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Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout: A Systematic Narrative Review of the Literature

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Background: Burnout is a widespread, multifactorial, and mainly psychological phenomenon. The pathogenesis of burnout is commonly described within the bio-psycho-social model of health and disease. Recent literature suggests that the phenomenon of burnout may be broader so that the three dimensions might not reflect the multifaceted and complex nature of the syndrome. Consequently, this review aims to identify the diversity of factors related to burnout, to define overarching categories based on these, and to clarify whether the bio-psycho-social model adequately describes the pathogenesis of burnout—holistically and sufficiently. Method: Five online databases (PubMed, PubPsych, PsychARTICLES, Psychology and Behavioral Sciences Collection, and Google Scholar) were systematically searched using defined search terms to identify relevant studies. The publication date was set between January 1981 and November 2020. Based on the selected literature, we identified factors related to burnout. We aggregated these factors into a comprehensible list and assigned them to overarching categories. Then, we assigned the factors to the dimensions of an extended model of health and disease. Results: We identified a total of 40 burnout-related factors and 10 overarching categories. Our results show that in addition to biological, psychological, and socio-environmental factors, various factors that can be assigned to a spiritual and work cultural dimension also play an important role in the onset of burnout. Conclusion: An extended bio-psycho-socio-spirito-cultural model is necessary to describe the pathogenesis of burnout. Therefore, future studies should also focus on spiritual and work cultural factors when investigating burnout. Furthermore, these factors should not be neglected in future developments of diagnosis, treatment, and prevention options.
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SYSTEMATIC REVIEW
published: 01 December 2021
doi: 10.3389/fpsyg.2021.722862
Frontiers in Psychology | www.frontiersin.org 1December 2021 | Volume 12 | Article 722862
Edited by:
Erich Christian Fein,
University of Southern
Queensland, Australia
Reviewed by:
Mohamed Metwally,
King’s College London,
United Kingdom
Elliot Berry,
Hebrew University of Jerusalem, Israel
*Correspondence:
Ian W. Listopad
Ian.Listopad@uni-wh.de;
ian.listopad@gmail.com
Specialty section:
This article was submitted to
Organizational Psychology,
a section of the journal
Frontiers in Psychology
Received: 09 June 2021
Accepted: 01 November 2021
Published: 01 December 2021
Citation:
Listopad IW, Michaelsen MM,
Werdecker L and Esch T (2021)
Bio-Psycho-Socio-Spirito-Cultural
Factors of Burnout: A Systematic
Narrative Review of the Literature.
Front. Psychol. 12:722862.
doi: 10.3389/fpsyg.2021.722862
Bio-Psycho-Socio-Spirito-Cultural
Factors of Burnout: A Systematic
Narrative Review of the Literature
Ian W. Listopad*, Maren M. Michaelsen, Lena Werdecker and Tobias Esch
Institute for Integrative Health Care and Health Promotion, Department of Medicine, Faculty of Health, Witten/Herdecke
University, Witten, Germany
Background: Burnout is a widespread, multifactorial, and mainly psychological
phenomenon. The pathogenesis of burnout is commonly described within the
bio-psycho-social model of health and disease. Recent literature suggests that the
phenomenon of burnout may be broader so that the three dimensions might not reflect
the multifaceted and complex nature of the syndrome. Consequently, this review aims to
identify the diversity of factors related to burnout, to define overarching categories based
on these, and to clarify whether the bio-psycho-social model adequately describes the
pathogenesis of burnout—holistically and sufficiently.
Method: Five online databases (PubMed, PubPsych, PsychARTICLES, Psychology and
Behavioral Sciences Collection, and Google Scholar) were systematically searched using
defined search terms to identify relevant studies. The publication date was set between
January 1981 and November 2020. Based on the selected literature, we identified factors
related to burnout. We aggregated these factors into a comprehensible list and assigned
them to overarching categories. Then, we assigned the factors to the dimensions of an
extended model of health and disease.
Results: We identified a total of 40 burnout-related factors and 10 overarching
categories. Our results show that in addition to biological, psychological, and
socio-environmental factors, various factors that can be assigned to a spiritual and work
cultural dimension also play an important role in the onset of burnout.
Conclusion: An extended bio-psycho-socio-spirito-cultural model is necessary to
describe the pathogenesis of burnout. Therefore, future studies should also focus
on spiritual and work cultural factors when investigating burnout. Furthermore, these
factors should not be neglected in future developments of diagnosis, treatment, and
prevention options.
Keywords: burnout, stress, spirituality, work culture, bio-psycho-socio-spirito-cultural model, burnout
dimensions, systematic narrative review
INTRODUCTION
One of the most common psychological symptoms that increasingly affect people is burnout,
which is commonly described as a consequence of chronic work-related stress (Melamed et al.,
2006; Maslach and Leiter, 2016). Maslach et al. (1996) describe burnout with three subscales:
(1) exhaustion, (2) depersonalization/cynicism, and (3) reduced professional efficacy/reduced
Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
personal accomplishment. A key aspect of burnout is
exhaustion which manifests as feelings of being overextended.
Depersonalization/cynicism refers to cynical and negative
attitudes toward work and people with whom one interacts (e.g.,
customers, colleagues). Reduced professional efficacy is related
to a lack of performance at work. According to Maslach et al.
(1996), burnout is characterized by high levels of emotional
exhaustion and depersonalization and low levels of professional
efficacy. The Maslach Burnout Inventory (MBI; Maslach et al.,
1996) has been developed based on these three subscales. Apart
from the MBI, there are also other instruments for measuring
burnout [e.g., Shirom-Melamed Burnout Measure (SMBM),
Shirom and Melamed, 2006; Oldenburg Burnout Inventory
(OLBI), Demerouti et al., 2001; Copenhagen Burnout Inventory
(CBI), Kristensen et al., 2005].
The stress model of Folkman and Lazarus (1985) represents
an established concept in explaining human stress reactions
(Riedl, 2013). Here, stress is not primarily understood as
a biological phenomenon but as a complex construct that
arises from the interactions between an individual and the
demands of a situation and is associated with both negative
and positive emotions (Folkman, 2008). Thus, the cognitive
appraisal processes of the individual are considered in the
stress model. Consequently, the decisive factor for a stress
reaction is not primarily the stimulus or the situation in
which a stimulus is perceived, but its appraisal by the
individual as well as the coping resources (Folkman et al.,
1986). However, the triggering of stress reactions does not
presuppose the conscious perception of stressors and the
possibility of coping with them. Complementing the theory
of Folkman et al. (1986), it is also possible in exceptional
cases to be (physiologically) stressed without perceiving it
and/or without feeling incompetent (Esch et al., 2002; Benson
and Stefano, 2005; McEwen, 2007, 2017; Esch and Stefano,
2010; Werdecker and Esch, 2018). In this respect, it would
also be possible to experience burnout without noticing
that there is, e.g., a coping problem. Thus, stress and its
consequences to health is a question of dose, controllability,
and possessing the inner resources to cope and manage
(Stefano et al., 2005).
In addition to Karasek’s (1979) demand-control model
and Siegrist (2002) effort-reward imbalance (ERI) model
(occupational gratification crisis), which are related to stress and
burnout (Violanti et al., 2018; Demerouti and Nachreiner, 2019),
there are also other approaches in stress and burnout research.
One model to explain the onset of burnout and disengagement
is the job demands-resource model (Demerouti et al., 2001).
