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Burnout during a long-termrehabilitation: comparing low burnout,high burnout – benefited, and highburnout – not benefited trajectoriesMarja Hätinen a , Ulla Kinnunen b , Anne Mäkikangas a , RaijaKalimo c , Asko Tolvanen a & Mika Pekkonen da Department of Psychology , University of Jyväskylä , Finlandb Department of Psychology , University of Tampere , Finlandc The Finnish Institute of Occupational Health , Finlandd Peurunka Medical Rehabilitation Centre , Laukaa, FinlandPublished online: 14 Apr 2009.

To cite this article: Marja Hätinen , Ulla Kinnunen , Anne Mäkikangas , Raija Kalimo , Asko Tolvanen& Mika Pekkonen (2009) Burnout during a long-term rehabilitation: comparing low burnout, highburnout – benefited, and high burnout – not benefited trajectories, Anxiety, Stress & Coping: AnInternational Journal, 22:3, 341-360, DOI: 10.1080/10615800802567023

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Burnout during a long-term rehabilitation: comparing low burnout,high burnout � benefited, and high burnout � not benefited trajectories

Marja Hatinena*, Ulla Kinnunenb, Anne Makikangasa, Raija Kalimoc,Asko Tolvanena and Mika Pekkonend

aDepartment of Psychology, University of Jyvaskyla, Finland; bDepartment of Psychology,University of Tampere, Finland; cThe Finnish Institute of Occupational Health, Finland;

dPeurunka Medical Rehabilitation Centre, Laukaa, Finland

(Received 31 March 2008; final version received 20 October 2008)

To focus rehabilitation activities among burnout clients more effectively, it isimportant to investigate who benefits from burnout interventions. This study(N�85) aimed at identifying burnout trajectories in terms of benefit, that is,subgroups of clients who share similar mean levels and changes in burnout duringa one-year rehabilitation intervention (17 days in total) with a six-month follow-up. After identifying the burnout trajectories, the relations of the trajectories withfactors describing the clients, antecedents, and consequences of burnout duringthe one-year intervention were examined. Three burnout trajectories wereidentified by growth mixture modeling: (a) low burnout (n�39), (b) high burnout� benefited (n�29), and (c) high burnout � not benefited (n�17). Positivechanges were detected in antecedents and consequences among the clients in thelow burnout and high burnout � benefited trajectories. Recovery from burnoutwas associated with increased job resources and decreased job demands, as well aswith increased job satisfaction and decreased depression. It seems that moreprecise targeting of rehabilitation is needed since the trajectories revealed not onlyclients with mild symptoms, but also clients who probably received this treatmenttoo late.

Keywords: burnout; rehabilitation intervention; job conditions; person-orientedapproach; growth mixture modeling

Burnout is a consequence of prolonged job stress and is most often characterized by

exhaustion, cynicism, and reduced professional efficacy (Maslach, Jackson, & Leiter,

1996). Exhaustion represents the individual strain dimension of burnout, describing

feelings of fatigue and depletion of emotional energy (Maslach, 1993; Maslach et al.,

1996). Cynicism and reduced professional efficacy go beyond the individual stress

experience by adding the employee’s attitude toward the job (cynicism) and toward

the self (feelings of inefficacy) into the conceptualization of burnout (Maslach,

2003). The component of cynicism refers to a distant and cynical attitude toward

one’s work, whereas reduced professional efficacy describes loss of competence and

productivity, and the tendency to evaluate negatively one’s past and present

accomplishments at work (Maslach et al., 1996).

*Corresponding author. Email: marja.hatinen@psyka.jyu.fi

ISSN 1061-5806 print/1477-2205 online

# 2009 Taylor & Francis

DOI: 10.1080/10615800802567023

http://www.informaworld.com

Anxiety, Stress & Coping

Vol. 22, No. 3, May 2009, 341�360

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Several studies have focused on identifying the primary antecedents and

consequences of burnout (for reviews see Maslach, Schaufeli, & Leiter, 2001;

Schaufeli & Enzmann, 1998), but considerably less effort has been devoted to

identifying effective ways to prevent or reduce burnout. One way to intervene in the

progression of burnout is through employee rehabilitation, which can be defined as a

tertiary preventive intervention. The main aims of employee rehabilitation are to

improve clients’ well-being and working ability, and to prevent further impairment ofthe working population; in other words, to maintain an able workforce in society.

However, to our knowledge, evidence is lacking regarding how effective rehabilita-

tion interventions are in reducing burnout. The present study aimed to provide

answers to this question by examining changes in burnout symptoms during a

rehabilitation intervention. In addition, the question of whether changes that might

occur in burnout symptoms would be related to changes in the antecedents and

consequences of burnout was examined. However, instead of studying change in

burnout from a variable-oriented approach (as in the majority of the burnout

studies), we examined change in burnout from a person-oriented approach.

A person-oriented approach was utilized for the following reasons. Firstly, in

Finland, employees referred for rehabilitation usually come from different work-

places and have different backgrounds (see Hatinen, Kinnunen, Pekkonen, &

Kalimo, 2007). Therefore, it is likely that the target population will be rather

heterogeneous, indicating that employees may have different rehabilitation needs (cf.

Bunce, 1997) and, consequently, may react to the same intervention differently.Additionally, because in Finland, as in many other countries, burnout is not

considered a mental disorder and no diagnostic guidelines are offered for its

identification (World Health Organization, 1992), burnout may be difficult to detect.

This is likely to lead to variation in diagnostic practices and even greater

heterogeneity in rehabilitation clients’ burnout levels, as assessed by measures such

as the Maslach Burnout Inventory (MBI; Maslach et al., 1996).

