout, developed by Golembiewski and his colleagues and tested in a series
of studies (see, for example, Golembiewski & Boss, 1992; Golembiewski, Munzenrider, &
Stevenson, 1986; Golembiewski & Munzenrider, 1988). One of the theoretical assumptions
upon which this model was based was that individuals experiencing burnout on the
dimension of emotional exhaustion do not necessarily experience either of the other two
clusters of symptoms. Indeed, Golembiewski and his colleagues (Golembiewski et al.,
1986,1988, 1992) have provided the notion that each phase or dimension of burnout may
develop independent of each other.
Maslach (1998, p. 70) has argued that adding the dimensions of cynicism and reduced
personal efficacy to the core dimension of emotional exhaustion was justified in that they
add the interpersonal aspect of burnout to the conceptualization of the phenomenon.
However, the emotional exhaustion scale of the MBI already includes items that tap
interpersonal aspects of work, like “working with people all day is really a strain for me”, and
“Working with people directly puts too much stress on me” (Maslach & Jackson, 1981).
Conceptually, therefore, the view of burnout as a syndrome consisting of three clusters of
symptoms lacks theoretical underpinnings, has not been supported by evidence demonstrating
a common etiology for the three dimensions, and includes two clusters of symptoms,
cynicism an reduced personal effectiveness, that appear to be too heterogeneous for
advancing our knowledge on burnout.
In sum, the MBI, the measurement scale whose process of construction has led
inductively to the above conceptualization, has been the most popular instrument for
measuring burnout in empirical research (for reviews of studies using it, see Collins, 1999;
Lee & Ashforth, 1996; Schaufeli & Enzmann, 1998). It contained items purportedly assessing
each of the three clusters of symptoms included in the syndrome view of burnout, namely
emotional exhaustion, cynicism or depersonalization, and reduced effectiveness or lowered
professional efficacy. It asks respondents to indicate the frequency over the work year with
which they have experienced each feeling on a 7-point scale ranging from 0 (never) to 6
(every day). Three indices are usually constructed, relating to each of the above dimensions
(for a recent psychometric critique, see Barnett, Brennan, & Careis, 1999). The factorial
validity of the MBI has been extensively studied (Byrne, 1994; Handy, 1988; Lee &
Ashforth, 1996; Schaufeli & Dierendonck, 1993; Schaufeli & Buunk, 1996). Most of the
researchers examining this aspect of MBI validity have reported that a three-factor solution
better fits their data than does a two-dimensional or a one-dimensional structure (for recent
examples, see Boles, Dean, Ricks, Short & Wang, 2000; Schutte, Toppinen, Kalimo, &
Schaufeli, 2000). Researchers using the MBI have most often constructed three different
indices corresponding to the three dimensions of emotional exhaustion, cynicism, and
reduced personal effectiveness. Several studies have argued, on both theoretical and
psychometric grounds, that the use of a total score to represent total burnout should be
avoided (e.g., Moore, 2000; Kalliath, O’Driscoll, Gillepsie & Bluedorn, 2000; Koeske &
Koeske, 1989). The emotional exhaustion dimension has been consistently viewed as the core
component of the MBI (e.g., Moore, 2000; Cordes, Dougherty & Blum, 1997; Burke &
Greenglass, 1995). Most studies have shown it to be the most internally consistent and stable
of the three components (Schaufeli & Enzmann, 1998). In meta-analytic reviews, it has been
shown to be the most responsive to the nature and intensity of work-related stress (Lee &
Ashforth, 1993; Schaufeli & Enzmann, 1998
Pines’ Burnout Model and Measure
Pines and her colleagues define burnout as the state of physical, emotional and mental
exhaustion caused by long –term involvement in emotionally demanding situations (Pines &
Aronson, 1988, p. 9). This view does not restrict the application of the term burnout to the
helping professions, as was initially the case with the first version of the MBI (Winnubst,
1993). Indeed, Pines and her colleagues have applied it not only to employment relationships
(Pines, Aronson & Kafry, 1981) and organizational careers (Pines & Aronson, 1988), but also
to marital relationships (Pines, 1988, 1996) and to the aftermath of political conflicts (Pines,
1993).
