Burnout is a type of prolonged response to chronic emotional and interpersonal stressors on the job. It has been conceptualized as an individual stress experience embedded in a context of complex social relationships, and it involves the person’s conception of both self and others. As such, it has been an issue of particular concern for human services occupations where: (a) the relationship between providers and recipients is central to the job; and (b) the provision of service, care, treatment or education can be a highly emotional experience. There are several types of occupations that meet these criteria, including health care, social services, mental health, criminal justice and education. Even though these occupations vary in the nature of the contact between providers and recipients, they are similar in having a structured caregiving relationship centred around the recipient’s current problems (psychological, social and/or physical). Not only is the provider’s work on these problems likely to be emotionally charged, but solutions may not be easily forthcoming, thus adding to the frustration and ambiguity of the work situation. The person who works continuously with people under such circumstances is at greater risk from burnout.

The operational definition (and the corresponding research measure) that is most widely used in burnout research is a three-component model in which burnout is conceptualized in terms of emotional exhaustion, depersonalization and reduced personal accomplishment (Maslach 1993; Maslach and Jackson 1981/1986). Emotional exhaustion refers to feelings of being emotionally overextended and depleted of one’s emotional resources. Depersonalization refers to a negative, callous or excessively detached response to the people who are usually the recipients of one’s service or care. Reduced personal accomplishment refers to a decline in one’s feelings of competence and successful achievement in one’s work.

This multidimensional model of burnout has important theoretical and practical implications. It provides a more complete understanding of this form of job stress by locating it within its social context and by identifying the variety of psychological reactions that different workers can experience. Such differential responses may not be simply a function of individual factors (such as personality), but may reflect the differential impact of situational factors on the three burnout dimensions. For example, certain job characteristics may influence the sources of emotional stress (and thus emotional exhaustion), or the resources available to handle the job successfully (and thus personal accomplishment). This multidimensional approach also implies that interventions to reduce burnout should be planned and designed in terms of the particular component of burnout that needs to be addressed. That is, it may be more effective to consider how to reduce the likelihood of emotional exhaustion, or to prevent the tendency to depersonalize, or to enhance one’s sense of accomplishment, rather than to use a more unfocused approach.

Consistent with this social framework, the empirical research on burnout has focused primarily on situational and job factors. Thus, studies have included such variables as relationships on the job (clients, colleagues, supervisors) and at home (family), job satisfaction, role conflict and role ambiguity, job withdrawal (turnover, absenteeism), expectations, workload, type of position and job tenure, institutional policy and so forth. The personal factors that have been studied are most often demographic variables (sex, age, marital status, etc.). In addition, some attention has been given to personality variables, personal health, relations with family and friends (social support at home), and personal values and commitment. In general, job factors are more strongly related to burnout than are biographical or personal factors. In terms of antecedents of burnout, the three factors of role conflict, lack of control or autonomy, and lack of social support on the job, seem to be most important. The effects of burnout are seen most consistently in various forms of job withdrawal and dissatisfaction, with the implication of a deterioration in the quality of care or service provided to clients or patients. Burnout seems to be correlated with various self-reported indices of personal dysfunction, including health problems, increased use of alcohol and drugs, and marital and family conflicts. The level of burnout seems fairly stable over time, underscoring the notion that its nature is more chronic than acute (see Kleiber and Enzmann 1990; Schaufeli, Maslach and Marek 1993 for reviews of the field).

An issue for future research concerns possible diagnostic criteria for burnout. Burnout has often been described in terms of dysphoric symptoms such as exhaustion, fatigue, loss of self-esteem and depression. However, depression is considered to be context-free and pervasive across all situations, whereas burnout is regarded as job-related and situation-specific. Other symptoms include problems in concentration, irritability and negativism, as well as a significant decrease in work performance over a period of several months. It is usually assumed that burnout symptoms manifest themselves in “normal” persons who do not suffer from prior psychopathology or an identifiable organic illness. The implication of these ideas about possible distinctive symptoms of burnout is that burnout could be diagnosed and treated at the individual level.

However, given the evidence for the situational aetiology of burnout, more attention has been given to social, rather than personal, interventions. Social support, particularly from one’s peers, seems to be effective in reducing the risk of burnout. Adequate job training that includes preparation for difficult and stressful work-related situations helps develop people’s sense of self-efficacy and mastery in their work roles. Involvement in a larger community or action-oriented group can also counteract the helplessness and pessimism that are commonly evoked by the absence of long-term solutions to the problems with which the worker is dealing. Accentuating the positive aspects of the job and finding ways to make ordinary tasks more meaningful are additional methods for gaining greater self-efficacy and control.