In the person-oriented approach, an individual is regarded as the unit of

measurement. The entire population is assumed to be heterogeneous with respect to

how the variables of interest influence each other (Laursen & Hoff, 2006). This

heterogeneity will then be manifested in the identification of different groups of

individuals who share similar associations among the variables (Bergman & Trost,

2006; Laursen & Hoff, 2006). Respectively, heterogeneity in longitudinal studies will

be manifested in the identification of different groups of individuals who share

similar patterns of relations among variables over time (Laursen & Hoff, 2006). In

this study, the purpose is to identify burnout trajectories, that is, subgroups of clients

who share similar mean levels of change in their burnout symptoms during arehabilitation intervention.

The focus of rehabilitation intervention is primarily on the individual-level,

aimed at increasing the clients’ resistance to job stressors. According to the review by

Schaufeli and Enzmann (1998), individual-level interventions have reduced emo-

tional exhaustion the most consistently. However, because several organizational and

job-related risk factors of burnout have been empirically identified thus far (Maslach

& Leiter, 2008), it could be argued that individual-level interventions are not enough

to tackle all the symptoms of burnout. One promising type of intervention that

functions more on the organizational level and which can be implemented in the

rehabilitation context is the participatory approach, derived from participatory

342 M. Hatinen et al.

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action research (PAR). The principles underlying the participatory approach are

built upon employee participation and increased job control, in addition to

collaboration and dialogue among supervisors, managers, employees, and research-

ers (Mikkelsen & Gundersen, 2003). Intervention studies that have used the

participatory approach have been successful in reducing job stress, and in stabilizing

and reducing exhaustion and cynicism (Hatinen et al., 2007; Le Blanc, Hox,

Schaufeli, Taris, & Peeters, 2007; Mikkelsen & Gundersen, 2003; Mikkelsen,Saksvik, & Landsbergis, 2000).

The Conservation of Resources (COR) theory deals with burnout and interven-

tions (Hobfoll & Freedy, 1993). The theory proposes four resource categories

(objects, conditions, personal characteristics, and energies) that people value and are

motivated to obtain, maintain, and protect. Burnout is expected to occur when these

resources are threatened or lost, or when a person invests resources but fails to regain

them. According to the COR theory, burnout interventions should focus on

enhancing resources and preventing vulnerability to resource loss (Hobfoll &

Freedy, 1993). The theory emphasizes that perceptions should be seen as real, rather

than as products of personality differences. Instead of underscoring personality

differences in perception, greater emphasis should be placed on the objective factors

(underlying events or circumstances) that shape perceptions. This is primarily

achieved by focusing on the causes of losses or, in the case of burnout, the objective

causes of worksite stress that underlie employees’ perceptions. The importance of

taking into account objective causes of burnout when designing interventions is inline with the view of Maslach and her colleagues (Maslach et al., 2001), who argue

that more organizational-level interventions are needed because, rather than focusing

on individual factors, interventions should focus on changing job-related situational

factors.

Job-related situational factors are considered to be the prime correlates of

burnout (Maslach et al., 2001). In a previous PAR study, changes in burnout levels

during an intervention were related to changes job-related situational factors

(Le Blanc et al., 2007). Le Blanc and colleagues showed that changes in perceptions

of job demands (workload) and job resources (job control, social support, and

participation) were related to changes in emotional exhaustion and depersonaliza-

tion during a one-year follow-up. These results were in line with the Demand-

Control Support model (Karasek & Theorell, 1990), which assumes that psycholo-

gical strain (such as burnout) is caused by a combination of high demand, low

control, and low social support (Le Blanc et al., 2007). In previous studies of the

various job-related situational factors, both job demands and resources have been

related to burnout symptoms, and in particular to exhaustion, whereas cynicism andreduced professional efficacy have been related in particular to lack of job resources

(e.g., Demerouti, Bakker, Nachreiner, & Schaufeli, 2001; Janssen, Schaufeli, &

Houkes, 1999; Lee & Ashforth, 1996). Of job demands, time pressure has been one of

the most significant contributors to burnout. According to the review by Schaufeli

and Enzmann (1998), time pressure together with workload explained 25�50% of the

variance of emotional exhaustion in cross-sectional studies.

Of job resources, both job control and workplace climate are important resource

factors in organizational settings (Maslach & Leiter, 2008). For example, negative

workplace climate and lack of job control have previously been related to burnout

(e.g., Demerouti et al., 2001; Lee & Ashforth, 1996). Resources are not only

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necessary to deal with job demands, but they are also important in their own right,

since they stimulate personal growth, learning, and development (Bakker &

Demerouti, 2007). It has been shown that it is also possible to enhance these

resources with interventions: Job control increased (Bond & Bunce, 2001; Hatinen et

al., 2007; Mikkelsen et al., 2000) and workplace climate improved (Hatinen et al.,

2007; Mattila, Elo, Kuosma, & Kyla-Setala, 2006) as a result of various participatory

interventions.Burnout has also been connected to various consequences for the individual and

for the organization (for reviews see Maslach et al., 2001; Schaufeli & Enzmann,

1998). However, this issue has received less research attention than the antecedents of

burnout. Depression and job satisfaction are among the most extensively studied

consequences of burnout (Schaufeli & Enzmann, 1998). These two phenomena are

particularly relevant in the rehabilitation context, since both have been related to

early retirement (e.g., Mein et al., 2000), an outcome that rehabilitation activities

seek to avoid. Previous studies have shown that burnout and depression (e.g., Ahola

et al., 2005), as well as burnout and job (dis)satisfaction (e.g., Schaufeli & Enzmann,

1998), are clearly linked, but not identical, phenomena. Depression has been most

consistently related to the exhaustion component of burnout (Schaufeli & Enzmann,

