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R E S E A R C H A R T I C L E Open Access
A systematic review including meta-analysis
of work environment and burnout
symptoms
Gunnar Aronsson
1*
, Töres Theorell
2,3
, Tom Grape
4
, Anne Hammarström
5
, Christer Hogstedt
6
, Ina Marteinsdottir
7
,
Ingmar Skoog
8
, Lil Träskman-Bendz
9
and Charlotte Hall
10
Abstract
Background: Practitioners and decision makers in the medical and insurance systems need knowledge on the
relationship between work exposures and burnout. Many burnout studies –original as well as reviews - restricted
their analyses to emotional exhaustion or did not report results on cynicism, personal accomplishment or global
burnout. To meet this need we carried out this review and meta-analyses with the aim to provide systematically
graded evidence for associations between working conditions and near-future development of burnout symptoms.
Methods: A wide range of work exposure factors was screened. Inclusion criteria were: 1) Study performed in Europe,
North America, Australia and New Zealand 1990–2013. 2) Prospective or comparable case control design. 3)
Assessments of exposure (work) and outcome at baseline and at least once again during follow up 1–5 years later.
Twenty-five articles met the predefined relevance and quality criteria. The GRADE-system with its 4-grade evidence
scale was used.
Results: Most of the 25 studies focused emotional exhaustion, fewer cynicism and still fewer personal accomplishment.
Moderately strong evidence (grade 3) was concluded for the association between job control and reduced emotional
exhaustion and between low workplace support and increased emotional exhaustion. Limited evidence (grade 2) was
found for the associations between workplace justice, demands, high work load, low reward, low supervisor support, low
co-worker support, job insecurity and change in emotional exhaustion. Cynicism was associated with most of these work
factors. Reduced personal accomplishment was only associated with low reward. There were few prospective studies with
sufficient quality on adverse chemical, biological and physical factors and burnout.
Conclusion: While high levels of job support and workplace justice were protective for emotional exhaustion, high
demands, low job control, high work load, low reward and job insecurity increased the risk for developing exhaustion. Our
approach with a wide range of work exposure factors analysed in relation to the separate dimensions of burnout
expanded the knowledge of associations, evidence as well as research needs. The potential of organizational interventions
is illustrated by the findings that burnout symptoms are strongly influenced by structural factors such as job demands,
support and the possibility to exert control.
Keywords: Burnout, Emotional exhaustion, Cynicism, Personal accomplishment, Job control, Job demands, Social support,
Review, Meta-analyses, GRADE system
* Correspondence: Gunnar.Aronsson@psychology.su.se
1
Department of Psychology, University of Stockholm, S-10691 Stockholm,
Sweden
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Aronsson et al. BMC Public Health (2017) 17:264
DOI 10.1186/s12889-017-4153-7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
The first articles on burnout were published in 1974 by
Herbert Freudenberger [1], a clinical psychologist work-
ing in an alternative health care agency, and in 1976 by
Christina Maslach [2], a social psychologist studying
workplace emotions. Since then the research field has
grown extremely rapidly and according to an article
2014 in the journal Burnout Research there are more
than 1000 journal articles on different aspects of burn-
out published every year [3].
The definition of burnout includes three dimensions;
emotional exhaustion,cynicism or depersonalization and
reduced personal accomplishment [4, 5]. Emotional ex-
haustion represents the basic individual stress dimensions
of burnout and refers to feelings of being depleted of one’s
emotional and physical resources. The cynicism (or
depersonalization) component represents the interper-
sonal context dimension of burnout. Reduced accomplish-
ment represents the self-evaluation dimension of burnout
and refers to feelings of incompetence and a lack of
achievement and productivity at work [5].
Burnout is seen as a process in time: increased coping
efforts with external demands leads to emotional exhaus-
tion, which is a trigger for depersonalization, which in
turn leads to diminished personal accomplishment adding
to further emotional exhaustion in a vicious cycle etc. [5].
This time-lag is important from a methodological
perspective. All persons with high scores on emotional
exhaustion have not reached depersonalisation and
reduced personal accomplishment.
Burnout is generally based on self-reports. The original
Maslach Burnout Inventory (MBI) is based on experiences
of workers in helping professions in the 1970:s. Later
research recognized that burnout is not a unique
phenomenon in human service professions and therefore
competing versions of the original Maslach Burnout
Inventory, such as the MBI-General Survey, and other in-
struments for burnout screening were developed. Versions
of the MBI are still the most frequently used question-
naires, but other well validated scales exist such as the
Pines Burnout measure [6] and the Copenhagen Burnout
Inventory [7].
The causes of burnout are generally divided into situ-
ational and individual ones, including personality. In the
core of situational work environment factors there are
different aspects of job demands, individual control at
work and level of social support [8].
Psychologically, burnout is regarded as a continuous
variable with individuals experiencing various levels of
burnout. But because doctors and the occupational
health services meet many people suffering from various
symptoms of burnout, there are practical reasons for a
differentiation between people who fulfil the pre-
required criteria for burnout. This is especially relevant
in Sweden, where in contrast to most other countries,
burnout and exhaustion syndrome are accepted diag-
noses and justify compensation.
Practitioners need a dichotomous concept especially
when interacting with representatives of the social insu-
rance and financial compensation systems in cases of
sick leave or disability, as well as when evaluating the
effects of treatment efforts. Both statistical and diagnos-
tic criteria have been used to transform a continuous
scale into a dichotomy that discriminates between
“cases”and “non-cases”[9]. The current review relates
to the practical context, namely to provide scientific
evidence for possible associations between working
conditions and near-future development of burnout. The
review does not assess magnitudes of different associa-
tions between the dimensions. However, as none of the
original studies included in the review used any “cut off
points”for a dichotomization in burnout/no burnout in
the medical and dichotomous sense, we have chosen to
use the term burnout symptoms instead of burnout.
Despite these difficulties, estimations of burnout levels
have been conducted in different populations. In Swedish
working population studies the prevalence has varied
between 6 and 18% [10, 11] and in the public debate in
Sweden burnout is seen as a serious public health issue.
Based on a large epidemiological study including around
12,000 Dutch employees, it is estimated that about 16% of
the Dutch working population is at risk of burnout and
that each year 6% of the Dutch workforce develop serious
burnout complaints [12]. In a review of 17 studies of
emergency nurses, who have been assumed to be vulne-
rable to burnout, on average more than 25% exceeded the
cut-off for the three dimensions of burnout [13]. In a
North-American context there is a Canadian study of a
sample of 63 workplaces and 2162 employees [14]. The
prevalence estimate of emotional exhaustion was 11,8,
cynicism 8,1, professional efficacy 11,1 and total burnout
3,9. The researchers used MBI-GS.
