2004 hatinen et al
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Burnout Patterns in Rehabilitation: Short-Term Changes in JobConditions, Personal Resources, and Health
Marja Hatinen, Ulla Kinnunen, Mika Pekkonen, and Antti AroUniversity of Jyvaskyla
This longitudinal study reports the patterning of the burnout symptoms and the changes in
employees job conditions, personal resources, and psychological health 4 months after a
rehabilitation intervention. The data were gathered by means of questionnaires before and after
a rehabilitation period. Four patterns were identified: not burned out (n 55), exhausted and
cynical (n 36), burned out (n 26), and low professional efficacy (n 18). These patterns
differed in terms of job resources, personal resources, and depression. There were both positive
and negative changes detected in participants psychological health and job resources at the
follow-up. The study shows the importance of identifying different burnout patterns in order to
focus rehabilitation activities more effectively.
There has been ample empirical evidence to show
that burnout is a serious threat to employees psycho-
logical health and working ability (Schaufeli & Enz-
mann, 1998; Schaufeli, Maslach, & Marek, 1993). In
addition, research has shown that burnout is not only
related to negative outcomes for the individual but
also to negative outcomes for the organization (for
reviews, see Burke & Richardsen, 2001; Cooper,
Dewe, & ODriscoll, 2001; Cordes & Dougherty,1993; Maslach, Schaufeli, & Leiter, 2001). It is there-
fore understandable that burnout intervention pro-
grams have been on the increase and that many recent
studies have focused on finding the best ways to
prevent and reduce burnout (e.g., Cooley &
Yovanoff, 1996; Rowe, 2000; Schaufeli, 1995; van
Dierendonck, Schaufeli, & Buunk, 1998).
One way to intervene in the progression of burnout
is employee rehabilitation, which is defined as a
tertiary preventive intervention (Cooper & Cart-
wright, 1997; Reynolds, 1997). In general, the mainreason for rehabilitation is to maintain and improve
employees working ability, to prevent disability,
and, thus, to ensure the supply of skilled and capable
individuals in the workforce. The present study was
targeted at employees who had sought and been
referred to rehabilitation courses aiming at reducing
job-related psychological health problems, such as
burnout, but also maintaining and promoting per-
sonal resources and working ability. Previous studies
on burnout have been criticized for healthy worker
effect, which means that relatively healthy individu-
als (i.e., only mild burnout symptoms) have mainly
been investigated (Schaufeli, Bakker, Hoogduin,Schaap, & Kladler, 2001). In this study this effect
was partly avoided as we investigated a group of
individuals who had sought treatment specifically
because of burnout. The primary objective of the
study was to examine the short-term changes in em-
ployees job- and individual-related variables after a
rehabilitation intervention.
A Person-Oriented Approach to Burnout
Most of the empirical work on burnout has beenvariable oriented. This approach focuses on statistical
relations between variables across individuals at
group level (Magnusson, 1998). Following this ap-
proach, each burnout symptom in isolation and their
relations to antecedents and outcomes have been the
main object of interest. In contrast, we used a person-
oriented approach, the aim being to discover the
distinctive configurations of factors that characterize
each individuals functioning (Magnusson, 1998).
Applied to the study of burnout, the person-oriented
approach posits that several burnout symptoms oper-ating simultaneously best capture the burnout phe-
nomenon; that is, we paid attention to covariations in
multiple burnout symptoms. Compared with the vari-
able-oriented approach, our focus here is on the pro-
Marja Hatinen, Ulla Kinnunen, Mika Pekkonen, andAntti Aro, Department of Psychology, University of Jyvas-kyla, Jyvaskyla, Finland.
The research project Job Burnout: Evaluation, Develop-ment and Effectiveness of Intervention (Grant No 100118)
was financially supported by the Finnish Work EnvironmentFund.
Correspondence concerning this article should be ad-dressed to Marja Hatinen, Department of Psychology, Uni-versity of Jyvaskyla, P.O. Box 35, FIN 40014, Jyvaskyla,Finland. E-mail: [email protected]
Journal of Occupational Health Psychology2004, Vol. 9, No. 3, 220237
Copyright 2004 by the Educational Publishing Foundation1076-8998/04/$12.00 DOI: 10.1037/1076-8998.9.3.220
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file of variable values, not the variables in themselves
(Bergman & Magnusson, 1998).