According to the model, variables of work can be divided into
demands and resources. An accumulation of demands (e.g.,
time pressure) can be related to the exhaustion component
of burnout. In contrast, job resources (e.g., job control) are
associated with work engagement (opposite pole of burnout)
through the motivational process of the model. The model was
additionally extended by an interaction effect between demands
and resources, since existing resources can mitigate the negative
effect of demands (Demerouti et al., 2001; González-Romá et al.,
2006).
Burnout is a risk that is associated with different stress-related
physical (Maslach et al., 2001), psychosomatic (e.g., Melamed
et al., 2006), and mental disorders such as depression and
anxiety (Koutsimani et al., 2019). Besides consequences for the
individual, there are also consequences in occupational health
such as reduced work engagement (Schaufeli and Bakker, 2004;
Maslach and Leiter, 2008, 2016; Schaufeli et al., 2009), which
can be associated with various forms of withdrawal resulting in
absenteeism and increased intention to quit (Alarcon, 2011; Kim
and Kao, 2014). Thus, burnout not only affects the individual,
but incurs costs for employers, the health system, and society
in general (Wigert and Agrawal, 2018; Borysenko, 2019; Smith,
2019; Werdecker and Esch, 2020).
Burnout in the ICD-11 and Current
Research
In the ICD-111of the World Health Organization (WHO),
burnout is described on the basis of the three burnout subscales
of Maslach et al. (1996) and attributed to chronic stress at work.
This means that people develop burnout when they cannot
successfully manage work stressors. Furthermore, burnout is
classified as an “occupational phenomenon” rather than a
medical condition [Werdecker and Esch, 2021; WHO (World
Health Organization), 2021].
Given extensive research in the field of stress and stress
physiology, burnout and its underlying causes are numerous
and complex (e.g., Esch, 2002, 2003; Esch and Stefano, 2010;
Werdecker and Esch, 2018, 2021). The symptoms can occur in
the case of overload due to accumulation of demands, lack of job
resources (Demerouti et al., 2001), as well as inappropriate and
insufficient health resources and resistance factors (individual
resilience and coherence factors) (Gillespie et al., 2007). In
addition, burnout seems to be associated with several factors
such as control, fairness, support, reward, coping strategies,
personality variables, etc. (Maslach and Leiter, 2008, 2016;
Alarcon et al., 2009; Kay-Eccles, 2012; Shin et al., 2014).
Although there are various studies examining burnout, there
is a lack of a holistic view—including whether biological,
psychological, and socio-environmental factors (based on the
established health and disease model) are sufficient to describe
the onset of the syndrome.
A Paradigm Shift in the Context of
Burnout?
This hypothesis is based on several strands from the
psychological, sociological, and medical literatures. According
to various authors, the established bio-psycho-social model by
Engel (1977) has limitations (e.g., Suls and Rothman, 2004;
Havelka et al., 2009; Babalola et al., 2017; Listopad et al.,
2021). The limitations concern, e.g., the isolation between the
individual dimensions, lack of consideration for the emotional
relationships between patients and professionals, possibility
of extension concerning the sociotype, with the subdivisions
of the environment into three domains [i.e., individual (intra-
personal); relationships (inter-personal), and context (work
1ICD-11 is the eleventh International edition of the Classification of Diseases.
Frontiers in Psychology | www.frontiersin.org 2December 2021 | Volume 12 | Article 722862
Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
and leisure environment, etc.)], as well as cultural and spiritual
aspects as supplementary dimensions (Sulmasy, 2002; Suls and
Rothman, 2004; McGee and Torosian, 2006; Esch, 2008a, 2011,
2019; Havelka et al., 2009; Babalola et al., 2017; Berry et al.,
2017; Listopad et al., 2021). There is preliminary evidence that
spirituality, meaningfulness, faith, and trust are pain- and stress-
reducing and essential within a holistic model of health and
disease (Sulmasy, 2002; McGee and Torosian, 2006; Esch, 2008a,
2011, 2019; Saad et al., 2017; Listopad et al., 2021). Likewise,
according to Esch (2017), the feeling of “home” (e.g., facets of
homeliness, belongingness, and environmental connectedness)
is biologically and culturally determined and—analogous to
spirituality—should not be missing from a model of health and
disease (Esch, 2008a, 2011, 2019; Listopad et al., 2021).
Initial studies indicate that psychological-mental aspects such
as inner/intrapersonal resources, e.g., perceived meaningfulness,
faith, belief, mindfulness, as well as the feeling of homeliness
in one’s environment, belongingness, and connectedness are
associated with life satisfaction, happiness, work engagement,
well-being, resilience, stress, and health maintenance (Esch and
Stefano, 2007; Esch, 2008a, 2011, 2019; Caglar, 2011; Daniel,
2014; Van Wingerden and van der Stoep, 2017; Scanlan and
Hazelton, 2019). In addition, there are preliminary studies that
draw attention to the limitations of the bio-psycho-social model,
as some factors (e.g., spirituality, perceived meaningfulness of
work, and sense of homeliness) associated with burnout cannot
be clearly attributed to Engel’s model published in 1977 (Golden
et al., 2004; Salmoirago-Blotcher et al., 2016; Carneiro et al.,
2019; Esch, 2019; Listopad et al., 2021). However, in this context,
the investigation of burnout within the bio-psycho-socio-spirito-
cultural model still represents a research gap (Esch, 2019;
Listopad et al., 2021) which we aim to address in our study.
Objectives
The present review aims to identify all relevant burnout factors
(variables related to burnout or [chronic] stress) that are
discussed in the literature to date. Furthermore, we aim at
aggregating these factors into overarching categories and listing
and enumerate them to achieve a better understanding. Next,
we assign these factors to various dimensions of the (extended)
health and disease model.
Consequently, we investigate the following research questions.
First, according to the current literature, what are the
factors associated with the onset of burnout? Second, to
which overarching categories can the identified factors be
summarized? Finally, is the bio-psycho-social model sufficient to
comprehensively describe the pathogenesis of burnout or is an
extension of the model necessary?
METHODS
The present study is based on a systematic narrative approach.
First, a systematic literature search with corresponding
search codes and defined inclusion and exclusion criteria was
performed. Subsequently, based on the underlying objectives of
the article, the results were presented using a narrative approach.
TABLE 1 | Used databases and generic search strings.
Databases Generic search strings
PubMed “Burnout[MeSH] AND (determinants[tiab] OR
variables[tiab] OR factors[tiab], OR reasons[tiab]
AND (“1981/01/01”[Date - Publication]: “300”[Date -
Publication]))”
PubPSYCH “TI=(“Burnout” (determinants, OR variables, OR
factors, OR reasons)) PY>=1981 PY<=2019”
PsychARTICLES “allintitle: Burnout”
Psychology and Behavioral
Sciences Collection
“allintitle: Burnout”
Google Scholar “allintitle: Burnout AND determinants OR variables”
Systematic Search Strategy
To reduce a possible bias in the literature selection and retrieve
relevant research studies, a systematic search procedure was
conducted (Jahan et al., 2016). For the literature search, databases
were selected that contain psychological, medical, as well as
social and health science articles. A two-stage search strategy
as recommended by various authors was applied (Green et al.,
2006; Ressing et al., 2009; Ferrari, 2015). First, the search
was conducted in the databases (1) PubMed, (2) PubPsych2,
(3) PsychARTICLES, (4) Psychology and Behavioral Sciences
Collection, and (5) Google Scholar3. The search criteria with
the various search terms (“burnout,” “determinants,” “variables,
“factors,” and “reasons”) are listed in Table 1.
As already mentioned above, for the PsychARTICLES and
Psychology and Behavioral Sciences Collection databases, we
decided to conduct an “umbrella” search strategy with the search
term “burnout” to attain a high number of eligible studies and
not to neglect potentially relevant investigations. This type of
search strategy was not possible for PubMed and PubPSYCH due
to the high number of hits (almost 20,000 articles in total) and
associated processing time involved in such a publication process.
