NTERNATIONAL R EVIEW OF I NDUSTRIAL AND O RGANIZATIONAL P SYCHOLOGY 2005 evidenced by a recent compendium of research on the CFS (Friedberg &

292 I NTERNATIONAL R EVIEW OF I NDUSTRIAL AND O RGANIZATIONAL P SYCHOLOGY 2005 evidenced by a recent compendium of research on the CFS (Friedberg &

Jason, 1998) which did not make any reference to burnout. CFS is an illness of unknown etiology associatedwith significant d isability; characteristic symptoms include profound fatigue lasting for 6 months or more, impaired memory or concentration, sleep disturbances, sore throat, and other symp- toms (for a discussion of the diagnosis and components of the CFS see Friedberg & Jason, 1998, pp. 49–65). Early references to the relevant disease entities often went under the symptomatic categories of asthenia, lassitude, lethargy, or listlessness. CFS is now recognizedas a legitimate disease state (Shafran, 1991). Idiopathic Chronic Fatigue (ICF) is CFS with fewer symptoms, but studies comparing CFS and ICF patients have found few clinically meaningful differences between the two categories, and ICF is now regarded as a point on a continuum leading to CFS (cf. Johnson, DeLuca, & Natelson, 1999).

Researchers who have studied the psychological pathogenesis of CFS tended to view clinical depression as antedating the development of this disease state since fatigue is one of the symptoms included in many measures of depression and it is present in all cases of CFS (Shafran, 1991). However, several studies have found that CFS is distinct from depression in both the biological and psychiatric domains (Friedberg & Jason, 1998, p. 24). The medical model of CFS disregards the role of stress in bringing about the disease (cf. Wessely, 1995). Only a small minority of those complaining of chronic fatigue are diagnosed as having CFS (Wessely, 1995). Etiologically, the role of burnout in bringing about CFS at some point is a working hypothesis that has yet to be systematically investigatedby future research (cf. Huibers et al., 2003). Huibers et al. (2003) pioneeredin this respect by exploring the relationship between burnout (gaugedby the MBI) andCFS in

a sample of 151 fatiguedemployees on sick leave. In this cross-sectional study of a highly selectedsample, they foundthat 44% of fatiguedemployees met CFS criteria and50% of them met the research criteria of being burned- out. The relations between burnout andthe CFS appear to be a promising area for future research.

Burnout and Chronic Fatigue

Fatigue is a common phenomenon accompanying any mental andphysical exertion, andit is characteristically task-specific andreversible. In contrast, chronic fatigue represents a situation wherein one’s energetic resources are not replenishedby rest or changing tasks (Michielsen, De Vries, & Van Heck, 2003). Chronic fatigue is a relatively common complaint presentedby employees andby patients visiting their primary care physicians (Bultmann, Kant, Kasl, Beurskens, & van den Brandt, 2002; Fuhrer & Wessley, 1995; Huibers et al., 2003); about 20% of the working population in different surveys reportedfatigue, with the prevalence rate ranging between 7% to

293 45%, depending on the instrument used and the applied cut-off points.

B URNOUT AND H EALTH R EVIEW

Different studies have found that about one-fifth of those patients who visit primary care clinics in different developed countries complain of chronic fatigue (e.g., Kroenke, Wood, Mangelsdorff, Meier, & Powell, 1988). Two epidemiological surveys, which covered sizable representative samples in the USA andin the UK, foundthat about 14% to 20% of the male respondents and about 20% to 25% of the female respondents described themselves as always feeling tiredor significantly fatigued(Shafran, 1991).

We couldnot findany study that systematically investigatedthe potential linkages between chronic fatigue andburnout or the potential etiological role of work-relatedstresses for both entities. One exception is the recent panel study of fatigue and burnout among 123 ambulance workers in the Nether- lands studied one year apart (van der Ploeg & Kleber, 2003). In this study it was foundthat the within-wave anddiachronic correlations of the fatigue subscale of the Checklist of Individual Strength, a chronic fatigue measure, andthe emotional exhaustion subscale of the MBI were, respectively, 0.50 and0.41, but the pattern of their relations with their expectedantecedents was quite similar. An examination of items included in scales constructed for the assessment of chronic fatigue indicate that they include components that are analogous to those representedin the popular measures of burnout, such as physical andmental exhaustion in the scale constructedby Michielsen (Michielsen et al., 2003), andphysical fatigue, red ucedmotivation, and reduced activity in the frequently used scale constructed by Smets and her colleagues (Smets, Garssen, Bonke, & De Haes, 1995). A recent psycho- metric comparison of six fatigue questionnaires concluded that they are all unidimensional (De Vries, Michielsen, & Van Heck, 2003). The task of theoretically andempirically integrating chronic fatigue research and burnout research is a major challenge that has yet to be confronted.