1998), whereas job dissatisfaction has been related to depersonalization (Lee &

Ashforth, 1996; Schaufeli & Enzmann, 1998). Depression and burnout may develop

in tandem (McKnight & Glass, 1995). This was shown in a two-year longitudinal

study among nurses, in which scores for depression and emotional exhaustionchanged concurrently (McKnight & Glass, 1995). On the basis of a few longitudinal

studies, however, it seems that burnout may lead to depression (e.g., Ahola &

Hakanen, 2007; Greenglass & Burke, 1990). One recent longitudinal study, which

investigated the associations between job strain, burnout, and depression, suggested

that there is, in fact, a reciprocal relationship between burnout and depressive

symptoms (Ahola & Hakanen, 2007). However, the route from burnout to

depression was stronger. According to the few existing longitudinal studies on

burnout and job satisfaction, it also appears that burnout leads to poor job

satisfaction (Burke & Greenglass, 1995; Wolpin, Burke, & Greenglass, 1991). A study

of school-based educators showed that work stressors were associated with increased

burnout that, in turn, resulted in decreased job satisfaction a year later (Wolpin

et al., 1991).

This study approaches the reduction of burnout from both the individual-level

and participatory perspectives. Both of the interventions include tests, examinations,

physical exercises, group discussions, and individual counseling sessions conducted

by multidisciplinary rehabilitation professionals (for more details, see Hatinen,Kinnunen, Pekkonen, & Aro, 2004). The only difference between the two

rehabilitation interventions is that the participatory intervention includes two

collaboration days. During these days, the focus is on the empowerment of clients

by building their capacity to solve self-identified job-related problems and by

providing organizational support for this process through the involvement of

workplace representatives.

The present study aimed at identifying burnout trajectories from the benefit

viewpoint during a one-year rehabilitation, with a six-month follow-up. After

identifying burnout trajectories on the basis of levels and changes in the three

burnout symptoms across time, we studied the associations between the burnout

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trajectories and job-related antecedents, as well as consequences of burnout. The

design of the study consisted of one pre-test and three post-test measurements.

To our knowledge, a person-oriented approach has not previously been taken to

study long-term changes in burnout; therefore, our first hypothesis concerning the

expected burnout trajectories was exploratory and based mainly on the findings of

variable-oriented studies. Previous intervention studies have shown mixed results interms of decreases in the three burnout symptoms. Generally, exhaustion has

decreased, whereas decreases in cynicism and reduced professional efficacy have not

been so consistent (Schaufeli & Enzmann, 1998). For example, cognitive-behavioral

techniques usually have led to a decrease in exhaustion but, only in some cases, also

to a decrease in cynicism (e.g., Blonk, Brenninkmeijer, Lagerveld, & Houtman, 2006)

or reduced professional efficacy (e.g., Van Rhenen, Blonk, van der Klink, van Dijk,

& Schaufeli, 2005). Some interventions have not clearly shown a decrease in burnout

either at the group level (e.g., Mackenzie, Poulin, & Seidman-Carlson, 2006) or at the

individual level (e.g., Hatinen et al., 2004).

Therefore, we expected to find one trajectory comprising clients with a high

initial level of burnout symptoms that would subsequently decrease (benefited

trajectory) and one trajectory with a high initial burnout level that would remain

stable (not-benefited trajectory) during the follow-up. Additionally, the assumption

that identifying burnout is difficult due to the insufficient diagnostic guidelines led us

to expect to find a trajectory with low burnout symptoms.Secondly, we examined whether burnout trajectories would differ following two

types of intervention, namely, traditional (individual-level rehabilitation) and

participatory (focusing on improving job conditions through participatory activities)

interventions. On the basis of the above-mentioned studies showing the effectiveness

of different participatory approaches (Hatinen et al., 2007; Le Blanc et al., 2007;

Mikkelsen & Gundersen, 2003; Mikkelsen et al., 2000) and on the empirically

identified organizational and job-related risk factors of burnout (Maslach & Leiter,

2008), we expected that the majority of the clients from the participatory

intervention would comprise the high burnout � benefited trajectory, whereas the

majority of the clients from the traditional intervention would comprise the high

burnout � not benefited trajectory.

Thirdly, we expected that the time pressure at work would decrease in the high

burnout � benefited trajectory, whereas job control would increase and workplace

climate would improve during the intervention. This expectation was based on the

assumption that clients whose burnout symptoms decreased would be those in theparticipatory intervention and those whose symptoms did not decrease would be

those participating in the traditional intervention. Positive changes among those in

participatory intervention were expected because in this intervention it is possible to

tackle relevant problems at work, among which time pressure is one of the most

common problem (Schaufeli & Enzmann, 1998). Furthermore, because the

participatory approach relies on employee participation, collaboration, and dialogue

among participants (Mikkelsen & Gundersen, 2003), expectations on increased job

control, and improved workplace climate seemed to be justified. In contrast, we

assumed that, in the high burnout � not benefited trajectory, time pressure would not

change or would even increase, and that job control and the quality of the workplace

climate would either not change or would be further impaired during the

intervention.

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Finally, because earlier studies have shown that burnout may lead to depression

and job dissatisfaction, we expected that the decrease in burnout during the

intervention would lead to a decrease in depression and an increase in job

satisfaction in the high burnout � benefited trajectory. Furthermore, we hypothesized

that if a high level of burnout did not change during the intervention, as would be

the case in the high burnout � not benefited trajectory, depression would not change

or it would increase, while job satisfaction would not change or would decrease.