Instead, a refined search code was applied here. Secondly, a
review of the references was carried out during the full-text
screening (“snowball” method). The “snowballing” approach was
additionally chosen as it has been recommended by different
authors (DePoy and Gitlin, 1993; Green et al., 2006; Karpetis,
2019) as an important technique to fill in possible gaps in the
database search.
Inclusion and Exclusion Criteria
Various empirical quantitative and qualitative studies, reviews,
and theoretical articles focusing on burnout were eligible for
inclusion in the current review. English and German language
studies published between January 1981 and November 2020
2The literature search in PSYNDEX for publication references of German
psychological has been neglected, as the literature search in PubPsych already
covers it.
3The search in the PsycINFO database was not used as the recommended
minimum number of databases was reached. According to Green et al.
(2006), it is recommended to use at least two databases for the literature
research in a narrative review, so that the prerequisite corresponds to current
literature recommendations.
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Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
have been considered. The year 1981 was chosen due to the
development of the MBI (Maslach and Jackson, 1981). The
starting date has already been used in another literature review
on work stress and burnout by Schaufeli and Peeters (2000). Since
burnout is mainly investigated as an “occupational phenomenon”
and accordingly listed in the future ICD-11 [WHO (World
Health Organization), 2021], the articles included are limited
to working adults. In addition, we try to consider comparable
populations by focusing on the workforce. Studies that did not
refer to burnout (e.g., when burnout was equated with depression
and surveyed with a depression inventory) were excluded due
to different underlying concepts and potential causes, while
identified studies that were related to (chronic) stress at work
and therefore associated with burnout [due to the definition
in the ICD-11; WHO (World Health Organization), 2021]
were included. In addition to cross-sectional and longitudinal
studies, reviews (meta-analyses, systematic reviews, and narrative
reviews), as well as theoretical articles were reviewed as they also
contain relevant results and references on burnout.
Systematic Analysis Procedure
For each search engine, we documented the search results.
After the articles were identified in the corresponding databases,
the titles and abstracts were screened. Based on the inclusion
and exclusion criteria, 260 articles were eligible (first stage of
the search). As mentioned, during the full-text screening, a
review of the references was also performed to identify further
eligible articles (“snowball technique,” second stage of search).
In the second stage of search (reviewing the reference list), 116
additional articles were found. Thus, a total of 376 articles were
full-text screened, while 122 articles were finally included in this
review (see Figure 1). According to Krause et al. (2015), we
used an evidence table (consisting of source/study type, sample,
study objective, method, results, general comments, and possible
overarching category of identified burnout factors) for a better
overview and summary.
RESULTS
The identified literature was diverse in terms of study design
and setting. Although the MBI was predominant, other burnout
questionnaires (e.g., SMBM, Shirom and Melamed, 2006; OLBI,
Demerouti et al., 2001) were also used. Even though some studies
focused on selected occupations and sectors, the results were
largely homogeneous with regard to burnout factors. In the
following, we will present the findings sorted by factors and their
overarching categories. At the end of the chapter, we will assign
the factors to the model of health and disease.
Identified Burnout Factors and Their
Superordinate Categories (Research
Question 1 and Research Question 2)
The selected studies provide the results according to the current
state of the literature. Here, we present the identified factors
associated with burnout (research question 1) as well as the
corresponding overarching categories (research question 2).
Based on all relevant burnout factors identified through
our search, we have aggregated the factors (e.g., appropriate
workload/working time) into 10 categories (e.g., working
environment) using an evidence table as recommended by
Krause et al. (2015) and an inductive category formation
(Mayring, 2015). To ensure clarity and structure, as well as
contextual relationships, we listed the categories according to
the dimensions (biological dimension, psychological dimension,
etc.) of the health and disease model; even when factors can be
assigned to multiple dimensions. The following categories for
the burnout factors were identified: (1) lifestyle, (2) physical and
mental health, (3) self-reference, (4) relaxation, (5) work-to-life
interrelation, (6) support, (7) working environment, (8) Big Five
personality traits, (9) perceived meaningfulness and (10) sense
of homeliness. Table 2 illustrates the allocation of the burnout
factors to the, respectively, defined categories and their direction
(+/–) in relation to their association with burnout.
(1) Lifestyle
In the course of the literature search, various burnout factors
were identified that can be assigned to lifestyle, such as exercise,
limited use of information and communication technology,
healthy nutrition, and reduced consumption of cigarettes, alcohol,
and medication.
Exercise
Various studies prove the relation between exercise such as
aerobic and anaerobic physical activities and its relationship with
burnout (Jonsdottir et al., 2010; Toker and Biron, 2012; Lindwall
et al., 2014; Hu et al., 2016; Dreher et al., 2018). According to Hu
et al. (2016), workers who work more than 60 h a week and do
not engage in any physical activity have the highest risk ratio of
developing burnout. It was demonstrated that professionals who
are engaged in light physical activity or moderate physical activity
are less likely to report high levels of burnout and perceived
stress compared to professionals who are not engaged in physical
activity (sedentary lifestyle) (Stenlund et al., 2009; Jonsdottir
et al., 2010; Gerber et al., 2013; Tsai et al., 2013; Dreher et al.,
2018).
Limited Use of Information and Communication Technology
(ICT)
ICT refers to the interaction with various devices (mobile phone,
computer, etc.) and programs (e.g., applications) and can be
associated with the development of technostress (stress that
results from the use of technological devices) (Listopad and
Brünner, 2020). Various identified studies demonstrated the
relationship between the use of ICT and burnout (Popoola and
Oluwole, 2013; Derks and Bakker, 2014; Maier et al., 2015).
According to Popoola and Oluwole (2013) as well as Maier
et al. (2015), the use of ICT can lead to technostress, which can
contribute to techno-exhaustion, which in turn is significantly
associated with work exhaustion and burnout. Their findings
highlight that smartphone use is moderately positively correlated
with emotional exhaustion and can prevent professionals from
building psychological detachment to work-related issues which
is important for relaxation, and which can help professionals
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Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
FIGURE 1 | PRISMA flow diagram of the systematic literature selection process.
to recover from stress (Sonnentag and Fritz, 2007; Sonnentag
et al., 2010; De Jonge et al., 2012; Sonnentag, 2018). Another
study reports that digitalization and the related technostress
can be associated with technology-related work-home conflicts,
invasion of privacy, work overload, avoidance of role ambiguity,
and job insecurity, thus promoting burnout and stress (Maier
et al., 2015).
Healthy Nutrition
This factor includes foods that are rich in complex carbohydrates,
proteins, Vitamin B, Vitamin C, and Magnesium (e.g., Esch and
Stefano, 2007, 2010; Esch, 2011; Esch and Esch, 2016; Singh,
2016). Furthermore, the enjoyment of food as well as mindful
eating also plays a central role in stress management (Esch and
Esch, 2016). Currently there are only first indications regarding
the negative connection between healthy nutrition and (chronic)
stress (e.g., Esch and Stefano, 2007; Esch, 2010; Esch and Esch,
2016; Singh, 2016).
Reduced Consumption of Cigarettes, Alcohol, and
Medication
This factor includes a lifestyle with various components.
A cross-sectional study by Soares et al. (2007) with 3,591
women identified a relationship between an increased burnout
risk and the consumption of cigarettes and psychoactive as
well as somatic medication. Their analysis also showed that
medications are associated with high burnout—regardless of age,
financial burden, illness, work demands, depression, and somatic
complaints. In addition, Ahola et al. (2012) demonstrated that
burnout is associated with high alcohol consumption.