The person-oriented approach to burnout (see
Bergman & Magnusson, 1997, 1998; Magnusson,
1998) was applied because we wanted to explore thepatterning of the burnout symptoms within an indi-
vidual, instead of studying one symptom at a time
interindividually. By examining the possible burnout
patterns and differences in antecedents and outcome
variables between these patterns, we expected to be
able to provide some practical implications for pro-
fessionals working in the burnout rehabilitation field.
As Farber (2000) stated, it is important to identify
different manifestations of burnout to be able to treat
burnout successfully. Overall, we aimed at contrib-
uting to an understanding of the burnout phenomenonitself in the rehabilitation context, as this is a context
in which the syndrome has rarely been studied.
Burnout and Interventions
Burnout develops as a reaction to prolonged expo-
sure to job stressors (Maslach, 2000), and it is char-
acterized by exhaustion, cynicism, and reduced pro-
fessional efficacy (Maslach, Jackson, & Leiter,
1996). The Maslach Burnout InventoryGeneral
Survey (MBIGS) is a measure of burnout that canbe used in any occupational context. Therefore, its
items are generic, making no reference to people or
personal relationships at work, contrary to the items
of earlier versions of the MBI (Maslach & Jackson,
1981, 1986). The items representing exhaustion in
the MBIGS describe the core component of the
syndrome, that is, the depletion or draining of emo-
tional resources in doing ones work (Maslach et al.,
1996). The cynicism component reflects indifference,
or a negative or distant attitude toward ones work in
general, and it can be characterized as dysfunctionalcoping, in which employees develop cynicism about
their work to distance themselves from it (Leiter &
Schaufeli, 1996). The third burnout dimension, re-
duced professional efficacy, represents a decline in
ones feelings of competence and effectiveness in
regard to both the social and nonsocial aspects of
occupational accomplishments.
The previous intervention studies and meta-analy-
ses (e.g., Bond & Bunce, 2000; Reynolds, 1997; van
der Klink, Blonk, Schene, & van Dijk, 2001) have
tried to establish what kinds of interventions areeffective from the perspective of psychological
health. To sum up, interventions using cognitive
behavioral strategies and focusing on an individual
rather than on an organizational level were found to
be successful for reducing work-related stress, burn-
out, and mental health. The rehabilitation interven-
tion in this study was individual oriented in a sense
that it did not try to directly change employees
working conditions. Instead, the intervention usedprimarily cognitive behavioral techniques by modi-
fying employees appraisals of stressful situations
and helping employees to deal with their stress.
More specifically, the three burnout symptoms
have reacted differently to activities aiming at their
alleviation. Basically, the various interventions have
resulted in a lower level of emotional exhaustion
(e.g., Cooley & Yovanoff, 1996; Higgins, 1986;
Rowe, 2000; Schaufeli, 1995; van Dierendonck et al.,
1998), whereas the components of cynicism and pro-
fessional efficacy have turned out to be more difficultto change by interventions. For example, van Dier-
endonck et al. (1998) found that no changes occurred
in the level of cynicism, whereas feelings of reduced
personal accomplishment initially increased rather
than decreased after 6 months of a 5-week group-
based intervention program. This intervention pro-
gram aimed at the cognitive restoration of equity
perceptions on the interpersonal and organizational
levels.
Also, shorter follow-ups than 6 months have re-
sulted in positive changes in job stress and burnout.After a 3-month follow-up, Bunce and West (1996)
found that an intervention designed to create innova-
tive responses to job stressors resulted in improve-
ments in work-related stress. Schaufeli (1995) re-
ported a decrease in emotional exhaustion one month
after a 3-day burnout workshop. Additionally, Rowe
(2000) found that emotional exhaustion decreased
and personal accomplishment increased at a 2-month
follow-up after a coping skills training program.
Burnout Development and Patterning
of the Symptoms
The different manifestations of burnout, that is,
patterning of burnout symptoms within an individual,
may be due to the particular phase or developmental
cycle of burnout an individual is going through. Ac-
cording to the different burnout development theo-
ries, the three dimensions of burnout develop either
partially simultaneously (Leiter, 1991, 1993) or in-
dependently over time (Golembiewski & Munzen-rider, 1984, 1988; Leiter & Maslach, 1988; van Dier-
endonck, Schaufeli, & Buunk, 2001). In fact, there
are three contrasting views of this developmental
progress. As the first symptom, Leiter and Maslach
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(1988) proposed emotional exhaustion, Golem-
biewski and Munzenrider (1984, 1988) depersonal-
ization, and van Dierendonck et al. (2001) reduced
personal accomplishment. In addition, the burnout
patterns may relate to the fact that individuals react tocertain sources of stress in ways that are natural to
them, stemming from their personal history, includ-
ing personality, available resources, and life experi-
ences (Friedman, 1996). We assumed that this might
lead to different developmental pathways, which in
turn may appear as various burnout patterns.