There is a growing tendency to view burnout as a dynamic process, rather than a static state, and this has important implications for the proposal of developmental models and process measures. The research gains to be expected from this newer perspective should yield increasingly sophisticated knowledge about the experience of burnout, and will enable both individuals and institutions to deal with this social problem more effectively.

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Any organization which seeks to establish and maintain the best state of mental, physical and social wellbeing of its employees needs to have policies and procedures which comprehensively address health and safety. These policies will include a mental health policy with procedures to manage stress based on the needs of the organization and its employees. These will be regularly reviewed and evaluated.

There are a number of options to consider in looking at the prevention of stress, which can be termed as primary, secondary and tertiary levels of prevention and address different stages in the stress process (Cooper and Cartwright 1994). Primary prevention is concerned with taking action to reduce or eliminate stressors (i.e., sources of stress), and positively promoting a supportive and healthy work environment. Secondary prevention is concerned with the prompt detection and management of depression and anxiety by increasing self-awareness and improving stress management skills. Tertiary prevention is concerned with the rehabilitation and recovery process of those individuals who have suffered or are suffering from serious ill health as a result of stress.

To develop an effective and comprehensive organizational policy on stress, employers need to integrate these three approaches (Cooper, Liukkonen and Cartwright 1996).

Primary Prevention

First, the most effective way of tackling stress is to eliminate it at its source. This may involve changes in personnel policies, improving communication systems, redesigning jobs, or allowing more decision making and autonomy at lower levels. Obviously, as the type of action required by an organization will vary according to the kinds of stressor operating, any intervention needs to be guided by some prior diagnosis or stress audit to identify what these stressors are and whom they are affecting.

Stress audits typically take the form of a self-report questionnaire administered to employees on an organization- wide, site or departmental basis. In addition to identifying the sources of stress at work and those individuals most vulnerable to stress, the questionnaire usually measures levels of employee job satisfaction, coping behaviour, and physical and psychological health comparative to similar occupational groups and industries. Stress audits are an extremely effective way of directing organizational resources into areas where they are most needed. Audits also provide a means of regularly monitoring stress levels and employee health over time, and provide a base line whereby subsequent interventions can be evaluated.

Diagnostic instruments, such as the Occupational Stress Indicator (Cooper, Sloan and Williams 1988) are increasingly being used by organizations for this purpose. They are usually administered through occupational health and/or personnel/human resource departments in consultation with a psychologist. In smaller companies, there may be the opportunity to hold employee discussion groups or develop checklists which can be administered on a more informal basis. The agenda for such discussions/ checklists should address the following issues:

• job content and work scheduling
• physical working conditions
• employment terms and expectations of different employee groups within the organization
• relationships at work
• communication systems and reporting arrangements.

Another alternative is to ask employees to keep a stress diary for a few weeks in which they record any stressful events they encounter during the course of the day. Pooling this information on a group/departmental basis can be useful in identifying universal and persistent sources of stress.

Creating healthy and supportive networks/environments

Another key factor in primary prevention is the development of the kind of supportive organizational climate in which stress is recognized as a feature of modern industrial life and not interpreted as a sign of weakness or incompetence. Mental ill health is indiscriminate—it can affect anyone irrespective of their age, social status or job function. Therefore, employees should not feel awkward about admitting to any difficulties they encounter.

Organizations need to take explicit steps to remove the stigma often attached to those with emotional problems and maximize the support available to staff (Cooper and Williams 1994). Some of the formal ways in which this can be done include:

• informing employees of existing sources of support and advice within the organization, like occupational health
• specifically incorporating self-development issues within appraisal systems
• extending and improving the “people” skills of managers and supervisors so they that convey a supportive attitude and can more comfortably handle employee problems.

Most importantly, there has to be demonstrable commitment to the issue of stress and mental health at work from both senior management and unions. This may require a move to more open communication and the dismantling of cultural norms within the organization which inherently promote stress among employees (e.g., cultural norms which encourage employees to work excessively long hours and feel guilty about leaving “on time”). Organizations with a supportive organizational climate will also be proactive in anticipating additional or new stressors which may be introduced as a result of proposed changes. For example, restructuring, new technology and take steps to address this, perhaps by training initiatives or greater employee involvement. Regular communication and increased employee involvement and participation play a key role in reducing stress in the context of organizational change.