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Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
TABLE 2 | Identified burnout factors, their categories, direction of association with burnout and the assignment to the bio-psycho-socio-spirito-cultural model.
(Continued)
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TABLE 2 | Continued
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Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
(2) Physical and Mental Health
The factors physical health, mental health/well-being, happiness,
life satisfaction, and job satisfaction/positive experience at work are
assigned to the category physical and mental health.
Physical Health
This factor encompasses various physical states. There is
initial evidence regarding an association between burnout and
obesity, musculoskeletal disorders, cardiovascular disease, onset
of coronary heart disease, and type 2 diabetes (Ahola et al., 2012;
Ahola and Hakanen, 2014).
Mental Health/Well-Being
Similar to WHO (World Health Organization) (2018), the
factors (subjective) well-being and mental health are considered
analogously. Mental health is a state in which people can cope
with daily stressors, work productively, and are able to contribute
to the community [WHO (World Health Organization), 2018].
Well-being applies to inter- and intraindividual levels of positive
functioning (e.g., relationships with others, self-referential
attitudes, personal growth) (Burns, 2016). A significant
relationship between burnout and depression, as well as between
burnout and anxiety has been demonstrated by Koutsimani et al.
(2019) and Ortega-Campos et al. (2019). Similar correlations
between burnout and mental disorders, as well as burnout and
well-being, are also shown by other authors (e.g., Hapke et al.,
2013; Ahola and Hakanen, 2014; Siu et al., 2014; Johnson et al.,
2018; Schwarzkopf et al., 2019).
Happiness
According to Diener (2000), the factor happiness can be
defined as the moods and emotional reactions of workers to
circumstances at work and at home, so that they play a central
role—both inside and outside organizations (Seligman, 2002).
Happiness thus refers to the affective and subjective evaluation of
people’s lives. People experience happiness when they feel many
pleasant and few unpleasant emotions (Diener, 2000). Various
authors demonstrate that happiness is negatively associated with
burnout and stress (Van Dierendonck et al., 2005; Feicht et al.,
2013). Moreover, Demerouti et al. (2018) showed that generally
perceived happiness is not only strongly negatively associated
with exhaustion, but also strongly positively associated with
disengagement at work.
Life Satisfaction
Life satisfaction is a multi-factorial construct with affective-
evaluative and cognitive-evaluative components. The affective
components are characterized by the presence of positive
emotions and the absence of negative ones. In contrast, the
cognitive-evaluative components are composed of global and
domain-specific satisfaction in various areas of life (Diener et al.,
1985). The negative relationship between life satisfaction and
burnout have been shown by various authors (e.g., Hayes and
Weathington, 2007; Senter et al., 2010; Otero-López et al., 2014;
Hakanen and Bakker, 2017).
Job Satisfaction/Positive Experience at Work
This factor includes the personal attitude of an employee toward
work. It can also be linked to a sense of competence and
success at work (Gallavan and Newman, 2013). According to
various studies, low job satisfaction in different occupations and
industries is associated with significantly higher levels of burnout
(Senter et al., 2010; Matin et al., 2012; Scanlan and Hazelton,
2019), while increased job satisfaction or positive experience
at work are negatively related to burnout and corresponding
subscales (Swoboda et al., 2005; Gallavan and Newman, 2013;
Tarcan et al., 2017; Scanlan and Hazelton, 2019). Likewise, a
study by Bilge (2006) discovered that the most important variable
that predicts all three Maslach’s burnout subscales is intrinsic
job satisfaction.
(3) Self-Reference
The factors resilience, perfectionistic striving, self-efficacy,
self-esteem, adaptive coping styles, and mindfulness
identified in the literature can be assigned to the
category self-reference.
Resilience
This factor encompasses the ability to cope with stressful life
situations using personal and socially mediated resources, and
to maintain health (Fletcher and Sarkar, 2013; Färber and
Rosendahl, 2018). Resilience is not exclusively a psychological
phenomenon. Besides cognitive behavior, it is also assigned
to the area of relaxation and mindfulness, as well as physical
training and sports (Stahl et al., 2015; Esch, 2020). In the
current review, it is assigned to self-reference. Besides health,
resilience is related to factors such as coping style and optimism
(Gillespie et al., 2007; Windle, 2010). Nevill and Havercamp
(2019) showed weak negative correlations between resilience and
emotional exhaustion, as well as resilience and depersonalization,
while there was a weak positive association between resilience
and professional efficacy. Other studies support the negative
relationship between resilience and burnout (Watson et al., 2019;
Ogi´
nska-Bulik and Michalska, 2021).
Perfectionistic Striving
Perfectionistic striving describes the employees’ intention to
do things perfectly (Rice and Liu, 2019). According to various
identified studies perfectionistic striving is negatively related to
burnout (Hill and Curran, 2016; Gnilka et al., 2017; Rice and
Liu, 2019). In a meta-analysis, Rice and Liu (2019) found a
weak negative relationship between perfectionist striving and
burnout, reduced personal efficiency, and depersonalization, and
no significant relationship between perfectionist striving and
emotional exhaustion.
Self-Efficacy
Self-efficacy means that people have the belief that they
have some control over their actions and therefore trust in
being able to achieve a certain goal (Bandura, 1997). Recent
studies suggest that self-efficacy is negatively related to burnout
(e.g., Salanova et al., 2002; Alarcon et al., 2009; Cicognani
et al., 2009; Shojia et al., 2016). In a study by Skaalvik and
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Skaalvik (2007), self-efficacy correlates negatively with emotional
exhaustion, depersonalization, and reduced professional efficacy.
This association is also supported by Wilk and Moynihan (2005),
who demonstrated that self-efficacy is negatively associated with
emotional exhaustion.
Self-Esteem
This factor is generally defined as a global self-assessment
(Alarcon et al., 2009), which consists of two aspects; belief
in one’s own abilities and belief in one’s basic value (Locke
et al., 1996). Based on recent literature, there is evidence
that self-esteem is negatively related to burnout and subscales
such as emotional exhaustion, depersonalization, and personal
accomplishment (Rosse et al., 1991; Janssen et al., 1999; Alarcon
et al., 2009), whereas low self-esteem is positively related to
burnout (Golembiewski and Kim, 1989).
Adaptive Coping Styles
Coping strategies are generally considered to occur at the
cognitive and behavioral level (Werdecker and Esch, 2018).
In modern stress theory, biological and psychological stress
mechanisms (McEwen, 2007; Werdecker and Esch, 2018) are
combined according to the concept of the allostatic load
(“stability through change”) by (Sterling and Eyer, 1988, p. 636),
which is an extension of the concept of homeostasis (Selye,
1973; Esch, 2003). Adaptive coping styles comprises various
functional coping strategies in dealing with stress. The negative
relation between adaptive coping styles (e.g., positive reframing,
using emotional support, humor) and burnout or (chronic)
stress has been confirmed by various studies and within various
professional groups (Cicognani et al., 2009; Doolittle et al.,
2013; Shin et al., 2014; Gnilka et al., 2017; Mattei et al., 2017).
Furthermore, there is also evidence that a positive relationship
between dysfunctional coping strategies (e.g., denial, behavioral
disengagement, self-blame) and burnout exists (Payne, 2001;
Cicognani et al., 2009; Doolittle et al., 2013; Shin et al., 2014;
Mattei et al., 2017; Akinsulure-Smith et al., 2018; Nevill and
Havercamp, 2019). Consequently, the need for adaptive coping
strategies is important for individuals in dealing with stress
and burnout.