Method

Participants and procedure

The participants were 85 clients who had been accepted for rehabilitation following

physician-diagnosed job-related psychological health problems. In the International

Classification of Diseases and Related Health Problems, burnout can be coded

(Z73.0) as a factor that influences health status and contact with health services

(ICD-10; World Health Organization, 1992). Both interventions of the study are

discretionary medical rehabilitation. Discretionary means that there is no subjective

right to rehabilitation and that the budget is annually confirmed by the Finnish

Parliament (Suoyrjo et al., 2007). The treatment is offered to those under 50 years of

age. Clients are not excluded for mild depression, anxiety, and self-esteem problems

since these usually coincide with burnout. Additionally, clients may suffer from

various physical problems. To be eligible for rehabilitation, clients have to be

employed when seeking rehabilitation, although, they can be on sick leave.

The application procedure was the same for both traditional and participatory

interventions. The employee applicants sent their medical report and rehabilitation

application to the local social insurance institution, from where they were referred to

a rehabilitation center. A physician at the rehabilitation center made the final

selection of the clients. The design and duration of both interventions were also

similar and they were carried out in groups of 8�10 clients within a rehabilitation

center by qualified and experienced professionals. The ethics committee of the

rehabilitation center approved the study.

Questionnaires were used as the data collection method. The questionnaires were

coded by number at the rehabilitation center and forwarded to the researchers. The

clients filled out the questionnaires four times: (a) at the center before they started

the rehabilitation (Time 1 [T1]; N�85); (b) by mail four months after the first 12-day

rehabilitation period (Time 2 [T2]; n�80); (c) 12 months after the first rehabilitation

period (i.e., eight months after their second five -day rehabilitation period), before

they left the rehabilitation center (Time 3 [T3]; n�78); and (d) by mail six months

after the rehabilitation had ended (Time 4 [T4]; n�69). Thus, both interventions

were conducted within two periods covering 17 days and overseen by the

rehabilitation professionals (not the researchers).

Contents of interventions

This study comprised clients from a traditional (n�65) and a participatory (n�20)

intervention. The traditional intervention was the type of rehabilitation program to

which burned-out employees are normally referred. The clients came from various

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workplaces for this intervention, which focuses mainly on individual-level solutions

to enhance clients’ health and well-being by helping them to cope with occupational

stress, as well as to increase their physical, social, and psychological resources. The

primary aim is to help clients to identify and evaluate their own resources and the

factors that burden them in the work situation and life in general in order to be able

to intervene in the progression of burnout.

The participatory intervention was an individually focused intervention com-

bined with an individual�organizational strategy (see Schaufeli & Enzmann, 1998).

This approach differed from the PAR approach, however, in that the researchers were

not involved in the intervention process (as they are in action research) and the

intervention was implemented in rehabilitation center instead of being implemented

in clients’ workplaces. The clients in this intervention came from two workplaces.

The intervention was basically the same as the traditional intervention but included

individual�organizational level activities, most specifically a link to the clients’

workplaces: During the rehabilitation process (one day per period), clients’ super-

visor, a member of the local occupational health and safety organization, and a

representative from the local occupational health care were invited to the

rehabilitation center to discuss the clients’ job situation together with the clients

and rehabilitation personnel. The purpose of these discussions was to acknowledge

and identify the job-related causes that have led to deterioration in the clients’ job-

related psychological health, and to find ways to improve the clients’ job conditions

in the workplaces. Additionally, the purpose was to actively involve workplace

representatives in this process.

Measures

Burnout

Three subscales of the Finnish version of the Maslach Burnout Inventory-General

Survey (MBI-GS; Kalimo, Hakanen, & Toppinen-Tanner, 2006; Maslach et al.,

1996) were used to measure job-related burnout four times. Exhaustion was

measured with five items (e.g., ‘‘I feel emotionally drained from my work;’’ T1

Cronbach’s a�.95, T2 a�.94, T3 a�.94, and T4 a�.95), cynicism with five items

(e.g., ‘‘I have become less enthusiastic about my work;’’ T1 Cronbach’s a�.87, T2

a�.85, T3 a�.92, and T4 a�.81), and professional efficacy with six items (e.g., ‘‘In

my opinion, I am good at my work;’’ T1 Cronbach’s a�.81, T2 a�.83, T3 a�.84,

and T4 a�.87) using a seven-point scale from zero (never) to six (every day). High

scores on exhaustion and cynicism and low scores on professional efficacy indicate

burnout.

Job-related antecedents of burnout

The antecedents were measured twice during rehabilitation: at the beginning of the

intervention (T1) and after the second period of the intervention (T3). The measure

of time pressure at work consisted of three items (e.g., ‘‘Do you have to hurry to get

your work done?;’’ T1 Cronbach’s a�.65, T3 a�.62), which were rated using a five-

point scale from one (never), to five (all the time). Job control was measured with

nine items that described to what extent the respondents were able to control

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different aspects of their work (e.g., workload and quality of work; T1 Cronbach’s

a�.90, T3 a�.87). The responses were rated on a five-point scale from one (very

little) to five (very much). The quality of workplace climate measured the atmosphere

in the workplace by five items (e.g., encouraging and supporting new ideas) on a five-point response scale from one (totally disagree) to five (totally agree; T1 Cronbach’s

a�.72, T3 a�.89). These last three scales have been used in Finnish occupational

studies and validated by the Finnish Institute of Occupational Health (e.g., Elo,

Leppanen, Lindstrom, & Ropponen, 1990).