Few of the systematic reviews and meta-analyses of
burnout in a working context published during the last
15 years have required a longitudinal design; most are
based on studies applying a cross-sectional design. There
have been many meta-analyses of different occupational
groups mostly based on studies applying cross-sectional
design. A common conclusion from those occupational
group studies is the need for more and methodologically
better studies - which underlines the need for reviews of
high quality studies.
The most recent systematic review [15] was based on
six longitudinal studies. It was restricted to psychosocial
working conditions and to the dimension of emotional
exhaustion and a total burnout measure. The results
from that review “point to a relationship between
psychosocial working conditions and the development of
Aronsson et al. BMC Public Health (2017) 17:264 Page 2 of 13
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emotional exhaustion/burnout. Particularly high job de-
mands seem to play a role in the development of emotional
exhaustion”. The influence of low job control on burnout
dimensions was inconsistent.
Alarcon [16] reviewed studies from 1990 to 2010 and
analysed 231 samples on the associations between job
demands, resources and job attitudes with any of the
three dimensions of MBI and excluded studies with total
MBI measures of burnout and also other measures of
burnout. Most of the primary studies included used
cross-sectional designs, which Alarcon concludes as be-
ing an important limitation. The results “suggested that
higher demands, lower resources, and lower adaptive
organizational attitudes were associated with burnout
and with all the three burnout dimensions. In particular,
results in the study showed stronger relations than
previous meta-analyses have suggested”.
The aim of this review was to provide systematically
graded evidence in longitudinal studies for possible associ-
ations between working conditions and near-future devel-
opment of symptoms of burnout, emotional exhaustion,
cynicism and reduced personal accomplishment among
the employees. Compared with most previous systematic
reviews the present study had a broader approach, both
regarding exposure factors and burnout dimensions,
which have mostly been restricted to emotional exhaus-
tion. In addition we have somewhat different criteria than
most other studies for specifying the scientific evidence
since we are using the GRADE-system.
Methods
In accordance with our interest in generating knowledge
for practitioners and decision makers in the medical and
insurance systems we have chosen to use the internation-
ally recognized GRADE- system for our scientific evalu-
ation [17]. The GRADE-system has been developed with
the purpose of grading evidence for intervention effects in
health care, but the system has been adapted to
epidemiological evaluation. The GRADE system is often
applied in reviews conducted within the Cochrane Colla-
boration and is increasingly used internationally e.g., by
the World Health Organization. Accordingly results from
systematic reviews can be more easily compared. As far as
the authors know there is no published study that has
used the GRADE system for evaluating the evidence of
burnout research.
We conducted and funded this systematic review
within the framework of the Swedish Agency for Health
Technology Assessment and Assessment of Social Ser-
vices (SBU), a public agency with the charge of providing
impartial and scientifically reliable information to
decision makers and health care providers [18].
As far as it was possible the presented review was
performed in accordance with PRISMA [19].
Search strategy
The search strategy and inclusion criteria were formu-
lated by the expert group, which was recruited among
Swedish academic high ranking specialists in psychiatry
(three), epidemiology and stress research (three), work
psychology (one) and family practice (one).
Systematic literature search was performed for the
period 1990 to 2013 (August) in the following data
bases: PubMed, Embase, Psychinfo, Arbline (Swedish
database), Cochrane library and NIOSHTIC-2. A com-
bination of controlled search words (e.g. Medical Subject
Headings/MeSH) and free-text words were used. The
search strategy (exemplified by the search in the
PubMed data base) is available at http://www.sbu.se/
223E. The literature search, which also included a
parallel study of depression articles, resulted in 20 819
abstracts. The depression study has been published [20].
Only original studies, not reviews, were used. Because
some articles covered both outcomes –burnout and
depression - it is not possible to give the exact number
of burnout studies in the steps of the review process, see
Fig. 1.
Fig. 1 Flow chart of the literature search, screening, review- and
quality assessment
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Inclusion criteria
The inclusion criteria for studies were:
1. The study should have examined the importance of
the work environment for symptoms of burnout.
Our review was not confined to any specific kind of
work environment factors. Psychosocial factors but
also exposure to physical/chemical/ergonomic
factors were screened (associations between those
latter exposures and burnout have been investigated
in cross-sectional studies so we wanted to explore if
there could be studies of higher quality).
2. The studies should be relevant for Swedish
conditions and focused on people at work. The
review was confined to studies from the Western
world (Europe, North America, Australia and
New Zealand).
3. The studies should have been published between the
years 1990 and 2013 in scientific journals and
written in English. The time limitation was based on
our assumption that the conditions in working life
have changed so extensively during the last 25 years
that the external validity and relevance of older
studies may be questioned.
4. A minimum of 100 persons should have been
included in the exposed group and the results were
controlled for at least age and gender.
5. Only prospective cohort, case control (with design
equivalent to prospective) and randomized
intervention studies were included. By case control
studies with “design equivalent to prospective”we
are referring to studies with strict definition of cases
recruited in a representative way in the same
population as the control group.
6. Assessments of exposure should have been made
before burnout onset.
7. Doublets were systematically identified and only the
most relevant publication in a doublet was included.
Analyses of relevance and quality
Abstract screening and full-text assessment for inclusion
criteria were conducted by three persons: an information
specialist at SBU, a psychiatrist and a specialist in occu-
pational medicine. This first screening resulted in 115
full-text articles that met the inclusion criteria. Then the
recruited experts judged relevance and quality of these
115 studies on the basis of the relevance/quality criteria,
their experience as researchers and their knowledge of
the field. The expert group was divided into pairs with
as widely differing specialities in the pair as possible.
Concordance in judgements of relevance and quality
(see below) was trained. After the training sessions, each
member of the pair did the assessments separately, and
then discordances were discussed within the pair. If
disagreement remained, another pair was asked to make
an independent judgement. If that decision was in dis-
agreement with the first group, we made a joint decision
in the whole group of experts. The articles were randomly
assigned to the four pairs (with avoidance of author bias).
In the first phase, the expert group judged relevance.
Detailed relevance criteria are presented in http://
www.sbu.se/upload/Publikationer/Content0/1/223E/
Inclusion%20criteria_occupational%20exposure_depres-
sion_burnout.pdf.
Secondly, the quality assessments were performed.
Three levels of quality rating were used, and in the final
grading process only the two highest quality levels studies
were accepted. Accordingly the important dividing line
was between poor and medium high quality whereas the
distinction between medium high and high was less cru-
cial. Studies on the borderline between low and medium
high quality were accordingly re-examined by the whole
group. In all steps in the review procedure, pre-set evalu-
ation forms were used. They were very detailed and aimed
at focused attention to formulation of research question,
selection of study population, recruitment, attrition,
choice of exposure and outcome measures and statistical
methods. The relevance form contained nine specified
questions concerning study design, associations studied,
research questions, population, follow up time. The
quality form contained 31 questions and additionally five
summarizing questions regarding selection, exposure
assessment, outcome assessment, attrition and interpret-
ation. For a more detailed description of the criteria and
evaluation forms, see http://www.sbu.se/223E.