Mindfulness
Mindfulness can be described as the ability to focus attention on
the current moment in a non-judgmental manner (Kabat-Zinn,
1991). A high level of mindfulness is associated with a lower level
of burnout and chronic stress (Esch et al., 2013; Di Benedetto
and Swadling, 2014; Esch, 2014; Yang et al., 2017; Nevill
and Havercamp, 2019). Other identified studies have shown
that mindfulness training, contemplation, and meditation are
negatively associated with burnout and chronic stress (Möltner
et al., 2017; Kinnunen et al., 2020).
(4) Relaxation
The factors recovery/psychological detachment and sufficient sleep
are assigned to category relaxation in the present review.
Recovery/Psychological Detachment
Recovery activities and psychological detachment are closely
connected. Recovery activities refer to what people do after work
(e.g., physical activity, reading books) and thereby experience
psychological detachment from work (can be differentiated
into cognitive, emotional, and physical detachment) (De
Jonge et al., 2012; Niks et al., 2017). Various authors
identified a positive relationship between few recovery activities
(and resulting low psychological detachment) and emotional
exhaustion, psychosomatic complaints, disengagement, or even
creativity at work (Sonnentag and Fritz, 2007; Sonnentag
et al., 2010; Hakanen and Bakker, 2017; Sonnentag, 2018).
Furthermore, De Jonge et al. (2012) showed a negative
relationship between emotional as well as physical detachment
and emotional exhaustion. According to Sonnentag et al. (2010),
a high workload, emotional dissonance, and low work spatial
boundaries at home (e.g., through home office) are associated
with poor psychological detachment from work during non-
working time, while a poor psychological detachment from
work is positively associated with emotional exhaustion, low
work engagement, psychosomatic complaints, and the need
for recovery.
Sufficient Sleep
This factor refers to a sleep duration of more than 6 h, as
has been defined by Söderström et al. (2012). In a 2-year
longitudinal study, Söderström et al. (2012) identified insufficient
sleep as the main risk for burnout among employees from
different industries. Sleep has a central role in coping with
demands. It has been shown that people can be more sensitive
to emotional and stressful stimuli and events during sleep
deprivation (Vandekerckhove and Cluydts, 2010; Gothe et al.,
2019). An increase in burnout or burnout-related symptoms
such as physical fatigue, reduced performance, and emotional
exhaustion can occur more frequently with reduced sleep
(Söderström et al., 2012; Sonnentag, 2018).
(5) Work-to-Life Interrelation
Two burnout-related factors that we identified in the literature
can be assigned to the category work-to-life interrelation:
avoidance of role conflicts due to working hours and appropriate
distribution of working hours.
Avoidance of Role Conflicts Due to Working Hours
This factor means the prevention of difficulties in balancing
work and private life and associated role conflicts (e.g., mother
vs. manager). Various studies identified that conflicts between
work and private life are positively related to burnout in
various occupational groups and industries (e.g., Allen et al.,
2000; Brauchli et al., 2011; Vassos and Nankervis, 2012;
Demerouti et al., 2018; Fenwick et al., 2018; Wu et al., 2018).
Similarly, emotional exhaustion decreases with increasing work-
life accordance (Tugsal, 2017). The time-related role conflicts
between work and private life do not only relate to the family,
but also to conflicts outside the family such as leisure time and
engagement (friends, volunteer work, etc.).
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Appropriate Distribution of Working Hours
This factor represents the need for appropriate distribution
of working hours among family members. Employees, whose
working hours are more or less than they and their partner would
like, tend to be more distant, distracted, and alienated at work
than colleagues who are satisfied with their working hours. The
same applies to employees whose working hours are distributed
differently than they and their partner would prefer (Barnett
et al., 1999). Even if employees have voluntarily reduced their
working hours, the association with burnout at work is less strong
the more their own working hours and those of their partner are
perceived as appropriate. The relationship between the number
of working hours and burnout thus depends on the extent to
which the working hours meet the requirements of the employee,
their partner and possibly their children (Barnett et al., 1999).
(6) Support
The factors private support and collegial support are assigned to
the category support.
Private Support
This factor describes a variety of social sources in dealing with
work-related stress. A study with traffic police officers showed
that private support (e.g., family, friends) is negatively associated
with burnout and positively associated with job satisfaction
and productivity (Baruch-Feldman et al., 2002). Other studies
also demonstrated the relationship between family support
and burnout (Greenglass et al., 1994; Lee and Ashforth, 1996;
Yildirim, 2008).
Collegial Support
It includes support from individuals within the organization.
Various studies demonstrated a positive association between
lack of support by superiors or coworkers and one or more
aspects of burnout (Vilardaga et al., 2011; Vassos and
Nankervis, 2012); a negative relationship was found for the
burnout subscale professional efficacy (Lindblom et al., 2006).
Similarly, other authors found a negative relationship between
supervisor/coworker support and burnout (Lee and Ashforth,
1996; Charoensukmongkol et al., 2016; Demerouti et al.,
2018), while Charoensukmongkol et al. (2016) found coworker
support was negatively associated with emotional exhaustion
and depersonalization.
(7) Working Environment
The burnout factors appropriate workload/working time,
control at work/autonomy, avoidance of role ambiguity, positive
perception of the management, relevant job skills in relation to
job requirements, job and career development, low self-control
demands and cognitive control deficits, and positive psychosocial
work climate identified in the current literature can be assigned
to the category working environment.
Appropriate Workload/Working Time
This factor represents the demands placed on employees during
their work, which may be a high workload that is associated with
overtime. According to various studies, a high workload and long
working hours are associated with increased burnout (Garrosa
et al., 2006; Lindblom et al., 2006; Maslach and Leiter, 2008,
2016; Vassos and Nankervis, 2012), while a low or manageable
workload seems to be a protective factor against the risk of
burnout (Lasalvia et al., 2009; Asensio-Martínez et al., 2017). For
example, in a study of university employees, Montero-Marín et al.
(2011) showed that people who work more than 40 h a week have
a higher risk of burnout than people who work <35 h a week.
Control at Work/Autonomy
Control at work or autonomy means to be able to influence
both conditions and activities at the workplace (Frese and Zapf,
1994). Various authors have demonstrated that low work control
at work/low autonomy is associated with an increased risk of
burnout (Garrosa et al., 2006; Lasalvia et al., 2009; Brouwers et al.,
2011; Vilardaga et al., 2011; Asensio-Martínez et al., 2017).
Avoidance of Role Ambiguity
In the current review, role ambiguity describes the lack of a
clear allocation of responsibilities for the work being carried out
(Maslach and Leiter, 2008). Various identified studies highlight
the positive relationship between role ambiguity and burnout
(Garrosa et al., 2006; Maslach and Leiter, 2008; Vassos and
Nankervis, 2012).
Positive Perception of the Management
This factor describes the employees’ individual perception of
management (i.e., the feeling of guidance and leadership,
interpersonal job demands) in the company. Profit et al. (2014)
demonstrated a negative association between positive perception
of the management and emotional exhaustion, while Reynolds
(2016) found that a negative perception of management was
associated with increased burnout.
Relevant Job Skills in Relation to Job Requirements
This factor means the avoidance of professional overload. This
implies that the existing job skills/resources of employees are
sufficient to cope with the content-related-demands at work.
According to Vassos and Nankervis (2012), there is a significant
positive moderate relationship between lack of resources
and emotional exhaustion, while no significant relationship
to depersonalization and personal accomplishment could be
identified. Furthermore, according to Swoboda et al. (2005), a
lack of job skills in relation to job requirements is a risk factor
for burnout.