Much like the case of the MBI, the Pines et al. conceptualization and measure of
burnout, the BM (Burnout Measure) emerged from clinical experience and case studies. In
the process of actually constructing the BM measure, Pines and her colleagues have moved
away from their original conceptualization to an empirical definition that regards burnout as a
syndrome of co-occurring symptoms that include helplessness, hopelessness, entrapment,
decreased enthusiasm, irritability, and a sense of lowered self-esteem (cf. Pines, 1993). None
of these symptoms is anchored in the context of work or employment relationships. The BM
is considered a one-dimensional measure yielding a single composite burnout score. As we
have noted, the overlap between the conceptual definition and the operational definition of
the BM is minimal (cf. Schaufeli & Enzmann, p. 48). In addition, the discriminant validity of
the BM, relative to depression, anxiety, and self-esteem, is in doubt (cf. Shirom & Ezrachi,
2003). This has led researchers to describe the BM as a general index of psychological
distress that encompasses physical fatigue, emotional exhaustion, depression, anxiety, and
reduced self-esteem (e.g., Schaufeli & Dierendonck, 1993, p. 645; Shirom & Ezrachi, 2003).
Therefore, it appears irrelevant to assess the linkage between burnout and indicators of
mental health like depression or anxiety using questionnaire measures, since the overlap
between the items used to gauge burnout by the BM and depression or anxiety is considerable
(Shirom & Ezrachi, 2003). As we were unable to find any evidence linking the BM to
disease end states or to physiological risk factors for physical disease, we have not included
studies that have used it in this review.
Shirom-Melamed Burnout Model and Measure (SMBM)
The conceptualization of burnout that underlies the Shirom-Melamed Burnout
Measure (SMBM) was inspired by the work of Maslach and her colleagues and Pines and her
colleagues, and views burnout as an affective state characterized by one’s feelings of being
depleted of one’s physical, emotional, and cognitive energies. Burnout follows prolonged
exposure to chronic stress. Relative to chronic stress, event-based conceptualizations of
stress, like those that relate to critical life events or acute stress and to episodic stress or
hassles, derive from different theoretical approached (Derogatis & Coons, 1993) and has been
found to be differently related to physiological risk factors in coronary heart disease (Kahn &
Byosiere, 1992).
Theoretically, the SMBM was based on Hobfoll’s (1989, 1998) Conservation of
Resources [COR] theory. COR theory’s fundamental tenets are that people have a basic
motivation to obtain, retain, and protect that which they value, including material, social, and
energetic resources. According to COR theory (Hobfoll, 1989, 1998) stress at work occurs
when individuals are either threatened with resource loss, lose resources, or fail to regain
resources following resource investment. One of the corollaries of COR theory is that stress
does not occur as a single event, but rather represents an unfolding process, wherein those
who lack a strong resource pool are more likely to experience cycles of resource loss. The
affective state of burnout is likely to exist when individuals experience a cycle of resource
loss over a period of time at work (Hobfoll & Freedy, 1993). For example, a reference
librarian who comes to work every morning to face yet another line of students impatiently
awaiting her help, lacking opportunities to replenish her resources, is likely to cycle into a
forceful spiral of resource loss and as a result feel burned out at work.
The conceptualization of burnout formulated by Shirom (1989) based on COR theory
(Hobfoll & Shirom, 1993, 2000) relates to energetic resources only, and covers physical,
emotional, and cognitive energies. Burnout thus represents a combination of physical
fatigue, emotional exhaustion, and cognitive weariness, three closely interrelated factors
(Hobfoll & Shirom, 2000) that can be represented by a single score of burnout. Physical
fatigue refers to feelings of tiredness and low levels of energy in carrying out daily tasks at
work, like getting up in the morning to go to work. Emotional exhaustion refers to feeling too
weak to display empathy to clients or coworkers and lacking the energy needed to invest in
relationships with other people at work. Cognitive weariness refers to feelings of slow
thinking and reduced mental agility. Each component of burnout covers the draining and
depletion of energetic resources in a particular domain.
There are three reasons for the focus on the combination of physical fatigue,
emotional exhaustion and cognitive weariness in the conceptualization of burnout that has led
to the construction of the SMBM. First, these forms of energy are individually possessed, and
theoretically are expected to be closely interrelated. COR theory postulates that personal
resources affect each other and exist as a resource pool, and that lacking one is often
associated with lacking the other (Hobfoll & Shirom, 2000). Empirical research conducted
with the SMBM has supported the linkage among physical fatigue, emotional exhaustion and
cognitive weariness (e.g., Melamed, Kushnir & Shirom, 1992; Shirom, Westman, Shamai, &
Carel, 1997). Second, the three forms of individually possessed energy included in the
SMBM represent a coherent set that does not overlap any other established behavioral
science concept, like depression and anxiety or like aspects of the self-concept such as self-
esteem and self-efficacy. Third, the conceptualization of the SMBM clearly differentiates
burnout from stress appraisals anteceding burnout, from coping behaviors that individuals
may engage in to ameliorate the negative aspects of burnout like distancing themselves from