The relationship between fatigue andpsychological distress in general and depression in particular has been explored in several studies. For example, in

a study of 3,784 primary-care patients in France, Fuhrer and Wessely (1995) foundthat there was a strong relationship between fatigue anddepression, but fatigue was neither sensitive nor specific to the diagnosis of depression. In a study of 12,095 employed adults in the Netherlands (Bultmann et al., 2002), a prevalence rate of 22% for fatigue and23% for psychological distress was found, but, while closely associated, the evidence led this group of researchers to conclude that these conditions are different and can

be measuredindependently.

The Medicalization of Burnout?

In recent years, in being the first to label individuals with high scores on burnout scales as ‘cases’ or ‘patients’, a group of Dutch researchers have impliedthat these instruments have clinical valid ity (Schaufeli, Bakker,

294 I NTERNATIONAL R EVIEW OF I NDUSTRIAL AND O RGANIZATIONAL P SYCHOLOGY 2005 Hoogduin, Schaap, & Klader, 2001; Schaufeli & Buunk, 2003). This group

of researchers was able to demonstrate empirically that the emotional exhaustion and depersonalization subscales of the MBI distinguished between burned-out and nonburned-out patients at a psychotherapeutic treatment center (Schaufeli et al., 2001). Presently, there are no clinically validated cut-off points available with respect to any of the instruments usedto assess burnout, with most researchers using arbitrary cut-off points like the 80th or 90th percentile (Schaufeli, in press; Schaufeli et al., 2001). Psychometrically, establishing cut-off scores to define ‘clinical burnout’ is bound to be dependent on the country, gender, age, and occupational characteristics of the sample studied since levels of burnout have been shown to be closely dependent on them (cf. Schaufeli & Enzmann, 1998).

In the burnout literature, employees who admit that they are burned-out do not necessarily become stigmatized as inept or incompetent employees. On the contrary, anecdotal evidence suggests that managers regard burned- out employees as those highly committedto their job andorganization, those who invest in their tasks andduties andtherefore tendto experience burnout. In their recent meta-analysis of burnout research that usedthe MBI between 1982 and1994, Lee andAshforth (1996) identifiedseven empirical studies of the relationship between burnout andorganizational commitment. Across the seven studies, the mean corrected correlation between these variables

fore, both popular opinion andresearch evidence support the argument that those who report being burned-out carry a minimal stigmatizing burden. The diagnosis of their complaint is not confined to their personal vulner- abilities but rather extends to the job, organization, and family contexts implicatedin the burnout process (e.g., Leiter & Maslach, 1988; Maslach et al., 2001; O’Driscoll & Schubert, 1988). Restricted individual access to those resources that can be appliedto cope effectively with work-related stresses, thereby reducing their impact on burnout, is often viewed as a prime cause of burnout (Schaufeli & Buunk, 2003; Shirom, 2003b).

Possible Organizational Implications of Burnout

The set of findings presented in this review reinforces the need to search for preventive measures to combat stress andburnout. Earlier organization studies provide sufficient reasons to combat burnout in an attempt to prevent low morale, reduced motivation, increased absenteeism, and reduced performance effectiveness. The new data suggest that effective measures to prevent burnout may also prove to be protective to health andbeneficial to physical well-being, andmay result in reduceddisability, loweredhealthcare costs, prevention of early retirement, andperhaps even the prevention of premature death.

295 Adverse organizational conditions have been shown to be more significant

B URNOUT AND H EALTH R EVIEW

in the etiology of burnout than personality factors (Schaufeli & Enzmann, 1998). The lesson to burnout researchers is that it is plausible that individual traits predisposing employees to burnout interact with organizational features that are conductive to the development of burnout. As an example, when a major economic slump moves management to require that all employees increase their input of available personal energy andtime to ensure the organization’s survival, those employees who possess high self- esteem are less likely to experience burnout as a result (Cordes & Dougherty, 1993).