The following aspects of quality were considered:
1.) Representativeness of study sample
Studies based on population samples and samples
from companies and occupational groups were
accepted. Representativeness and ways of defining
and recruiting the sample as well as attrition in different
steps were considered. Statistical considerations
and insightful discussions of possible consequences of
a systematic drop-out for findings were required in
case of marked drop-out problems.
2.) Confounding. Age and gender should have been
considered. Most of the included studies were based
upon specific occupational cohorts, for instance
dentists, nurses, primary school teachers. In these
studies socioeconomic status was not considered
to be confounding. In the studies based upon the
general working population income, education or
social class were used as confounders. Life habits,
e.g. smoking habits and alcohol consumption, were
not taken into account as potential confounders.
3.) Prospective data colle ction. All result s of the studies
included in this review are based upon assessments
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of exposure at baseline and assessment of burnout at
follow-up at least 1 years later. In the calculations of
associations, a design with either exclusion of
subjects with burnout at baseline or adjustment for
baseline level of burnout was required.
4.) For both exposure and out come a ssessments
psychometrically standardised and validated
methods were required. Well established methods
enable comparisons across studies and therefore
contribute to higher quality rating.
5.) Designs that enable the analysis of a dose response
relationship contributed to a high quality rating. For
instance, in a few studies the work environment was
assessed in two or three subsequent waves and the
development of symptoms of burnout followed up
after the last exposure assessment. Exposure to
defined work environment factors on one, two or
three occasions could be regarded as a progressive
duration of exposure and was regarded as equivalent
of a dose-response analysis.
Even between studies of specific work environment
factors there were differences with regard to operationali-
zation of exposure. Examples are job strain (combination
of high psychological demands and low decision latitude)
and effort reward imbalance (combination of high effort
and poor reward). Since the overall aim of the present
study was to grade total evidence, not to assess magnitude
of associations, and since it was impossible to re-construct
operationalizations in such a way that they would match
one another we decided to use the definitions presented
by the authors themselves and to mostly abstain from
assessment of overall magnitude of the different
relationships.
The final list of studies judged to be of high or
medium high quality is listed in Additional file 1.
The evidence procedure
An important aspect of the systematic review process was
to systematically and transparently assess the scientific
evidence. According to the GRADE instructions explicit
consideration should be given to each of the GRADE
criteria for assessing the quality of evidence (risk of bias/
study limitations, directness, consistency of results,
precision, publication bias, magnitude of the effect,
dose-response gradient, influence of residual plausible
confounding and bias “antagonistic bias”) although
different terminology may be used.
The GRADE-system uses four levels of evidence. For
level 4 (=High), randomized trials are required and there
were no such published relevant studies in our search. For
observational studies of the kind included in the present
review, the highest possible grade is Moderate = 3 if there
is sufficient reason for an upgrading from the normal level
for such studies of 2 (=Limited). Level 1 (=Very limited)
corresponds to evidence based on case reports and case
series or on reports with downgraded evidence from
observational studies.
We allowed for upgrading the scientific evidence when
there was strong coherence of results between studies -
according to the most recent guidelines [21]. Accordingly
when there were many published observational studies of
medium high or high quality with homogenous results the
evidence was graded on level 3. Such upgrading was done
for two exposures, job control and low workplace support.
Level 3 can also be used when there are relatively few
studies if there are unanimous findings with high odds
ratios (above 2.0). There were no such cases in our review.
Meta analyses/Forest plots
In the studies reported results were reported as calcula-
tions of associations, e.g., expressed as odds ratios from
multiple logistic regressions, multivariate correlations or
multiple linear regression coefficients. As a base for the
GRADE-assessment the results were transformed into
multiple logistic regression odds ratios whenever pos-
sible. Forest plots were used for visual interpretation. To
assist in illustrating the results, and as a contribution to
the overall assessment, these forest plots (meta-analyses)
were constructed when in at least two studies the same
risk factor was analysed and mathematically comparable
data was provided using the Comprehensive Meta-
Analysis software package (www.meta-analysis.com/
index.php). Since the participants in the various studies
might be construed as coming from the same population
(workers) or from different populations (i.e., according
to each study’s inclusion criteria) we chose to use a fixed
effects model. The strength of the scientific evidence,
using data from all of the included studies (not just
those illustrated in the meta-analyses), was determined
by pairs of the authors of this paper and then discussed
and confirmed by all authors. The forest plots were
based on studies presenting associations as odds ratios,
including studies where odds ratios could be calculated
(see Fig. 2a–c legends). In forest plots, we chose to use
data from the least adjusted model from each study. The
main rationale for this was that these models were more
comparable between studies than other models, since
the more adjusted ones were adjusted to widely different
potential confounders.
Figure 2, 3, 4 shows forest plots for control, job de-
mands and workplace support. For the other work factors
studied, we present odds ratios and confidence intervals in
the text and the number of studies which were used for
the calculations of odds ratios.
The researchers in the included studies had chosen a
wide range of different statistical measures to express as-
sociations between occupational exposure and burnout
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symptoms. Therefore, it was not possible to conduct
formal mathematical homogeneity analyses including the
entire data material. The expert group conducted a com-
bination of mathematical and narrative sub-group analyses
to explore whether the results were homogenous when
subgroups of studies were compared. Comparisons
concerned results from general population studies versus
specific occupational cohorts, occupational environments
in North America, Europe vs. the Nordic countries and
for high vs medium high quality studies. Inspection of the
confidence interval distributions, as well as estimated
average odds ratios and their confidence intervals showed
homogeneous results across those dichotomies. Homo-
geneity test could not be conducted on burnout screening
instruments, since very few studies used any other instru-
ment than the MBI [4]. Nor was it possible to carry out
separate analyses for men and women, since the articles
rarely presented gender specific results.
The numbers of participants in Table 1 are from the
follow up. In a few studies such data were not available,
and in those cases we present numbers of participants at
the first data collection.
Figure 1 is a summary of the number of articles that
were perused in the different steps. As mentioned the
project and search process also included depression as
outcome for a review of depression and work environ-
ment [20]. As mentioned the first screening resulted in
115 full-text articles on organizational and psychosocial
factors and symptoms of burnout that met the inclusion
criteria and 40 of these were judged relevant by the ex-
pert group. Of these, 15 studies were of low quality in
our three-graded scale of quality and were accordingly
excluded. Finally, the grading of evidence were based on
25 articles of high or medium quality.
For physically demanding work, two studies met the
criteria and for physical environment only one study was
of medium or high quality. These three studies also
included organizational and psychosocial factors, and are
presented among the 25 studies on these factors. Con-
cerning exposure to chemical and biological factors, noise
Fig. 2 Association between low level of control (e.g. decision latitude and authority are used as synonyms of control) and development of
emotional exhaustion. The graph is based on data from the least adjusted model in studies expressing the strength of the association either as
odds ratios or as correlations (the latter have been transformed into odds ratios).