Job and Career Development
This factor consists of various facets. These facets represent
the development within the organization (consisting of little
uncertainty and career development) and to organizational
confidence with respect to general trust in the principal,
colleague, and client (Caglar, 2011). According to different
authors, job insecurity and lack of career development are
associated with burnout (Lasalvia et al., 2009; Basi´
nska
and Wilczek-Ruzyczka, 2013; Riley et al., 2018; Petitta
and Jiang, 2019). In addition, organizational confidence
was identified as an aspect that is related to burnout
(Caglar, 2011).
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Low Self-Control Demands and Cognitive Control Deficits
This factor describes the control and inhibition of undesired
behavior and emotions such as anger at work (e.g., in the
service sector). Self-control occurs when people try to change
the way they would spontaneously feel, think, or behave,
which is associated with stress and resource consumption (e.g.,
through physiological arousal) (Muraven and Baumeister, 2000;
Neubach and Schmidt, 2006; Schmidt et al., 2007). According
to Schmidt et al. (2007), employees tend to rate their work
as more strenuous in terms of perceived self-control demands
if they are prone to severe cognitive control deficits. Thus,
the level of self-control demands might reflect not only the
objective work situation but also, to a lesser extent, the
(in-)ability to control oneself. The self-control demands are
correlated moderately positively with emotional exhaustion and
depersonalization, while cognitive control deficits are strongly
positively correlated with the two burnout subscales (Schmidt
et al., 2007). This finding is also consistent with the job demand-
control model (JDC) by Karasek (1979). In the JDC model,
psychological demands and control are defined as key aspects
of work in relation to the development of burnout and stress
(Rostamabadi et al., 2019).
Positive Psychosocial Work Climate
This factor describes the psychological work climate between
employees in an organization. According to Roomaney et al.
(2017), interpersonal conflict at work is a significant predictor
for emotional exhaustion and depersonalization. Other authors
also found associations between psychosocial work climate and
burnout or stress (Crawford et al., 2010; Profit et al., 2014; Eisele,
2015; Riley et al., 2018).
(8) Big Five Personality Traits
The factors emotional stability, extraversion, conscientiousness,
agreeableness, and openness are assigned to the category of Big
Five personality traits.
Emotional Stability
Emotional stability is the general tendency to be free of
negative emotions such as frustration, irritability, guilt, as well
as depression and anxiety; the opposite is called neuroticism
(Costa and McCrae, 1992; McCrae and John, 1992; Dinkel,
2008). Various studies have shown a positive correlation between
neuroticism and burnout for different professions and industries
(Bakker et al., 2006; Alarcon et al., 2009; Armon et al., 2012;
Magnano et al., 2015; Bianchi, 2018; Tang et al., 2018; Castillo-
Gualda et al., 2019). Specifically, neuroticism is positively
associated with emotional exhaustion, depersonalization, and
reduced professional efficacy (Zawadzka et al., 2018), while there
is a negative association between neuroticism and professional
efficacy (De la Fuente Solana et al., 2013; Ortega-Campos et al.,
2019; Ramirez-Baena et al., 2019).
Extraversion
Extraversion is the extent to which one is enthusiastic, active,
sociable, and fun-loving (Costa and McCrae, 1992; McCrae and
John, 1992; Dinkel, 2008). According to various authors, a high
level of extraversion is associated with two or more aspects
of burnout (Bakker et al., 2006; Castillo-Gualda et al., 2019).
The personality trait is negatively correlated with emotional
exhaustion, depersonalization, and reduced professional efficacy
(Zawadzka et al., 2018), whereas the relationship between
extraversion and professional efficacy is positive (Alarcon et al.,
2009; De la Fuente Solana et al., 2013; Ortega-Campos et al., 2019;
Ramirez-Baena et al., 2019).
Conscientiousness
This personality trait reflects the extent to which one is well-
organized, self-disciplined, planful, achievement oriented, and
responsible (Costa and McCrae, 1992; McCrae and John, 1992;
Dinkel, 2008; Alarcon et al., 2009). Studies demonstrated a
negative relationship between conscientiousness and burnout
(Armon et al., 2012; Castillo-Gualda et al., 2019). Furthermore,
several studies identified a negative correlation between
conscientiousness and emotional exhaustion, depersonalization,
as well as reduced professional efficacy (Zawadzka et al., 2018;
Ortega-Campos et al., 2019), while a positive relationship
was found between conscientiousness and professional
efficacy (Alarcon et al., 2009; De la Fuente Solana et al.,
2013; Ramirez-Baena et al., 2019).
Agreeableness
Agreeableness is the extent to which someone is cooperative,
trusting, and sympathetic toward others (Costa and McCrae,
1992). Individuals with a high value in this personality trait
tend to describe themselves as cooperative, altruistic, and
sensitive (Magnano et al., 2015). The negative association
between agreeableness and burnout has been demonstrated
in various studies (Bakker et al., 2006; Tang et al., 2018).
Similarly, other authors demonstrated negative associations
between agreeableness and emotional exhaustion, agreeableness
and depersonalization, as well as agreeableness and reduced
professional efficacy (Zawadzka et al., 2018), whereas the
relationship between agreeableness and professional efficacy
was positive (Alarcon et al., 2009; De la Fuente Solana et al.,
2013; Castillo-Gualda et al., 2019; Ortega-Campos et al., 2019;
Ramirez-Baena et al., 2019).
Openness
Openness is the extent one is open to culture and experience
(Magnano et al., 2015). In the identified literature, this
personality trait shows a weak, and repeatedly non-significant
correlation with burnout or corresponding subscales (Zellars
et al., 2000; Bakker et al., 2006; Alarcon et al., 2009; De la Fuente
Solana et al., 2013; Castillo-Gualda et al., 2019; Ramirez-Baena
et al., 2019). According to various authors, openness is negatively
associated with emotional exhaustion and depersonalization and
positively associated with professional efficacy (Castillo-Gualda
et al., 2019; Ortega-Campos et al., 2019).
(9) Perceived Meaningfulness
General spirituality/faith/belief, perceived meaningfulness of work,
and (work) sense of coherence are burnout factors that we have
identified in the current literature and assigned to category
perceived meaningfulness.
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General Spirituality/Faith/Belief
This factor refers to a feeling or belief of being connected with
something “higher.” Something that will still be there before and
after oneself and that is beyond everyday experience, e.g., God
or nature (Esch, 2011). The relationship between spirituality,
faith, belief and burnout or stress was examined in several
general population studies (Van Dierendonck et al., 2005; Esch,
2008a,b, 2010, 2011, 2017, 2019; Doolittle et al., 2013; Daniel,
2014; Ho et al., 2016; Yang et al., 2017; Watson et al., 2019).
Initial evidence points to the direction that individuals who are
more religious or spiritual than others tend to possess higher
resilience levels and are therefore less likely to be affected by
burnout (Carneiro et al., 2019). Various studies support the
negative relationship between spirituality and burnout (Ho et al.,
2016; Kim and Yeom, 2018). In addition, there is a negative
relationship between spirituality and emotional exhaustion,
spirituality and depersonalization, and a positive relationship
between spirituality and professional efficacy (Doolittle et al.,
2013). Moreover, spiritual experiences and practices such
as prayer, meditation, contemplation, mindfulness training,
especially through the induction of reward mechanisms and the
physiological relaxation response, can reduce pain and stress and
thus promote health (e.g., Esch and Stefano, 2007, 2010; Esch,
2008a, 2011).
Perceived Meaningfulness of Work
This factor describes the individually perceived meaningfulness
of work that exists independently of the perception of society
(e.g., perception that one’s own work has a socially assigned
meaning) (Listopad et al., 2021). It is also associated with
a sense of coherence (what happens on the outside of the
individual resonates with what is felt inside) (Esch, 2019).