Consequences of burnout

Consequences of burnout were measured twice during rehabilitation: at thebeginning of the intervention (T1) and after the second period of the intervention

(T3). The level of depressive symptoms was measured with the Beck Depression

Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), which is a 21-

item questionnaire measuring respondents’ negative thoughts (e.g., suicidal

thoughts), feelings (e.g., sadness), and behavior (e.g., crying). The items were rated

on five- to six-point scales. The higher the BDI score, the more severe the level of

depressive symptoms (T1 Cronbach’s a�.91, T3 a�.92). Job satisfaction was

measured with 13 items from the Finnish version of the Job Diagnostic Survey (JDS;Vartianen, 1989). Three items measured a respondent’s satisfaction with his/her

supervisor (e.g., ‘‘To what extent are you satisfied with the degree of respect and fair

treatment you receive from your boss’’), five items measured personal development

possibilities (e.g., ‘‘To what extent are you satisfied with the feeling of worthwhile

accomplishment you get from doing your job’’), two items measured salary (e.g., ‘‘To

what extent are you satisfied with the amount of pay and fringe benefits you

receive’’), and three items measured relationships at work (e.g., ‘‘To what extent are

you satisfied with the people you talk to and work with on your job;’’ T1 Cronbach’sa�.85, T3 a�.85). The response scale was from one (very dissatisfied) to five (very

satisfied).

Type of intervention, sociodemographic factors, and clinical characteristics

The type of intervention program was coded as 1�traditional and 2�participatory.

Sociodemographic factors included age (in years), gender (1�man, 2�woman),

socioeconomic status (1�blue-collar, 2�white-collar worker), living with a partner(1�no, 2�yes), total hours worked per week, and years worked in current position

and organization. Clinical characteristics consisted of the number of prolonged

illnesses, self-reported use of antidepressants (1�no, 2�yes), and extra therapeutic

counseling during rehabilitation (1�no, 2�yes), and respite from work (1�no, 2�yes; e.g., studying, unemployment, sick-leave, part-time retirement). These factors

were taken into account in order to find out the associates of burnout trajectories.

Statistical analysis

Growth Mixture Modeling (GMM) was used to investigate whether there was

heterogeneity in the rehabilitation pathways of burnout (Muthen, 2006; Muthen &

Muthen, 2000). In the GMM, latent trajectory classes that were expected to differ in

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their level and growth rate in the burnout components (i.e., exhaustion, cynicism,

and reduced professional efficacy) were investigated. In this study, clients within a

trajectory were treated as homogeneous with respect to their development. Three

criteria were used to decide the number of trajectories (Nylund, Asparouhov, &

Muthen, 2007): (a) the Bootstrap Likelihood Ratio Test (BLRT); (b) the Bayesian

Information Criterion (BIC); and (c) the usefulness and clarity of the latent

trajectory classes in practice. Muthen (2006) suggests using the BLRT since the

BLRT has been a very consistent indicator of trajectories, followed by the BIC in

Monte Carlo simulation studies (Nylund et al., 2007). The BLRT compares the

solutions of different numbers of trajectories. A low p-value (pB.05) indicates that

the k-1 model has to be rejected in favor of a model with at least k trajectories. The

analyses were performed using the Mplus statistical package (Version 4.0; Muthen &

Muthen, 1998�2005). The missing data method was used, which allowed us to use all

the observations in the data set to estimate the parameters in the models. The

method of estimation used was robust maximum likelihood (MLR).

After identifying the burnout trajectories, we examined, by using either the chi-

square test or one-way analysis of variance (ANOVA), whether the trajectories would

differ in the type of intervention, or in sociodemographic and clinical characteristics.

The post-hoc comparisons were tested either with Scheffe’s (equal variances

assumed) or Tamhane’s (equal variances not assumed) test. ANOVA for repeated

measures was used to examine the changes in the antecedents and consequences of

burnout between the burnout trajectories during the one-year intervention. In these

analyses, the antecedents and consequences acted as dependent variables, burnout

trajectories and time as independent variables.

All the dependent variables were analyzed separately. If the Group�Time

interaction effect was significant, we proceeded with the univariate analysis. Because

of the small sample size, main or interaction effects are not, however, likely to be

detected (Landsbergis & Vivona-Vaughan, 1995; Mikkelsen et al., 2000; Tabachnick

& Fidell, 2001). Therefore we also analyzed the within-participants effects on each

trajectory separately with ANOVA for repeated measures. SPSS 15 was used as a

statistical tool in these analyses.

Results

Trajectories for burnout

Table 1 presents the results of the GMM by showing the fit indices for the solutions

with different numbers of latent trajectory classes. As can be seen from the table, the

Table 1. Fit indices for growth mixture models of burnout symptoms with different numbers

of latent trajectory classes.

Number of

trajectory classes

Log

likelihood

Number of free

parameters BIC

BLRT approximate p-value

k-1 versus k trajectory

2 �1220.2 37 2604.70 0.0000

3 �1197.7 44 2590.84 0.0000

4 �1180.7 51 2587.89 0.2083

Note: BIC, Bayesian Information Criterion; BLRT, Bootstrap Likelihood Ratio Test.

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BLRT supported a three-trajectory solution. On the basis of the BIC indices, a four-

trajectory solution was supported (i.e., had lowest BIC). However, one of these four

trajectories was small, consisting of nine cases only. Taking this information into

account, together with the fact that the BLRT is recommended by Muthen (2006),

the three-trajectory solution was chosen for the subsequent analysis.

Table 2 and Figure 1 show the results of the three-trajectory solution. The

baseline means of the burnout symptoms and their linear trends are shown in Table

2. Trajectory 1 (n�29) was characterized by a high initial level of exhaustion and

cynicism, the mean level of which decreased over time. The level of reduced

professional efficacy was also relatively high in this trajectory, but there were no

mean level changes in this burnout component. This trajectory was named high

burnout � benefited. Trajectory 2 (n�17) was characterized by a high level of

exhaustion and cynicism but, contrary to trajectory 1, their mean level remained at

the same high level across time. The level of reduced professional efficacy was highest

in this trajectory. Consequently, this trajectory was labeled as high burnout � not

benefited. Trajectory 3 (n�39) was characterized by stable low levels of the three

burnout dimensions. Consequently, no mean changes were evident in this trajectory

across time. This trajectory was labeled as low burnout.