1
Data have been re-calculated to show the association between
low level of control and development of emotional exhaustion (data in these studies are originally presented as association between high level
of control and emotional exhaustion)
Fig. 3 Association between job demands and development of emotional exhaustion. The graph is based on data from the least adjusted model
in studies expressing the strength of the association either as odds ratios or as correlations (the latter have been transformed into odds ratios).
Please note that data from two more studies (Lorente Prieto 2008 and Koponen, 2010) are included in the evidence-rated result; however data
from these studies could not be illustrated in the graph due to the data format
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Fig. 4 Association between low workplace support and development of emotional exhaustion. The graph is based on data from the least
adjusted model in studies expressing the strength of the association either as odds ratios or as correlations (the latter have been transformed
into odds ratios). Please note that data from two more studies (Burke 1995 and Koponen 2010) are included in the evidence-rated result; however
data from these studies could not be illustrated in the graph due to the data format
Table 1 A summary of the evidence for associations between work environment factors and different dimensions of burnout
Work factor Burnout dimensions –participants, number of studies and scientific evidence
Emotional
exhaustion
Depersonalisation,
cynicism
Reduced personal
accomplishment
a
Burnout or symptoms
of exhaustion
Relationship between occupational environment and MORE burnout
Low job control 19 769 9 ⊕⊕⊕○1 396 4 ⊕⊕○○ 123 1 ⊕○○○ 3 252 2 ⊕⊕○○
Demands, unspecified 21 014 13 ⊕⊕○○ 1 354 4 ⊕⊕○○ ––– 5 807 3 ⊕⊕○○
Demands, emotional 1 591 5 ⊕⊕○○ 701 3 ⊕⊕○○ 123 1 ⊕○○○ 952 1 ⊕○○○
Demands from patients 1 050 3 ⊕⊕○○ 1 040 3 ⊕⊕○○ 207 1 ⊕○○○ –––
Low co-worker support 12 788 4 ⊕⊕○○ 708 2 ⊕⊕○○ 123 1 ⊕○○○ –––
Low super-visor support 16 073 5 ⊕⊕○○ 708 1 ⊕○○○ 123 1 ⊕○○○ 952 1 ⊕○○○
Low work-place support 19 747 9 ⊕⊕⊕○681 3 ⊕⊕○○ 485 2 ⊕○○○ 3 863 4 ⊕⊕○○
High work load 2 290 7 ⊕⊕○○ 1 908 6 ⊕⊕○○ 821 3 ⊕⊕○○ 1 201 2 ⊕⊕○○
Low reward 569 2 ⊕⊕○○ 569 2 ⊕○○○ 569 2 ⊕○○○ –––
Job insecurity 12 449 3 ⊕⊕○○ ––– ––– – ––
Relationship between occupational environment and LESS burnout
Workplace justice 921 3 ⊕⊕○○ 446 1 ⊕○○○ 446 1 ⊕○○○ 662 1 ⊕○○○
The scientific evidence is insufficient
Job strain ––– ––– – – 2 555 1 ⊕○○○
Job development ––– ––– – – 952 1 ⊕○○○
Work place conflicts 3 004 1 ⊕○○○ ––– – – – ––
Threats 585 1 ⊕○○○ –––––––
Lack of feedback 207 1 ⊕○○○ –––––––
Aspects of the occupational role 274 1 ⊕○○○ 274 1 ⊕○○○ 274 1 ⊕○○○ 952 1 ⊕○○○
Long working week 523 1 ⊕○○○ ––– ––– – ––
Physical environment ––– – – ––– 362 1 ⊕○○○
a
Includes outcome from Copenhagen Burnout Inventory (CBI), which measures symptoms of fatigue and exhaustion [7]
Criteria for evidence grading
⊕⊕⊕○There is moderate scientific evidence for a relationship between exposure and outcome. The result is based on studies of high quality
⊕⊕○○There is limited scientific evidence for a relationship between exposure and outcome. The result is based on studies of high or moderate quality
⊕○○○It is not possible to determine if there is a relationship between exposure and outcome. The motivation is that one or several conditions apply: 1) no study
fulfilled the inclusion criteria, 2) none of the studies fulfilling the inclusion criteria were relevant to the hypothesis tested in the present review, 3) all relevant
studies were of low quality or 4) studies were of high or moderate quality –but one or several limitations applied, e.g. inconsistency between studies
Has not been reviewed, due to lack of studies that fulfilled our inclusion criteria
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and vibration, there were no studies meeting the inclusion
criteria.
The datasets generated and/or analysed during the
current study are available in the SBU repository,
http://www.sbu.se/223E.
Results
In all the 25 studies exposure was based on self-report
in standardized and validated questionnaires. For job
demand and control the most commonly applied
instruments were the Job Content Questionnaire (JCQ)
[22] and Copenhagen Psychosocial Questionnaire [23].
About ten different scales were used for the exposure
assessments.
With regard to burnout, a handful of well validated
instruments were used in the included articles. In 18 of
the 25 studies, MBI, MBI-General Survey [4, 5] or the
Dutch adaption of MBI, the Utrecht Burnout Question-
naire [24] were used. The other screening scales were the
CBI (Copenhagen Burnout Inventory) [7], Oldenburg
Burnout Questionnaire [25], Shirom-Melamed Burnout
Questionnaire [26] and the Proactive Coping Inventory
[27]. CBI was used in three studies and the other instru-
ments in only one study each. In general there are high
correlations between these measures. These were reasons
for non-differential use of the measures.
Work environment factors
Table 1 shows the results of the evidence grading
process. The overall picture is that most of the stud-
ies were focused on emotional exhaustion and some-
what fewer on the dimension of depersonalisation.
For (reduced) personal accomplishment and for the
burnout measure there was often only one relevant
study of sufficient quality in relation to a defined
work factor. For the work factor low reward in
relation to depersonalisation and to reduced personal
accomplishment there were two studies of sufficient
quality (Maslach & Leiter 2008; van der Ploeg &
Kleber 2003), but the GRADE-assessment was “limited
scientific evidence”because of inconsistent results in
the two studies.
In the following, we present weighted odds ratios for
the associations between the work factor and the burn-
out measure. For several of the exposure measures, such
as job control, demands and workplace support, we also
present forest plots.