Senior management has a role to play in instituting preventive measures, including steps to ameliorate chronic work-related stress, particularly overload, training programs designed to promote effective stress management techniques, andon-site recreational facilities. Organizational interventions to reduce burnout have great potential, but are difficult to implement, by virtue of the complexities involved, and costly, in terms of resources required. The changing nature of employment relationships, including the transient and dynamic nature of the employee–employer psychological contract (Sparrow & Cooper, 2003), entails putting more emphasis on individual-oriented approaches to combat burnout. The role of individual coping resources, including self-efficacy, hardiness, and social support from friends and family, may become more important in future interventions.

It has been arguedthat workplace-basedinterventions, aimedat reducing stress and modifying some of the maladaptive responses to stress, often have little or no effect (Briner & Reynolds, 1999). Is this also true of interventions designed to ameliorate burnout? Most of the burnout interventions reported in the literature are individual-oriented and provide treatment, not prevention, much like other stress interventions (Nelson, Quick, & Simmons, 2001). There have been hardly any reports on interventions basedon a systematic audit of the structural sources of workplace burnout with the objectives of alleviating or eliminating the stresses leading to burnout.

Longitudinal Studies of the Process of Burnout

The proposition that the early stages of burnout are more likely to be accompaniedby heightenedanxiety while the more ad vancedstages of burnout may be linked to depressive symptomatology needs to be tested in longitudinal research. Yet another example where longitudinal research might be beneficial is in connection with the above proposition that high levels of burnout may predict the incidence of CFS.

Situational and Self-concept Moderators of the Effects of Burnout on Health

One important area of future research concerns the possibility that there are situational andself-concept variables that moderate the effects of burnout on health. One of the predictions of COR theory is that individuals who lack strong resources are more likely to experience cycles of resource losses. Unabated, such cycles are likely to result in the chronic depletion of energy (i.e., progressive burnout). Cherniss (1995) arguedthat the advance of burnout is contingent upon individuals’ levels of self-efficacy, and there is some support for this contention (Brouwers & Tomic, 2000). Lower levels of burnout are to be expectedin work situations that allow employees to experience success andthus feel efficacious; namely, under job andorgani- zational conditions that provide opportunities to experience challenge, control, feedback of results, and support from supervisors and co-workers (cf. Brouwers & Tomic, 2000; Schaufeli & Buunk, 1996). Thus, Chang and his colleagues (Chang, Rand, & Strunk, 2000) found, in a study of working college students, that optimism was a potent negative predictor of the emotional exhaustion scale of the MBI even after the effects of stress were controlled. Chang et al. (2000) concluded that concrete affirmation of job accomplishments, such as by merit awards, and increasing employees’ optimistic expectancies may lower their risk of job burnout. The possibility that these job features andwork characteristics may exert a moderating effect on the burnout–health relationship needs to be explored in future research.

Several interventions that have focusedon burnout attest to the impor- tance of the core self-evaluations of self-efficacy and mastery in understand- ing the effects of burnout on health. For example, a longitudinal research of burnout among teachers by Brouwers andTomic (2000) foundthat emotional exhaustion hada negative effect on self-efficacy beliefs andthat this effect occurredsimultaneously rather than over time. They reasoned that interventions that incorporate enactive mastery experiences, the most important source of self-efficacy beliefs, were likely to have an ameliorative effect on teachers’ emotional exhaustion. In a separate study, a multifaceted intervention that combinedpeer social support andthe bolstering of profes- sional self-efficacy was foundto reduce burnout (measuredby the SMBM) relative to a control group of nonparticipants (Rabin et al., 2000). Yet another example is the Freedy and Hobfoll (1994) study, in which the researchers enhancednurses’ coping skills by teaching them how to use their social support networks and individual mastery resources, leading to a significant reduction in emotional exhaustion in the experimental group relative to the untreatedcontrol group.

The role of personality factors in the etiological processes leading from burnout to physical health is complex andmultifaceted(Kahill, 1988). In a recent meta-analysis, Thoresen, Kaplan, Barsky et al. (2003) found, for 23