Various authors identified that a greater sense of perceived
meaningfulness of work is negatively related to burnout and
positively related to work engagement (e.g., Fragoso et al.,
2016; Van Wingerden and van der Stoep, 2017; Van Wingerden
et al., 2018; Esch, 2019; Scanlan and Hazelton, 2019), which
is why burnout can also be called as a “crisis of meaning”
(Esch, 2019, p. 61). A study by Van Wingerden and van
der Stoep (2017) found a strong negative correlation between
perceived meaningful work and emotional exhaustion and
between perceived meaningful work and cynicism, while the
correlation between perceived meaningful work and work
engagement was strongly positive. Another study (Listopad
et al., 2021) investigating burnout based on an extended
health and disease model, published after our database search,
demonstrated a negative association between positive meaning
and burnout, as well as meaning making through work
and burnout, in the context of perceived meaningfulness of
work. Similarly, positive meaning and work engagement, and
meaning making through work and work engagement were
positively associated. Since the publication of this study was
outside the considered publication date, it is not included in
the summary table. Nevertheless, these results highlight the
relevance of perceived meaningfulness of work in relation with
the syndrome.
(Work) Sense of Coherence (SOC)
This factor is composed of the elements sense of
comprehensibility, manageability, and meaningfulness and
is related to the salutogenesis (Antonovsky, 1987, 1996) to
explore and strengthen health protection facets and resistance
resources (Esch, 2020). A number of studies have transferred
these three elements to the level of work and organization in
order to provide a broadly applicable indicator of health-related
working conditions together with work-related coherence. In
this context, Bauer et al. (2015) found associations between work
SOC and specific work-related stressors (e.g., time pressure,
work interruptions) and resources (e.g., appreciation, holistic
understanding about one’s own work) as well as negative
(exhaustion, psychosomatic complaints, etc.) and positive health
outcomes (affective commitment, work engagement, etc.). A
significant relationship between SOC and burnout or underlying
subscales has been shown by two groups of authors in a cross-
sectional and longitudinal study (Levert et al., 2000; Kalimo et al.,
2003). It has also been demonstrated that the correlation between
SOC and emotional exhaustion is stronger among employees
between 51 and 60 years compared to younger age categories
(Van der Westhuizen et al., 2015). A longitudinal study over ten
years demonstrated that the SOC is a protective factor in relation
to burnout (Kalimo et al., 2003).
(10) Sense of Homeliness
In the course of the literature search, various factors related to
burnout were identified that can be assigned to a new overarching
category sense of homeliness. The factors we assign to this
category are sense of community, value congruence, and effort-
reward balance.
Sense of Community
The literature search provides various factors that can be
attributed to sense of community. Depending on the underlying
concept, the factor sense of community encompasses aspects
such as needs fulfillment, group membership, influence,
emotional connection (McMillan and Chavis, 1986; Prezza et al.,
1999), but also reward, fairness, values (Leiter and Maslach,
2006), communication, autonomy, corporate responsibility,
etc. (Majer and D’Amato, 2001). A study by Cicognani et al.
(2009) demonstrated a negative association between sense of
community and burnout. Furthermore, according to Asensio-
Martínez et al. (2017) and Maslach and Leiter (2008), there is a
negative relationship between sense of community and emotional
exhaustion, between sense of community and cynicism, as well
as a positive relationship between sense of community and
professional efficacy. A recent publication (Listopad et al., 2021)
also investigated the subscales of sense of community. The
authors identified a significant negative association between
needs fulfillment and burnout, group membership and burnout,
and emotional connection and burnout. The associations
between needs fulfillment, group membership, and emotional
connection and the dependent variable work engagement, in
contrast, were positive (Listopad et al., 2021).
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Value Congruence
This factor refers to the cognitive-emotional component of
perceived congruence of professional goals, expectations, and
personal value. It is thus closely linked to personal ideals and
motivations that originally attracted employees to their work
(Maslach and Leiter, 2008). According to the studies identified,
there is a negative relationship between value congruence and
burnout (Maslach and Leiter, 2008; Asensio-Martínez et al.,
2017), while there is a positive association between disagreeing
about values and burnout (Lindblom et al., 2006). Furthermore,
the associations between low values commitment and emotional
exhaustion, low values commitment and depersonalization, as
well as low values commitment and reduced professional efficacy
were positive (Vilardaga et al., 2011).
Effort-Reward Balance
The effort-reward imbalance (ERI) model is a model for
explaining the development of stress in the work context. Siegrist
(2002) assumes that gratification crises occur when the balance
between work input and corresponding reward is not balanced
from the employee’s perspective. ERI can be measured with the
ERI questionnaire (Siegrist et al., 2004) and includes the subscales
effort, reward, and excessive commitment. We also assign to this
factor the feeling of being treated appropriately by colleagues
and leaders (subjective justice). Various authors found a positive
relationship between ERI and burnout, and a negative association
between subjective justice and burnout (e.g., Lindblom et al.,
2006; Maslach and Leiter, 2008; Lasalvia et al., 2009; Tang
et al., 2018). In this context, Basi´
nska and Wilczek-Ruzyczka
(2013) demonstrated various associations. For example, demands
and lack of respect were positively associated with emotional
exhaustion. Increased demands, lack of respect, and greater job
security were positively associated with depersonalization. In
contrast, higher demands and greater job security were positively
associated with lower personal accomplishment.
Socio-Demographic Factors
Some of the investigated studies point to relationships between
socio-demographic factors such as work experience, gender,
relationship status, having children or educational level and
burnout. However, these findings are rather inconsistent so that
we did not include them in the table of main findings. Despite,
we provide a short overview of existing results in the following.
Although some studies suggest that young professionals with
little work experience are more likely to develop burnout (e.g.,
Garrosa et al., 2006; Soares et al., 2007; De la Fuente Solana
et al., 2013; Boštjanˇ
ciˇ
c et al., 2015; Simionato and Simpson, 2018),
some of the identified studies show no significant relationship
between age or work experience and burnout (e.g., Bilge,
2006; Yildirim, 2008; Matin et al., 2012; Tarcan et al., 2017;
Ezenwaji et al., 2018). It is not possible to conclusively evaluate
whether gender is related to burnout as some studies report
no association (Yildirim, 2008; Matin et al., 2012; De la Fuente
Solana et al., 2013; Ezenwaji et al., 2018). There is, however,
isolated evidence regarding the relationship between gender and
the burnout subscales (emotional exhaustions, depersonalization,
and reduced professional efficacy). While men predominantly
tend toward higher levels of depersonalization (Bilge, 2006;
Vassos and Nankervis, 2012; Cañadas-De la Fuente et al., 2015),
an increased value for emotional exhaustion has been reported
among women (Frese and Zapf, 1994). In terms of marital status,
according to Cañadas-De la Fuente et al. (2018), there is an
association between single or divorced individuals and burnout
(especially for men). Matin et al. (2012), on the other hand,
could not identify any associations between marital status and
burnout. Thus, the results regarding the connection between
the relationship status and burnout are also inconclusive (e.g.,
Maslach et al., 2001; Maslach, 2003; Bekker et al., 2005; Lin
et al., 2009; Al-Turki, 2010; Matin et al., 2012; Ayala and
Carnero, 2013; De la Fuente Solana et al., 2013; Cañadas-De la
Fuente et al., 2015, 2018). Furthermore, the results for having
children are also inconsistent, as in some studies, childlessness
is positively associated with burnout (Qu and Wang, 2015;
Cañadas-De la Fuente et al., 2018) and in others, there are
no associations (Coffey and Coleman, 2001; Queiros et al.,
2013). The relationship between the level of education and
burnout is equally inconclusive. While, according to Soares
et al. (2007), a poorer level of education is correlated with
an increased risk of burnout, Maslach et al. (2001) showed
that people with a higher level of education tend to have a
higher degree of burnout. The missing relationship between
education and burnout is also supported by the study of
Matin et al. (2012).