Differences in type of intervention, sociodemographic factors and clinicalcharacteristics according to the three burnout trajectories

We studied the associations between type of intervention, sociodemographic factors

and clinical characteristics and the three burnout trajectories in order to find out

whether the burnout trajectories would be related to these factors. The trajectories

differed in three factors: intervention program, number of prolonged illnesses, and

therapeutic counseling during rehabilitation. All the clients who composed the high

burnout � not benefited trajectory had been participants in the traditional program,

x2(2)�7.26, pB.05. The clients in the high burnout � benefited trajectory (M�1.69)

Table 2. Mean level estimates and standard errors for three burnout trajectories: results from

growth mixture modeling.

High burnout �benefited (n�29)

High burnout � not

benefited (n�17)

Low burnout

(n�39)

Growth mixture

model Estimate

Estimate/

SE Estimate

Estimate/

SE Estimate

Estimate/

SE

Exhaustion

Level 4.85 33.69 1.92 9.81 4.46 9.14

Linear trend �2.54 �12.34 �0.21 �1.15 �0.06 �0.20

Cynicism

Level 3.35 15.17 1.03 6.86 3.96 6.91

Linear trend �1.90 �6.79 0.28 1.38 0.39 1.10

Reduced professional efficacy

Level 2.37 9.06 1.66 7.86 2.89 7.71

Linear trend �0.24 �0.69 �0.18 �1.12 0.14 0.41

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had more self-reported prolonged illnesses than those in the low burnout trajectory

(M�0.90), F(2, 82)�4.24, pB.05. And, more clients in the low burnout trajectory

(87%) than in the high burnout � not benefited trajectory (53%), x2(2)�8.26, pB.05,

had not received extra therapeutic counseling during the rehabilitation process. The

differences in these factors between the three burnout trajectories are important to

acknowledge in order to interpret the results.

Est

imat

ed m

eans

of

burn

out s

ympt

oms

Est

imat

ed m

eans

of

burn

out s

ympt

oms

Est

imat

ed m

eans

of

burn

out s

ympt

oms

Exhaustion

Cynicism

Reduced professional efficacy

Trajectory 1 = high burnout-benefited (n= 29)

Trajectory 2 = high burnout-benefited (n= 17)

Trajectory 3 = low burnout-(n= 39)

0

1

2

3

4

5

6

Exhaustion

Cynicism

Reduced professional efficacy

0

1

2

3

4

5

6

Time 1 Time 2 Time 3 Time 4

Time 1 Time 2 Time 3 Time 4

Time 1 Time 2 Time 3 Time 4

Exhaustion

Cynicism

Reduced professional efficacy

6

5

4

3

2

1

0

Figure 1. Estimated growth curves for latent trajectory classes for burnout symptoms (0�never, 6�every day).

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Changes in antecedents and consequences of burnout according to burnout trajectories

Job demands

The 3 (burnout trajectories)�2 (time) ANOVA for repeated measures showed an

interaction effect for time pressure at work, F(2, 72)�4.07, pB.05. When analyzing

the three trajectories separately, the within-participants effects showed that time

pressure decreased among those in the high burnout � benefited and in the low

burnout trajectories (Table 3).

Job resources

The 3 (burnout trajectories)�2 (time) ANOVA for repeated measures showed a main

time effect for job control, F(1, 71)�5.44, pB.05, meaning that job control increased

in all three trajectories. However, when analyzing the three trajectories separately, the

within-participants effects showed that job control increased only among those in the

high burnout � benefited trajectory. Additionally, a group effect for workplace climate

was detected, F(2, 69)�6.15, pB.01, showing that those in the low burnout trajectory

experienced a better workplace climate compared to those in the high burnout � not

benefited trajectory. Moreover, the within-participants effects revealed an improve-

ment in the workplace climate in the low burnout and high burnout � benefited

trajectories (Table 3).

Depression

The 3 (burnout trajectories)�2 (time) ANOVA for repeated measures showed an

interaction effect for depression, F(2, 56)�8.69, pB.01, meaning that the level of

depression changed differently in the burnout trajectories. When the three

trajectories were analyzed separately, the within-participants effects showed that

depression decreased significantly among those in the low burnout and those in the

high burnout � benefited trajectories (Table 3).

Job satisfaction

When analyzing changes in job satisfaction with the 3 (trajectories)�2 (time)

ANOVA for repeated measures, a significant interaction effect for overall job

satisfaction was detected, F(2, 68)�6.21, pB.01. When analyzing the three

trajectories separately, the within-participants effects showed that job satisfaction

increased among those in the high burnout � benefited trajectory, whereas no

changes appeared in the two other trajectories (Table 3).

Discussion

The present study aimed at identifying burnout trajectories in a one-year rehabilita-

tion with a six-month follow-up. After identifying the trajectories, we studied

whether they were related to factors describing the clients, and to the antecedents

and consequences of burnout during the one-year rehabilitation intervention.

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Table 3. Within-subjects effects of antecedents and consequences of burnout according to three burnout trajectories.