On the basis of the developmental theories of
burnout, we expected to find such a pattern in which
rehabilitation clients would suffer from all burnout
symptoms, but also a pattern in which participants
would have relatively low scores on all three symp-toms. Furthermore, in Leiters (1991, 1993) develop-
mental model, emotional exhaustion arises first in
response to demanding work environment, which in
turn brings about depersonalization as a way of cop-
ing with increased strain (see also Lee & Ashforth,
1993; Leiter & Maslach, 1988). This implies that
exhaustion may occur alone, but the pattering of the
two symptoms emotional exhaustion and deperson-
alizationmay also be possible. Additionally, be-
cause diminished personal accomplishment develops
independently, depending on available job and indi-vidual resources (Leiter, 1991, 1993), we expected
that this dimension would occur alone.
The COR Theory, Job Conditions, and
Personal Resources
Many studies have shown differential relationships
between the three symptoms of burnout, job de-
mands, resources, and psychological health. The con-
servation of resources (COR) theory provides a use-ful framework within which to examine these
connections. By emphasizing that interventions
aimed at reducing burnout must focus on enhancing
employees resources and, thus, eliminating vulner-
ability to resource loss (Hobfoll & Freedy, 1993), it is
also in line with the aims of the rehabilitation inter-
vention examined in the present study. The basic idea
of the COR theory is that individuals strive to obtain
and maintain what they value, that is, resources.
Burnout may ensue if these resources are threatened,
lost, or when an individual invests in resources butdoes not get back what he or she expects. According
to the COR theory, prolonged exposure to demands
will eventually lead to physical and emotional ex-
haustion, which is the core component of burnout
(Hobfoll & Freedy, 1993). On the other hand, re-
sources help to overcome the need for defensive
coping, that is, depersonalization, which may occur
as the consequence of resource loss (in this case
depletion of emotional resources). Furthermore, re-sources help to promote self-efficacy, which repre-
sents the dimension of personal accomplishment in
the burnout syndrome. The theory defines four basic
categories of resources: objects, conditions, personal
characteristics, and energies. In this study we focused
on job conditions and personal characteristics.
The two main categories of job conditions de-
mands and resourcesare differently related to the
three burnout dimensions. Job demands and absence
of job resources are commonly seen as antecedents of
burnout (for reviews, see Cordes & Dougherty, 1993;Schaufeli & Enzmann, 1998). High job demands
(e.g., work overload, time pressure, unfavorable en-
vironmental conditions, interpersonal conflicts) have
been primarily found to be associated with high emo-
tional exhaustion (Demerouti, Bakker, Nachreiner, &
Schaufeli, 2000, 2001; Greenglass & Burke, 2000;
Janssen, Schaufeli, & Houkes, 1999; Lee & Ashforth,
1996; Leiter, 1991, 1993; Rafferty, Friend, & Lands-
bergis, 2001; Taris, Schreurs, & Schaufeli, 1999),
whereas lack of job resources (e.g., social support,
supervisor support, job control, workplace climate)have been related to either increased cynicism or
reduced personal accomplishment (Demerouti et al.,
2001; Janssen et al., 1999; Landsbergis, 1988; Lee &
Ashforth, 1996). Specifically, of the job demands, we
concentrated on time pressures at work, and of the
job resources, we concentrated on job control, work-
place climate, and supervisor satisfaction.
Coping strategies and sense of coherence (SOC)
can be defined as important personal resources that
play a significant role in employees psychological
health. Lack of these resources can be seen as ante-cedents of burnout, because they may predispose
employees to stress or burnout (see Antonovsky,
1979, 1987; Schaufeli & Enzmann, 1998). There is
also evidence that coping strategies (Stewart &
Schwarzer, 1996) and SOC (Feldt, Kinnunen, &
Mauno, 2000; Feldt, Leskinen, Kinnunen, & Ruop-
pila, 2003) are only moderately stable over time,
which may indicate that they can change, for exam-
ple, along with burnout development and, thus, be
considered as outcomes of burnout. Promoting these
resources was an important goal in the rehabilitationprocess under examination.