Assignment of Factors to the Model of
Health and Disease (Research Question 3)
The bio-psycho-social model of health and disease was postulated
more than four decades ago by Engel (1977). According to
the model, biological, psychological, and socio-environmental
aspects play an important role in the development of health and
disease and should therefore be considered in the description,
prevention, and treatment of diseases (Engel, 1977; Egger, 2008;
Havelka et al., 2009; Babalola et al., 2017; Lehman et al.,
2017). In general, the (i) biological dimension refers to the
physical elements of the body that influence and determine
mental and physical health (Havelka et al., 2009; Lehman et al.,
2017). The (ii) psychological dimension consists of cognitive,
emotional, motivational, attitudinal, and behavioral aspects and
encompasses the role of self, identity, personality, as well as
various coping strategies (Suls and Rothman, 2004; Egger, 2008;
Lehman et al., 2017). The (iii) socio-environmental dimension
refers to the physico-chemical aspects such as air pollutants,
nitrogen oxides, work environment, workplace conditions, but
also to interpersonal dynamics of the work or family environment
(Egger, 2008; Lehman et al., 2017). To answer our third research
question of whether the bio-psycho-social model is sufficient
to comprehensively describe the pathogenesis of burnout, we
assigned each of the identified factors to the dimensions of the
health and disease model. Many of the factors can unambiguously
be assigned to one or more of these dimensions. However, as
various authors postulated (Salmoirago-Blotcher et al., 2016;
Saad et al., 2017; Esch, 2019; Listopad et al., 2021), several factors
that have been identified to be related to burnout cannot easily be
Frontiers in Psychology | www.frontiersin.org 13 December 2021 | Volume 12 | Article 722862
Listopad et al. Bio-Psycho-Socio-Spirito-Cultural Factors of Burnout
attributed to biological, psychological, and socio-environmental
dimensions. Instead, they refer to spirituality and work culture.
Hence, we add two (sub-)dimensions in line with propositions
by Esch (e.g., 2008a, 2010, 2019) and Listopad et al. (2021),
namely a (iv) spiritual and a (v) work cultural dimension.
According to Esch (2008a, 2010, 2019) and Listopad et al.
(2021), spirituality and work culture (as semantic dimensions)
also play an important role in stress management and the
development of burnout. The dimension spirituality refers
to implicit/subjective factors (i.e., psychological-mental aspects
such as inner/intrapersonal resources) and includes various
spiritual experiences and practices such as prayer, meditation,
contemplation, mindfulness, and perceived meaningfulness
(Esch, 2008a, 2010, 2011, 2017, 2019). Work culture—as a further
dimension—is described as an “inner home” (Esch, 2017, p.
149), i.e., subjective connectedness, belongingness, or sense of
community (consisting of needs fulfillment, group membership,
influence, and emotional connection) and represents a coherence
between the outer world (e.g., values of the employer), and
the inner world (e.g., own values) (Listopad et al., 2021). In
the following, we describe the attribution of the factors to the
model dimensions.
(1) Lifestyle
We assign the factors exercise,limited use of ICT, healthy
nutrition, and reduced consumption of cigarettes, alcohol, and
medication to the (i) biological dimension due to neurobiological
processes involved. Furthermore, we also assign exercise,limited
use of ICT,healthy nutrition, and reduced consumption of
cigarettes,alcohol, and medication to the (ii) psychological
dimension, as it represents individual aspects of attitude and
behavior and can be attributed to, e.g., maladaptive coping
strategies. The factors limited use of ICT,healthy nutrition, and
reduced consumption of cigarettes, alcohol, and medication are
also allocated to the (iii) socio-environmental dimension, due to
their physico-chemical character.
(2) Physical and Mental Health
In this category, we assign the factors physical health and mental
health/well-being to the (i) biological dimension, e.g., due to
metabolic changes in the brain, neurotransmitters involved such
as serotonin, dopamine, and norepinephrine, as well as genetic
strain (Blows, 2000; Dfarhud et al., 2014; Woolfson, 2019).
Furthermore, we assign mental health/well-being,happiness,life
satisfaction, and job satisfaction/positive experience at work to the
(ii) psychological dimension through its relationship to cognitive,
emotional, motivational, attitudinal, and behavioral aspects.
We also allocate life satisfaction and job satisfaction/positive
experience at work to the (iii) socio-environmental dimension due
to the interpersonal dynamics in private and professional life and
their relation to satisfaction.
(3) Self-Reference
We allocate the burnout factors resilience and mindfulness to
the (i) biological dimension as it can also be linked with, e.g.,
relaxation, mindfulness, physical training, and sports (Esch,
2020). In addition, we assign resilience,perfectionistic striving,
self-efficacy, self-esteem, adaptive coping styles, and mindfulness
to the (ii) psychological dimension, based on individual attitude
and behavioral aspects, as well as the role of self and identity.
Beyond that, we assign resilience to the (iii) socio-environmental
dimension due to resilience-promoting aspects such as family,
friends, and work. In the last step within this category, we assign
mindfulness to the (iv) spiritual dimension, since it frequently
represents a spiritual practice (Esch and Stefano, 2004; Esch,
2011).
(4) Relaxation
We assign the factors recovery/psychological detachment and
sufficient sleep to the (i) biological dimension due to sleep
physiology, neurobiological processes, and the effects of the
factors with the body (Van Dongen et al., 2003; Sanford et al.,
2015). In addition, we assign recovery/psychological detachment
to the (ii) psychological dimension, as it is associated with
motivational, attitudinal, and behavioral aspects of individuals
and can also be a part of a coping strategy (Sonnentag and Fritz,
2007; Lehman et al., 2017).
(5) Work-to-Life Interrelation
The factors avoidance of role conflicts due to working hours
and appropriate distribution of working hours are assigned
to the (ii) psychological dimension due to the emotional,
attitude, and behavioral aspects within the health and disease
model. Moreover, we assign these two factors to the (iii)
socio-environmental dimension because of the corresponding
interpersonal dynamics within the family, friends, etc.
(6) Support
Both factors, i.e., private support and collegial support are
assigned to the (ii) psychological dimension, since it represents
individual coping strategies (Sonnentag and Fritz, 2007).
Similarly, we also assign these factors to the (iii) socio-
environmental dimension because, e.g., there are interpersonal
dynamics (e.g., family, friends) and social support is an external
factor within the work environment.
(7) Working Environment
We assign all factors, i.e., appropriate workload/working time,
control at work/autonomy,avoidance of role ambiguity,positive
perception of the management,relevant job skills in relation
to job requirements,job and career development,low self-
control demands and cognitive control deficits, as well as
positive psychosocial work climate to the (ii) psychological
dimension due to the cognitive, emotional, attitudinal, and
behavioral aspects. We also assign all mentioned factors to the
(3) socio-environmental dimension due to the interpersonal
dynamics of the working environment (e.g., among co-workers,
supervisors) as well as immediate work environment and
working conditions. Positive perception of the management
and positive psychosocial work climate are assigned to the (v)
work cultural dimension, as the perceived connectedness and
belongingness could be disturbed.
Frontiers in Psychology | www.frontiersin.org 14 December 2021 | Volume 12 | Article 722862