Associations between job control and emotional exhaus-
tion were analysed in a total of 9 studies (De Lange, Taris,
Kompier, Houtman & Bongers, 2004; Geuskens, Koppes,
van den Bossche & Joling, 2012; Janssen & Nijhuis 2004;
Koponen, Laamanen, Simonsen-Rehn, Sundell, Brommels
&Suominen, 2010; Langballe, Innstrand, Aasland &
Falkum 2011; Le Blanc, Hox, Schaufeli, Taris & Peeters,
2007; Magnusson-Hansson, Theorell, Oxenstierna, Hyde
& Westerlund, 2008; Maslach & Leiter 2008; Van der
Ploeg & Kleber, 2003). The results are very consistent,
eight of the nine point estimates were significantly above
1.0 (Fig. 2, note that some data were re-calculated from
correlations to odds-ratios). The weighed odds ratio for
these studies was 1.63, (95% CI 1.53 to 1.75). The results
supported a moderate scientific evidence (grade 3) for a
relationship between low job control and increased
emotional exhaustion.
Two studies (Borritz, Bultman, Rugulies, Christensen,
Villadsen & Kristensen 2005; Sundin, Soares, Grossi &
Macassa, 2011b) used the burnout measure and provided
support for limited scientific evidence for a relationship
between low job control and increased burnout (grade 2).
Job demands were the most frequently studied occupa-
tional exposure in the included studies. Unspecified psy-
chological demands were studied in relation to emotional
exhaustion in 13 studies (Bakker, Schaufeli, Sixma, Bosweld
& van Dierendonck, 2000: Chrisopoulos, Dollard, Winefield
& Dormann, 2010; De Lange et al., 2004; Demerouti, Le
Blanc, Bakker, Schaufeli & Hox, 2009; Geuskens et al.,
2012; Janssen et al., 2004; Koponen et al., 2010; Le Blanc et
al.,2007; Prieto, Salanova, Martinez & Schaufeli, 2008;
Magnusson-Hansson et al., 2008; Sundin, Hochwalder &
Lisspers, 2011a; Van de Ven, Van den Tooren & Vlerick.,
2013; Van der Ploeg et al., 2003). For 11 of them (not
Koponen et al., 2010 and Prieto et al., 2008) weighted
odds ratios could be calculated (Fig. 3). The results
were consistent, ten of eleven point estimates were
significantly above 1.0 (weighted OR of 2.53, 95% CI
2.36 to 2.71).
Unspecified psychological demands were also studied
in relation to depersonalisation and cynicism in 4 studies
(Bakker et al., 2000; Demerouti et al., 2009; Le Blanc et
al., 2007; Sundin et al. 2011a). For three of the four stud-
ies the point estimate was above 1.0 with a weighted
odds ratio of 2.37, 95% CI 1.86 to 3.03).
Emotional demands had been studied in relation to
emotional exhaustion in five studies (study Chrisopoulos
et al., 2010; Le Blanc et al., 2007; Prieto et al., 2008; Van
de Ven et al., 2013; Van der Ploeg et al., 2003). The point
estimate was above 1.0 in the four studies where it could
be calculated with a weighted odds ratio of 2.95, 95% CI
2.40 to 3.62.
Finally, demands from patients were studied in rela-
tion emotional exhaustion in three studies (Bakker et al.,
2000; Demerouti et al., 2009; Sundin et al. 2011a). Two
of the studies had 95% CI just below 1.0 (0.99-2.43 and
0.97 to 3.34) but the weighted odds ratio ended at 2.02
(1.50 to 2.72).
In summary, for all three aspects of demands (unspeci-
fied, emotional and from patients) the results supported
limited scientific evidence in relation to emotional
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exhaustion and depersonalisation (grade 2). For demands
and reduced personal accomplishment there were too few
studies for any conclusion.
Job strain, i.e. the combination of high psychological de-
mands and low decision latitude, was investigated in only
one study (Ahola & Hakanen, 2007). The study indicated
a strong association, but the scientific evidence was judged
insufficient since the association with burnout was investi-
gated only in one relevant study of sufficient quality.
Different sources of social support have been studied.
The strongest evidence (grade 3) was found for low work-
place support and emotional exhaustion without specified
source (Burke & Greenglass 1995a;, De Lange et al., 2004;
Geuskens et al., 2012; Janssen et al., 2004; Koponen et al.,
2010; Le Blanc et al., 2007; Magnusson-Hansson et al.,
2008; Sundin et al. 2011a; Van der Ploeg et al., 2003). The
weighted odds ratio based on seven of these studies
was 1.81 (95% CI 1.68 to 1.95) (Fig. 4). There was
also evidence (grade 2) for an association between
low supervisor support (Geuskens et al., 2012,
Magnusson-Hansson et al., 2008; Sundin et al. 2011a;
Theorell, Nyberg, Leineweber, Magnusson-Hansson &
Westerlund 2012; Van der Ploeg et al., 2003), as well
as for low co-worker support (Geuskens et al., 2012;
Magnusson-Hansson et al., 2008; Sundin et al., 2011a;
Van der Ploeg 2003) on one hand and emotional ex-
haustion on the other hand.
There were three studies on low workplace support
and depersonalization (Burke et al. 1995a; Le Blanc et al.
2007; Sundin et al. 2011a) with a weighted ratio 1.59,
(95% CI 1.11 to 2.26) and four studies (Borritz et al.
2005; Burke et al. 1995a,b; Sundin et al., 2011b) on low
workplace support and burnout. The scientific evidence
was rated limited (grade 2).
The high work load category refers to a mixed group of
stressors all of which result in a large volume of work. In
several of these studies the author refers to events leading
to a high work volume. It differs from demands, which
refer to rushed tempo (unspecified) or –and specified –
emotional demands and demands from patients. There
were 7 studies with focus on emotional exhaustion (Burke
et al., 1995b; Demerouti et al., 2009; Langballe et al., 2011;
Le Blanc et al., 2007; Prieto et al., 2008; Maslach et al.,
2008; Van der Ploeg et al., 2003). A weighted odds ratio
could be calculated for 5 of these which resulted in an
odds ratio of 4.22 (CI % 3.50 to 5.11). There was also evi-
dence for an association between high work load and the
dimension of depersonalisation/cynicism. In six studies
the outcome was described as depersonalisation. It was
only possible to calculate weighted odds ratio for two of
them (Maslach et al., 2008; Van der Ploeg et al., 2003) with
an OR of 2.52 CI 95% 1.85 to 3.44). For two of the three
studies on high work load and the outcome described as
cynicism (Demerouti et al., 2009; Le Blanc et al., 2007)
weighted odds ratios were calculated (3.03, CI 95% 3.03
(2.21 to 4.16). The analyses supported limited scientific
evidence (grade 2) in relation to the dimension of
depersonalisation/cynicism. There were three studies on
work load and reduced personal accomplishment. A
weighted odds ratio could not be calculated, but based on
a narrative analysis the evidence was rated limited.
Low reward had a weighted odds ratio of 1.86 (1.37 to
2.52) in relation to emotional exhaustion (Maslach et al.,
2008; Van der Ploeg et al., 2003).