Emotion-oriented coping (e.g., self-preoccupation
and fantasizing to reduce stress; Sears, Urizar, &
Evans, 2000) and avoidance-oriented or escape cop-
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ing (e.g., activities and cognitive changes aimed at
avoiding a stressful situation) have been associated
with a high level of burnout (Chan & Hui, 1995;
Leiter, 1991), whereas task-oriented or control cop-
ing (e.g., purposeful efforts aimed at solving or cog-nitively restructuring the problem) has been related to
a decreased level of burnout in the form of decreased
exhaustion and increased personal accomplishment
(Leiter, 1991). More specifically, task-oriented cop-
ing has accounted for the greatest proportion of the
variance in personal accomplishment (Sears et al.,
2000). This result is consistent with findings showing
that control coping is strongly related to personal
accomplishment (Greenglass & Burke, 2000; Lee &
Ashforth, 1996; Leiter, 1991) but weakly related to
emotional exhaustion and depersonalization (Lee &Ashforth, 1996).
Sense of coherence, or SOC, is defined as the
global orientation of an individual in terms of com-
prehensibility, manageability, and meaningfulness
(Antonovsky, 1979, 1987). Comprehensibility refers
to the cognitive controllability of ones environment,
manageability to the extent to which an individual
considers coping resources to be available, and mean-
ingfulness to the motivational component that deter-
mines whether a situation is appraised as challenging
and justifies making commitments. Strong SOC hasbeen negatively related to emotional exhaustion
(Feldt, 1997; Feldt, Kinnunen, & Mauno, 2000; Gil-
bar, 1998) as well as to the whole burnout syndrome
(Soderfeldt, Soderfeldt, Ohlson, Theorell, & Jones,
2000).
Depression and Burnout
Prolonged exposure to burnout and to other life
stressors can be manifested in depressive symptom-
atology. The COR theory suggests that symptoms ofdepression may emerge in an advanced stage of burn-
out because ofthe escalating spiral of losses (Hob-
foll & Shirom, 2001, p. 68). Depression is character-
ized by a range of general negative self-evaluations,
such as guilt, sense of failure, and eating and sleep
disturbances (Beck, Ward, Mendelson, Mock, & Er-
baugh, 1961). Some researchers suggest that burnout
is actually a form of depression (Hallsten, 1993); that
is, clinically exhaustion and depression share partly
similar symptoms (e.g., fatigue, loss of energy) and
statistically they share an appreciable amount of vari-ance (Brenninkmeyer, van Yperen, & Buunk, 2001;
Glass & McKnight, 1996). However, depression is
more often considered to be a negative health conse-
quence of burnout (Burke, Greenglass, & Schwarzer,
1996; Cooper et al., 2001; Glass, McKnight, &
Valdimarsdottir, 1993; Leiter & Durup, 1994;
Schaufeli & Enzmann, 1998). Empirical research has
established that although all burnout symptoms are
positively related to depression (Glass et al., 1993;Landsbergis, 1988; McKnight & Glass, 1995), emo-
tional exhaustion is closest to depression (Boles,
Dean, Ricks, Short, & Wang, 2000; Glass & Mc-
Knight, 1996; Leiter & Durup, 1994; Schaufeli &
Enzmann, 1998).
The Present Study
The present study examines the short-term changes
in employees job conditions, personal resources, and
psychological health after an employee rehabilitationintervention. Burnout was approached from a person-
oriented perspective; that is, the profiles of burnout
components are at focus, not the burnout components
themselves. Specifically, we addressed the following
research questions. First, we examined whether it
would be possible to identify homogeneous and
meaningful burnout patterns among the rehabilitation
clients. After identifying burnout patterns, we studied
whether there would be changes in the various burn-
out patterns at a follow-up 4 months later, first, in the
levels of burnout (exhaustion, cynicism, and profes-sional efficacy); second, in perceived job demands
(time pressures at work), job resources (job control,
workplace climate, supervisor satisfaction), and per-
sonal resources (coping strategies and SOC); and,
third, in the level of depression.
Because burnout has not been previously studied
from a person-oriented viewpoint, our hypotheses,
posited on the basis of the findings of variable-ori-
ented studies, were tentative only. First, we expected
to find various burnout patterns, because it is proba-
ble that individuals burn out in different ways overtime or they react differently to job stressors resulting
in different burnout symptoms. On the basis of the
developmental models of burnout (e.g., Leiter, 1991,
1993), we expected to find one pattern in which
participants would suffer from all burnout symptoms
and one in which the participants burnout levels
would be low or nonexistent. Besides, we assumed
that there would be a pattern in which exhaustion
might occur alone or together with cynicism and one
in which low professional efficacy would occur
alone.Second, on the basis of previous intervention stud-
ies that have resulted in reducing burnout at short
intervals (1 to 6 months; e.g., Cooley & Yovanoff,
1996; Schaufeli, 1995; van Dierendonck et al., 1998),
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we hypothesized that the level of exhaustion, in par-
ticular, would decrease in the burnout patterns during
the 4 months after the employee rehabilitation inter-
vention. It was assumed that decrease in exhaustion
would be most prominent in the pattern in which this
symptom might dominate.