High burnout � benefited (n�29) High burnout � not benefited (n�17) Low burnout (n�39)

Job-related

antecedents of

burnout

T1 T3 F p value T1 T3 F p value T1 T3 F p value

N M M valuea n M M valuea n M M valuea

Time pressure 25 3.78 2.88 22.47 B.001 13 3.35 3.87 3.87 .073 37 3.24 2.97 4.16 .049

Job control 25 2.67 3.09 9.89 .004 12 2.93 3.04 0.37 .558 37 3.22 3.30 0.45 .509

Workplace climate 25 2.82 3.22 5.61 .026 11 2.76 2.56 0.73 .412 36 3.26 3.64 6.83 .013

Consequences of

burnout

Depressionb 18 17.50 8.61 34.16 B.001 12 17.83 18.58 0.09 .766 29 8.48 5.72 6.92 .014

Job satisfaction 25 3.10 3.59 22.61 B.001 11 2.90 2.90 0.00 1.00 35 3.62 3.64 0.25 .876

Note: T1�pre-intervention, T3�post-intervention 12 months after the first rehabilitation period.aWithin-subjects effects on each trajectory separately with ANOVA for repeated measures.bRange 0�63.

An

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Burnout trajectories

Our first hypothesis that we would find three trajectories was supported. The

statistical solution preferred, however, a four-trajectory solution, which was rejected

because one of the trajectories had a small size. There appeared to be interindividual

change in how clients reacted to the interventions and how these reactions were

manifested in burnout symptoms across time. The high burnout � benefited

trajectory comprised clients whose burnout symptoms were at a high level but for

whom two symptoms � exhaustion and cynicism � decreased during the follow-up.

The high burnout � not benefited trajectory comprised clients whose high level of

burnout did not decrease during the follow-up. Besides a high level of exhaustion,

this trajectory was characterized by high levels of cynicism and reduced professional

efficacy across time. The low burnout trajectory comprised clients whose levels of

burnout symptoms were low and did not change during the follow-up. In line with

previous burnout intervention studies (e.g., Blonk et al., 2006; Hatinen et al., 2004;

van Dierendonck, Schaufeli, & Buunk, 1998), the results of the present study also

show that exhaustion and/or cynicism are the symptoms of burnout that seem to be

the most amenable to change. Moreover, consistently with other study findings (e.g.,

Hatinen et al., 2007; van Dierendonck et al., 1998), personal efficacy did not increase

as a result of the intervention.

Although, we expected few clients in the low burnout trajectory, this group was

quite large, consisting of 39 clients out of 85. Thus, these clients were not burned out

according to the MBI-GS and neither did they have significant depression according

to the BDI. The MBI measure has been found to have reasonable discriminatory

power; burnout and non-burnout patients differed in particular in emotional

exhaustion and depersonalization in a Dutch sample (Schaufeli, Bakker, Hoodguin,

Schaap, & Kladler, 2001). It seems that the present clients in the low burnout

trajectory were in a type of rehabilitation unsuited to their particular health

problems, indicating that referral for rehabilitation had not been appropriate. It is

possible that a rehabilitation program focusing clearly on the secondary preventive

level (so-called early rehabilitation) would have been more suitable for these clients.

When the low burnout trajectory was excluded and the decrease in burnout

symptoms was the sole criterion for benefit, a little more than half (63%) of the

clients benefited from their rehabilitation program. Half of those who participated in

the participatory program benefited from the intervention, whereas 29% of those

who participated in the traditional program benefited from the intervention.

Moreover, all those in the high burnout � not benefited trajectory were clients

from the traditional intervention. Thus, in the light of these percentages, our second

hypothesis expecting that those benefiting from the rehabilitation would in particular

have participated in the participatory intervention gained some support. It seems

that, in line with our previous rehabilitation intervention study (Hatinen et al., 2007),

the traditional type of intervention, which focuses largely on helping clients to cope

better with stress, may not be as successful as the participatory intervention in

reducing burnout symptoms. In contrast, the participatory intervention seemed

successful, as previous studies have also indicated (Hatinen et al., 2007; Le Blanc

et al., 2007; Mikkelsen & Gundersen, 2003; Mikkelsen et al., 2000). However, for 19

clients in the traditional intervention burnout decreased, indicating that, in some

cases, the traditional intervention is also effective in reducing burnout. It might be

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that these clients received enough support and resources from the rehabilitation to

change their own job and life situations, thereby decreasing their burnout symptoms.

How can the differential development of burnout in the two high burnout

trajectories during rehabilitation be explained? Two possible explanations concernthe type of intervention and clients’ personal situation. As discussed above, the

clients in the high burnout � not benefited trajectory received treatment (traditional

intervention) known to be less effective in the rehabilitation context (Hatinen et al.,

2007), but they may also have had personal and/or family problems that caused them

further psychological stress. This is indicated by the fact that they had most often

had additional counseling. This further stress might have limited the personal

resources available to them for recovery from burnout. Thus, in accord with the COR

theory, they may have been caught up in a cycle of resource loss (Hobfoll & Freedy,1993).

The differential development of burnout in these two high burnout trajectories

could also have resulted from higher baseline levels of cynicism and reduced

professional efficacy among those in the high burnout � not benefited trajectory, as

shown in Figure 1. The developmental theory of burnout by Leiter and Maslach

(1988) suggests that the appearance of cynicism and reduced professional efficacy

follows exhaustion, indicating a progressive and a more severe phase of burnout. It is

possible, then, that those in the high burnout � not benefited trajectory may havesuffered longer from burnout, which may have resulted in their having more severe

and resistant symptoms of burnout. These clients may have received rehabilitation

too late; thus, it can be speculated that they might have benefited from an earlier

referral for treatment. It is also possible that a prolonged exposure to burnout may

have led to other illnesses or problems, such as depression (e.g., Ahola & Hakanen,

2007), which prohibited the recovery process.

Longitudinal changes in antecedents and consequences of burnout

Our third hypothesis concerning the expected changes in job demands and resources

according to the three burnout trajectories was supported. Positive changes were

associated, especially, with the high burnout � benefited trajectory. In this trajectory,

time pressure decreased, and job control and workplace climate improved. The

decreases in job demands and increases in job resources reflected the recovery

process in the high burnout � benefited trajectory during the follow-up. Positive

changes occurred in the low burnout trajectory as well, that is, time pressuredecreased and workplace climate improved. As expected, no changes occurred in job

conditions in the high burnout � not benefited trajectory.