Job insecurity had a weighted odds ratio of 1.39 (1.22
to 1.57) based on all three studies in relation to
emotional exhaustion(Geuskens et al., 2012; Koponen et
al., 2010; Magnusson-Hansson et al., 2008). The result
for low reward and job insecurity supported limited
scientific evidence (grade 2).
There was an association between workplace justice
and decrease in emotional exhaustion (Koponen et al.,
2010; Maslach et al., 2008; Ramarajan, Barsade &
Burack, 2008) with an evidence grade of 2 (a weighted
odds ratio of 0.35, 95% CI 0.27 to 0.45 based on the
3studies).
Insufficient evidence (grade 1) was found for several
factors, which are listed in the lower part of Table 1.
Mostly there are no studies of sufficient quality. One
study investigated the association between physical
environmental factors (in a school environment, Burke
et al., 1995a) and burnout and showed a significant
association but one study is not enough for evidence.
Finally, there were no relevant studies with sufficient
quality of associations between exposures to vibrations,
chemical and biological factors on one hand and burn-
out on the other hand.
Discussion
The purpose of this systematic review was to describe,
summarize and grade evidence for associations between
work environment factors and the development of burnout
in its three dimensions. To our knowledge, the current
meta-analytic study and review is the first that has been
carried out according to the GRADE system [17]. Com-
pared with most previous systematic reviews the present
study had a broader approach, both regarding exposure fac-
tors and the separate burnout dimensions, and somewhat
different criteria compared to most other studies for
specifying the scientific evidence through the use of the
GRADE-system. Our review is based on a thorough litera-
ture search as well as upon a systematic evaluation of a
large number of publications. Thus, it includes several en-
vironmentalexposures,physicalaswellaspsychosocial.
Compared with the review and meta-analyses of Alarcon
[16] our review includes more and newer articles and
compared with the review of Seidler et al. [15] we included
Aronsson et al. BMC Public Health (2017) 17:264 Page 9 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
a much broader spectrum of work exposure factors as well
as outcomes (all three dimensions of burnout).
Our focus on all three dimensions of burnout contributed
to new knowledge concerning substantial associations as
well as research needs. The literature search showed that
there were many more studies of emotional exhaustion and
work exposure factors as compared to depersonalization
and reduced personal accomplishment. For personal ac-
complishment there was often only one study of sufficient
quality. In most cases the result indicated a relationship
between the investigated work factors and reduced personal
accomplishment. Our focus on all three dimensions of
burnout may be of interest in the ongoing discussion on
the tendency to reduce burnout to exhaustion and to a clin-
ical medical diagnosis. According to Maslach and Leitner
the driving force in that development is not scientific pro-
gress but rather practical and administrative reasons within
the ward and health system [28]. They argue instead for a
development of research on burnout profiles based on all
three dimensions and explorations of their probably differ-
ent relations to different aspects of the work environment.
Our study was not focused on burnout profiles. However,
due to its focus on all the three dimensions of burnout and
the broad spectra of work factors it may be a contribution
to the development of the “burnout profile approach”and
to expanded knowledge about the relation between the
different burnout dimensions and different work environ-
ment aspects.
Our review confirms previous knowledge in support of
the importance of control, demands and social support
in the development of burnout. The scientific evidence
was highest for associations between burnout symptoms
and job control (moderate) and low workplace support
(moderate). These work environment aspects have been
central in many work environment empirical studies
during the past three decades and therefore also in
earlier meta-analyses. An interpretation is that job
control “protects against”emotional exhaustion and
burnout. Job control and workplace support comprise,
together with job demands, the demand –control-
support model [29, 30]. That model has been used in
many studies of both cross-sectional and longitudinal
design during the last decades. In general the model
predicts mental ill-health [8, 31]. There was an indica-
tion of a relationship between the combination of high
psychological demands and low decision latitude labelled
job strain [29] and burnout, but the scientific evidence
was judged insufficient since the association was
supportedbydatafromonlyonerelevantstudyof
sufficient quality.
The inclusion of several exposure factors, which have
not been investigated in earlier systematic reviews and
meta-analyses, contributed to new knowledge. For some
of these factors (e.g. job strain, lack of feedback, job
development, workplace conflicts and threats) there
could be an indication of association with burnout or
one of the dimensions of burnout, but since there was
only one study of sufficient quality we judged it as
insufficient evidence. One or two further studies on
these aspects with results in the same direction will
provide an improved basis for evidence grading.
For some of the other predetermined occupational
factors, the extensive literature search did not identify any
studies; alternatively the studies were of insufficient quality.
There were few prospective studies with sufficient quality
of the relationship between adverse chemical, biological
and physical factors and burnout. A rationale for further
research would be cross-sectional studies indicating associ-
ations. Alternatively a small number of published studies
may be interpreted as low expectancy among researchers
that these factors could be related to burnout.
The literature search included articles published up to
August 2013. However, a more informal search in the
scientific literature (PubMed and PsycInfo until June 2016)
showed that few more prospective studies or other studies
with relevance for the conclusions in our review have been
published. A longitudinal study (9 years) by Evolahti,
Hultell & Collins [32] show rather strong fluctuations in
burnout level related to work aspects (control) and life situ-
ation among women, which may be interpreted as support
for the importance of control. One relevant meta-analysis,
largely based on cross-sectional studies, was identified. It
showed that job control had a stronger relationship with
depersonalization and personal accomplishment than with
emotional exhaustion [33]. None of these studies would
have changed our results and conclusions.
The present review has not specifically addressed the
economic cost for societies related to burnout, but such
costs may be considerable since burnout is related to
performance, sickness absence and disability pension. A
meta-analysis performed by Taris [34] supported the
association between emotional exhaustion and perfor-
mance. The evidence for the relationships between
depersonalization, personal accomplishment, and per-
formance was inconclusive. In a later meta-analytic study
including 115 different studies Swider and Zimmerman
[35], found that all three dimensions of job burnout had
independent correlations with different aspects of costs
and performance; .23 with absenteeism, .33 with turnover,
and .36 with job performance.
Methodological considerations
Our literature search was focused on the central data-
bases for work environment factors and health. There
may be a possibility that relevant studies could have
been published in business and management focused
journals, which were not included in our database
search. Our experience is that advanced quantitative
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.
burnout researchers without exception publish their
studies in psychological and medical journals. This was
supported by a simple search in Business Source Premier
on “Burnout”and “longitudinal”or “Burnout”and “pro-
spective”and got about 30 articles1990 to 2016.
All the included 25 studies were based upon self-reports
of occupational exposure and burnout outcomes. Until
now, there are no large epidemiological prospective stud-
ies with more objective measures of the exposure and the
outcome, i.e. not only self-reports but also assessments
from professionals in the health care system. Data with
subjective descriptions of both explanatory and dependent
factors increase the risk of inflated associations [36]. This
is particularly the case in cross-sectional studies while in
prospective studies this risk is less pronounced. Accord-
ingly, we only included prospective studies with data on
initial symptoms and standardized measures of exposure
and outcome. Future studies based on more objective
assessment of exposure would be beneficial because an
individual’s self-report of the work environment or how
work is perceived may be influenced by the level of emo-
tional exhaustion or burnout with obvious risk for reverse
causation. Of course this does not mean that only “objecti-
fiable”stress is harmful for health.