Secondary Prevention

Initiatives which fall into this category are generally focused on training and education, and involve awareness activities and skill- training programmes.

Stress education and stress management courses serve a useful function in helping individuals to recognize the symptoms of stress in themselves and others and to extend and develop their coping skills and abilities and stress resilience.

The form and content of this kind of training can vary immensely but often includes simple relaxation techniques, lifestyle advice and planning, basic training in time management, assertiveness and problem-solving skills. The aim of these programmes is to help employees to review the psychological effects of stress and to develop a personal stress-control plan (Cooper 1996).

This kind of programme can be beneficial to all levels of staff and is particularly useful in training managers to recognize stress in their subordinates and be aware of their own managerial style and its impact on those they manage. This can be of great benefit if carried out following a stress audit.

Health screening/health enhancement programmes

Organizations, with the cooperation of occupational health personnel, can also introduce initiatives which directly promote positive health behaviours in the workplace. Again, health promotion activities can take a variety of forms. They may include:

• the introduction of regular medical check-ups and health screening
• the design of “healthy” canteen menus
• the provision of on-site fitness facilities and exercise classes
• corporate membership or concessionary rates at local health and fitness clubs
• the introduction of cardiovascular fitness programmes
• advice on alcohol and dietary control (particularly cutting down on cholesterol, salt and sugar)
• smoking-cessation programmes
• advice on lifestyle management, more generally.

For organizations without the facilities of an occupational health department, there are external agencies that can provide a range of health-promotion programmes. Evidence from established health-promotion programmes in the United States have produced some impressive results (Karasek and Theorell 1990). For example, the New York Telephone Company’s Wellness Programme, designed to improve cardiovascular fitness, saved the organization $2.7 million in absence and treatment costs in one year alone.

Stress management/lifestyle programmes can be particularly useful in helping individuals to cope with environmental stressors which may have been identified by the organization, but which cannot be changed, e.g., job insecurity.

Tertiary Prevention

An important part of health promotion in the workplace is the detection of mental health problems as soon as they arise and the prompt referral of these problems for specialist treatment. The majority of those who develop mental illness make a complete recovery and are able to return to work. It is usually far more costly to retire a person early on medical grounds and re-recruit and train a successor than it is to spend time easing a person back to work. There are two aspects of tertiary prevention which organizations can consider:

Counselling

Organizations can provide access to confidential professional counselling services for employees who are experiencing problems in the workplace or personal setting (Swanson and Murphy 1991). Such services can be provided either by in-house counsellors or outside agencies in the form of an Employee Assistance Programme (EAP).

EAPs provide counselling, information and/or referral to appropriate counselling treatment and support services. Such services are confidential and usually provide a 24-hour contact line. Charges are normally made on a per capita basis calculated on the total number of employees and the number of counselling hours provided by the programme.

Counselling is a highly skilled business and requires extensive training. It is important to ensure that counsellors have received recognized counselling skills training and have access to a suitable environment which allows them to conduct this activity in an ethical and confidential manner.

Again, the provision of counselling services is likely to be particularly effective in dealing with stress as a result of stressors operating within the organization which cannot be changed (e.g., job loss) or stress caused by non-work related problems (e.g., bereavement, marital breakdown), but which nevertheless tend to spill over into work life. It is also useful in directing employees to the most appropriate sources of help for their problems.

Facilitating the return to work

For those employees who are absent from work as a result of stress, it has to be recognized that the return to work itself is likely to be a “stressful” experience. It is important that organizations are sympathetic and understanding in these circumstances. A “return to work” interview should be conducted to establish whether the individual concerned is ready and happy to return to all aspects of their job. Negotiations should involve careful liaison between the employee, line manager and doctor. Once the individual has made a partial or complete return to his or her duties, a series of follow-up interviews are likely to be useful to monitor their progress and rehabilitation. Again, the occupational health department can play an important role in the rehabilitation process.

The options outlined above should not be regarded as mutually exclusive but rather as being potentially complimentary. Stress- management training, health-promotion activities and counselling services are useful in extending the physical and psychological resources of the individual to help them to modify their appraisal of a stressful situation and cope better with experienced distress (Berridge, Cooper and Highley 1997). However, there are many potential and persistent sources of stress the individual is likely to perceive him- or herself as lacking the resource or positional power to change (e.g., the structure, management style or culture of the organization). Such stressors require organizational level intervention if their long-term dysfunctional impact on employee health is to be overcome satisfactorily. They can only be identified by a stress audit.

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