According to the COR theory (e.g., Hobfoll & Freedy, 1993), this recovery

process can be interpreted as a resource gain cycle: An increase in job resources � a

resource gain � results in a reduction in burnout. However, the reduction in burnout

may also have led to improved perceptions of job conditions (see De Lange, Taris,

Kompier, Houtman, & Bongers, 2004). Our study cannot resolve this causation

question since we were only able to examine concurrent changes in burnout and jobconditions in the present study. Similarly, we do not know whether the changes in the

perceptions of job conditions were the outcome of the rehabilitation activities.

Although, some of those clients in the benefited trajectory were treated in the

participatory intervention, which focused on changing the job conditions, some of

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the clients underwent traditional rehabilitation that did not focus on changing their

job conditions. Thus, the conclusion is that either the burnout clients whose mental

health improved may have perceived their job conditions more positively over time or

that positive changes in their job conditions resulted in recovery from burnout.Our fourth hypothesis on the consequences of burnout was partly supported. As

expected, most change occurred in the high burnout � benefited trajectory; that is,

depression decreased and job satisfaction increased. In the low burnout trajectory, a

positive development also occurred, as depression decreased. The decrease in

depression was especially meaningful among clients in the high burnout � benefited

trajectory, since the depression scores fell from the category of mild-to-moderate

depression to that of null-t.-to-minimal depression (Beck, Steer, & Garbin, 1988). As

McKnight and Glass (1995) have previously shown, burnout and depression developconcurrently. Our study findings are relevant to this issue since a concurrent decrease

in these two phenomena occurred.

As expected, the least changes occurred in the high burnout � not benefited

trajectory; the level of depression stayed at high level during the rehabilitation. This

is particularly alarming because, when a rehabilitation intervention is unable to

enhance clients’ mental health and at the same time clients are dissatisfied with their

jobs, there is a risk that these clients consider seeking early retirement or a disability

pension. It would be particularly important to examine why these clients did notbenefit from rehabilitation in order to develop treatment strategies suited to their

needs. Perhaps these clients would have benefited from a participatory type of

intervention. It is also possible that the clients would have benefited from a more

intensive type of intervention, such as therapy.

Strengths and limitations of the study

The strength of this study is the longitudinal research design in which change inburnout was followed for one-and-a-half years and change in perceptions of job

conditions and well-being for one year. In addition, we used the person-oriented

approach by applying a relatively new statistical method, GMM, which confirmed

three burnout trajectories.

The limitations of the study are the small sample size and the use of exclusively

self-report data. Furthermore, because of the lack of a control group, we are unable

to draw any conclusions as to whether the decrease in burnout symptoms in the high

burnout � benefited trajectory across time was due to the rehabilitation treatments.However, untreated burnout symptoms are generally stable over time (Schaufeli &

Enzmann, 1998). We cannot exclude the possibility that the clients in the high

burnout � benefited trajectory could have taken self-initiating actions (e.g., reducing

one’s own working hours) to improve their work situation.

One limitation that could have affected the results of the study is the proportion

of dropouts. Sixteen clients did not respond to every question in the MBI inventory

or at every measurement. Of these, seven responded to two out of four measurements

and one dropped out after the first measurement. Others responded at three out offour measurement times. It is possible that those who did not respond on each

occasion were more burned out; if so, the level of burnout would have been

underestimated. Moreover, the MBI-measure has received some criticism concerning

one of its subscales, lack of professional efficacy (Schaufeli & Salanova, 2007). The

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recent study suggests that using a newly constructed inefficacy scale, in which items

are reversed and reformulated, better captures the burnout phenomenon (Schaufeli

& Salanova, 2007). Therefore, in future studies, it might be reasonable to adopt an

inefficacy scale rather than a reversed efficacy scale when assessing burnout.

Practical implications

In practice, having heterogeneous groups of clients in the same rehabilitation

program is a problem. In a situation where we urgently need evidence-based

information to know what works and with what specific group, analyzing

heterogeneous samples is of limited help. Heterogeneous samples lead to small or

non-significant effect sizes, which in turn could lead to the conclusion that

interventions have little or no effect. Furthermore, the research field is in direneed of appropriate and effective interventions. Therefore, inclusion and exclusion

criteria on burnout need to be defined rigorously in line with the contents of the

intervention. Without clear criteria, it is difficult to draw conclusions as to what

extent the variation in outcomes is due to the sample and what to the intervention.

Creating specific inclusion and exclusion criteria for burnout is, however, particularly

challenging, since the research field has not achieved common agreement on the

conceptualization of burnout. In spite of this disagreement, it is important that the

criteria chosen are explicit and that the benefits are assessed according to thosecriteria.

From a practical point of view, it is recommended that rehabilitation profes-

sionals as well as organizations focus on changing the job conditions of burnout

employees by decreasing the demands made on them and increasing their job

resources. Although, our study cannot say anything about the causal effects between

job conditions and burnout, it clearly showed that there were concurrent changes in

them. Another critical factor in whether or not clients benefit from a burnout

intervention is the timing of rehabilitation and the severity of burnout. Receivingrehabilitation at the right time may prevent burnout symptoms becoming severe and,

consequently, prevent the development of further problems.

Acknowledgements

The research project on which this paper is based, ‘‘Job Burnout: Evaluation, Developmentand Effectiveness of Intervention,’’ was financially supported by the Finnish Work Environ-ment Fund (Grant No. 100118), the Finnish Cultural Foundation, and the Social InsuranceInstitution of Finland.

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