Unfortunately, the analytical structure only allowed us
to look at single exposure factors. Of course, there may
be interaction between different classes of exposures.
In the forest plots, we chose to use data from the least
adjusted model from each study. The main rationale for
this was that these models were more comparable be-
tween studies than other models, since the more adjusted
ones were adjusted to widely different potential con-
founders. However, in general the differences between the
least adjusted and the more adjusted models were rather
small. For transparency, we have listed data in both least
and most adjusted models, see tables at http://
www.sbu.se/223E. An important point is that if a study
presented data using several statistical models, all data
from all models were included in the assessment of
scientific evidence for all of the results presented in this
systematic review.
As was mentioned, the expert group conducted sub-
group analyses to explore whether the results were
homogenous when subgroups of studies were compared.
Accordingly results were compared for studies of partici-
pants from the general population vs. specific occupations,
occupational environments in North America, Europe vs.
the Nordic countries. Inspection of the confidence interval
distributions, as well as sub-populations’summary odds
ratios and their confidence intervals showed homogeneity
across those dichotomies.
Data from the 25 included studies did not allow for us
to conduct statistically acceptable comparisons between
men and women, since only few studies presented
gender-separated data. A review by Purvanova and
Muros [37] based on 183 studies, which included studies
with cross-sectional design, showed that female em-
ployees were slightly more often emotionally exhausted
than men, while men were somewhat more frequently
depersonalized than women. Psychosocial factors outside
work may interact with job exposure factors in relation
to the risk of burnout, and such interactions may differ
between men and women. This is a topic for further re-
search with more advanced design and gender stratified
analyses.
It cannot be excluded that some work environment
factors may interact positively or negatively in relation
to burnout outcomes. The lack of interaction shown in
many cross-sectional studies does not exclude that such
interactions exist because they may need a prolonged
period of time to develop or did not have sufficient
power for interaction tests. Our approach with focus on
single factors can be explained by the lack of complex
longitudinal studies where interaction effects had been
studied. There is a need for future studies on this issue.
Conclusions
While high levels of job support and workplace just-
ice were protective for emotional exhaustion, high de-
mands, low job control, high work load, low reward
and job insecurity increased the risk for developing
exhaustion. Despite the large number of studies on
burnout, this systematic review found rather few
studies of methodologically high quality. There is a
need for more detailed studies of the different dimen-
sions of burnout in relation to work exposure factors.
The potential importance of organizational interven-
tions is illustrated by the findings that the development of
the burnout syndrome is influenced by structural work
environment factors such as job demands, low possibility
to exert control and non-supportive workplaces. For most
of the studied exposures the observed risks were of limited
or moderate size, but despite this, the risks may still have
a societal importance. If a work environment factor has a
30% prevalence and is associated with a relative risk
of 1.6, the resulting population attributable risk is 7%,
i.e. the proportion of disease in the exposed group
that could be prevented by eliminating the risk factor.
Accordingly, when an occupational exposure is fre-
quent, even a moderately elevated risk associated with
it becomes important in a societal context. Thus, the
results presented here and elsewhere imply a strong
need for improved psychosocial work environments to
prevent burnout. The fact that the source of burnout
often lies in structural work environment factors
points at the potential value of multifactorial inter-
ventions. Strict studies of such interventions will
Aronsson et al. BMC Public Health (2017) 17:264 Page 11 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
generate more knowledge about the burnout
phenomenon and would contribute useful knowledge
for preventive measures.
Additional file
Additional file 1: The 25 studies judged to be of high or medium high
quality. (DOC 32 kb)
Acknowledgements
Not applicable
Funding
This study has been funded by the Swedish Council of Health Technology
Assessment. The Swedish Government has had no role in the work, neither
in the scientific work itself nor in the writing of the article. The review has
been funded by the Swedish Council of Health Technology Assessment.
Availability of data and material
The datasets generated and/or analysed during the current study are
available in the SBU respository http://www.sbu.se/223E.
Authors’contributions
GA made substantial contribution to conception, analysis and interpretation
of data and has written large parts of the manuscript. TT was chairman of
the expert committee, TG, AH, CHo, IM, LTB, IS and Cha, have all contributed
substantially to the expert panel work and have made important comments
to the manuscript. CHa has performed most of the statistical work and
contributed both to the conceptualizing and the writing of the manuscript.
All authors read and approved the final manuscript.
Authors’information
The authors deliberately represent a diversity of academic fields, namely
psychiatry (LTB, IS, IM), work psychology (GA), occupational epidemiology
(AH, CH), stress research (TT) and general practice (TG).
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable (se above).
Ethics approval and consent to participate
All studies perused in this review have been approved by the scientific
ethical committees in their universities. They have all been published in
international scientific journals with peer review. Accordingly, no additional
ethical approval has been required.
Author details
1
Department of Psychology, University of Stockholm, S-10691 Stockholm,
Sweden.
2
Stress Research Institute, University of Stockholm, Stockholm,
Sweden.
3
Department of Neuroscience, Karolinska Institutet, Stockholm,
Sweden.
4
Health Care Centre, Norrtälje, Sweden.
5
Department of Public
Health and Clinical Medicine, University of Umeå, Umeå, Sweden.
6
Division
of Occupational Medicine, Institute for Environmental Medicine, Karolinska
Institutet, Solna, Sweden.
7
Division of Psychiatry, University of Linköping,
Linköping, Sweden.
8
Department of Psychiatry and Neurochemistry,
University of Gothenburg, Gothenburg, Sweden.
9
Division of Psychiatry,
University of Lund, Lund, Sweden.
10
Swedish Council of Health Technology
Assessment, Stockholm, Sweden.
Received: 3 September 2016 Accepted: 1 March 2017
References
1. Freudenberger HJ. Staff burn‐out. J of Social Issues. 1974;30(1):159–65.
2. Maslach C. Burnout. Hum Behav. 1976;5(9):16–22.
3. Maslach C, Leiter M. Editorial. Burnout Res. 2014;1:1–2.
4. Maslach C, Jackson SE. The measurement of experienced burnout. J Org
Behav. 1981;2(2):99–113. doi:10.1002/job.4030020205.
5. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;
52(1):397–422. doi:10.1146/annurev.psych.52.1.397.
6. Pines AM, Aronson E, Kafry D. Burnout: From tedium to personal growth.
New York: Free Press; 1981. p. 15.
7. Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen
Burnout Inventory: A new tool for the assessment of burnout. Work &
Stress. 2005;19(3):192–207. http://www.tandfonline.com/doi/abs/10.1080/
02678370500297720.
8. Bakker AB, Costa PL. Chronic job burnout and daily functioning: A
theoretical analysis. Burnout Research. 2014;1(3):112–9. doi.org/10.1016/j.
burn.2014.04.003.
9. Schaufeli WB, Leiter MP, Maslach C. Burnout: 35 years of research and
practice. Career Dev Int. 2009;14(3):204–20. http://dx.doi.org/10.
1109%2FEMR.2010.5645750.
10. Hallsten, L., Bellaagh, K., & Gustafsson, K. (2002). Utbränning i Sverige –En
populationsstudie [Burnout in Sweden- A population study]. Arbete & Hälsa
2002:6 Stockholm: National Institute for Working Life; (in Swedish).
11. Lindblom KM, Linton SJ, Fedeli C, Bryngelsson L. Burnout in the working
population: relations to psychosocial work factors. Int J Behav Med. 2006;
13(1):51–9. http://www.ncbi.nlm.nih.gov/pubmed/16503841.
12. Kant IJ, Jansen NWH, Van Amelsvoort LGPM, Mohren DCL, Swaen GMH.
Burnout in de werkende bevolking. Resultaten van de Maastrichtse Cohort
Studie. [Burnout in the working population. Results of the Maastricht Cohort
Study]. Gedrag & Organisatie. 2004;17:5–17.
13. Marchand A, Blanc M-E, Durand P. Genre, âge, profession, secteur
économique et santé mentale en milieu de travail: Les résultats de l’étude
SALVEO. Revue canadienne de santé publique/Can J of Pub Health. 2015;
106:e223–9. http://dx.doi.org/10.17269/CJPH.106.4672.
14. Adriaenssens J, De Gucht V, Maes S. Determinants and prevalence of
burnout in emergency nurses: A systematic review of 25 years of research.
Int J Nurs Stud. 2015;52(2):649–61. http://www.ncbi.nlm.nih.gov/pubmed/
25468279.
15. Seidler A, Thinschmidt, M, Deckert S, Then F., Hegewald J,
Nieuwenhuijsen, K & Riedel-Heller, S. G. The role of psychosocial
working conditions on burnout and its core component emotional
exhaustion–a systematic review. J Occup Med Toxic 2014;9, 1, 10.
Retrieved from http://www.occup-med.com/content/9/1/10.
16. Alarcon GM. A meta-analysis of burnout with job demands, resources, and
attitudes. J of Voc Behav. 2011;79(2):549–62. doi.org/10.1016/j.jvb.2011.03.007.
17. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Schünemann HJ.
GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary
of findings tables. J Clin Epidemiol. 2011;64(4):383–94.
18. Assessment and Evidence. http://www.sbu.se/en/Assessment-and-Evidence/.
19. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. Ann of Intern
Med. 2009;151(4):264–9. doi:10.7326/0003-4819-151-4-200908180-00135.
20. Theorell T, Hammarström A, Aronsson G, Bendz LT, Grape T, Hogstedt C,
Hall C. A systematic review including meta-analysis of work environment
and depressive symptoms. BMC Public Health. 2015;15(1):738. doi:10.1186/
s12889-015-1954-4.
21. The Grade Approach. http://handbook.cochrane.org/chapter_12/12_2_1_
the_grade_approach.htm.
22. Karasek RA. Job content questionnaire and user’s guide. Lowell: University
of Massachusetts; 1985.
23. Kristensen TS, Hannerz H, Høgh A, Borg V. The Copenhagen Psychosocial
Questionnaire-a tool for the assessment and improvement of the psychosocial
work environment. Scand J Work Environ & Health. 2005;31(6):438–49. doi:10.
5271/sjweh.948 .
24. Schaufeli WB, Salanova M, González-Romá V, Bakker AB. The measurement
of engagement and burnout: A two sample confirmatory factor analytic
approach. J Happ Stud. 2002;3(1):71–92.
25. Demerouti E, Mostert K, Bakker AB. Burnout and work engagement: a thorough
investigation of the independency of both constructs. J Occup Health Psychol.
2010;15(3):209–22. http://psycnet.apa.org/doi/10.1037/a0019408.
26. Shirom A, Melamed S. A comparison of the construct validity of two
burnout measures in two groups of professionals. Int J of Stress Manag.
2006;13(2):176–99. http://psycnet.apa.org/doi/10.1037/1072-5245.13.2.176.
27. Greenglass E, Schwarzer R, Jakubiec D, Fiksenbaum L, Taubert S. The
proactive coping inventory (PCI): A multidimensional research instrument. In
Aronsson et al. BMC Public Health (2017) 17:264 Page 12 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
20th International Conference of the Stress and Anxiety Research Society (STAR),
Cracow, Poland 1999, July, Vol. 12, p. 14.
28. Maslach C, Leiter M. Understanding the burnout experience: recent research
and its implications for psychiatry. World Psychiatry. 2016;15(2):1–9.
doi:10.1002/wps.20311.
29. Karasek RA, Theorell T. Healthy work: stress, productivity, and the
reconstruction of working life. New York: Basic books; 1990.
30. Johnson JV, Hall EM. Job strain, work place social support, and
cardiovascular disease: a cross-sectional study of a random sample of the
Swedish working population. Am J Pub Health. 1988;78(10):1336–42.
31. Stansfeld S, Candy B. Psychosocial work environment and mental health—a
meta-analytic review. Scand J Work Environ Health. 2006;32:443–62.
Retrieved from http://www.jstor.org/stable/40967597.
32. Evolahti A, Hultell D, Collins A. Development of burnout in middle-aged
working women: A longitudinal study. J Women’s Health. 2013;22(1):94–103.
33. Park HI, Jacob AC, Wagner SH, Baiden M. Job control and burnout: a
meta‐analytic test of the conservation of resources model. Appl Psychol.
2014;63(4):607–42. http://onlinelibrary.wiley.com/doi/10.1111/apps.12008/
abstract.
34. Taris TW. Is there a relationship between burnout and objective performance?
A critical review of 16 studies. Work & Stress. 2006;20(4):316–34. doi:10.1080/
02678370601065893.
35. Swider BW, Zimmerman RD. Born to burnout: A meta-analytic path model
of personality, job burnout, and work outcomes. J Voc Behav. 2010;76(3):
487–506. http://dx.doi.org/10.1016/j.jvb.2010.01.003.
36. Theorell T, Hasselhorn HM. On cross-sectional questionnaire studies of
relationships between psychosocial conditions at work and health—are
they reliable? Int Arch Occup Environ Health. 2005;78(7):517–22. doi:10.
1007/s00420-005-0618-6.
37. Purvanova RK, Muros JP. Gender differences in burnout: A meta-analysis. J
Voc Behav. 2010;77(2):168–85. http://dx.doi.org/10.1016/j.jvb.2010.04.006.
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