Third, because emotional exhaustion has been re-
lated to high job demands in previous studies (De-
merouti et al., 2000, 2001; Greenglass & Burke,
2000; Janssen et al., 1999; Lee & Ashforth, 1996;
Leiter, 1991, 1993; Rafferty et al., 2001; Taris et al.,
1999), we expected that in the burnout pattern in
which the exhaustion component (either alone or
combined with cynicism) might dominate, sufferers
would experience higher job demands compared withthe pattern in which reduced professional efficacy
component might dominate. Individuals character-
ized by the reduced professional efficacy would be
likely to experience a lower level of job resources
than those in whose burnout pattern exhaustion might
dominate (Demerouti et al., 2001; Janssen et al.,
1999; Landsbergis, 1988; Lee & Ashforth, 1996).
Furthermore, because the primary purpose of the
rehabilitation intervention applied in this study was
to improve employees resources by teaching the
skills to cope with stress and cognitive reevaluationsof stressful situations, we expected that especially
personal resources would improve during the reha-
bilitation period. Treatment strategies that are based
on cognitive behavioral strategies have turned out to
be effective in previous studies (e.g., Bond & Bunce,
2000; van Dierendonck et al., 1998). Thus, of per-
sonal resources, task-oriented coping and SOC would
increase, and emotion-oriented and avoidance-ori-
ented coping would decrease in all burnout patterns
during the postintervention follow-up. However, we
did not expect major changes in job demands or job
resources during the short follow-up due to the fact
that aiming at changing job conditions in the work-
places was not the target of the intervention.
Fourth, we hypothesized that in the burnout pattern
in which exhaustion (alone or combined with cyni-
cism) might dominate, individuals would experience
a higher level of depression compared with those
patterns dominated by reduced professional efficacy
(see Boles et al., 2000; Glass & McKnight, 1996;
Leiter & Durup, 1994; Schaufeli & Enzmann, 1998).We also expected that as in previous studies after a
short-term follow-up (e.g., Bond & Bunce, 2000), the
level of depression in every pattern would decrease
during the 4-month follow-up period.
Method
Participants and Procedure
The participants consisted of 135 clients from a rehabil-itation center situated in central Finland. The mean age of
the clients was 51.2 years (SD 5.5). Most were women
(60%) and living with a partner (married or cohabiting,
74%). The majority of them had completed either a voca-
tional school (31%) or a vocational college (30%) educa-
tion. Occupationally, 35% were blue-collar employees (e.g.,
postmen, bus drivers), 44% lower white-collar employees
(e.g., nurses, clerical workers), and 21% higher white-collar
employees (e.g., teachers, managers). Average hours
worked weekly were 44.3 (SD 11.2) per week.
The participants were recruited from two rehabilitation
programs on the first day of their arrival after a brief
introduction to the study. In this introduction, the voluntarybasis, confidentiality, and anonymity of the participantswere emphasized. Eight clients out of 143 were unwilling to
participate in the study, and during the 4-month follow-up
period, there were 7 dropouts. Thus, of the 135 clients who
participated in the first measurement (Time 1), 128 werestill in the study 4 months later (Time 2).
Both the employee rehabilitation programs, Vitality andEnergy for Working Life (Vitality) and Maintaining andPromoting Working Ability (Working Ability), fromwhich the participants were recruited during the years
2000 2001, have been set up in accordance with the Finn-ish rehabilitation legislation by the Social Insurance Insti-
tution of Finland. The former program is aimed at individ-uals suffering from job-related psychological health
problems. Of the 135 participants, 65 were on this program,
which lasts for a whole year and consists of two rehabili-
tation periods (12 5 days) conducted at the rehabilitation
center. The latter program is directed at individuals whose
working ability is substantially threatened or diminished
because of disease, disability, or disorder. Of the 135 par-
ticipants, 70 were from this program. This rehabilitation
program lasts for 112 years and includes three or fourrehabilitation periods (13 12 5 5 days) conducted at
the rehabilitation center.
The present study focused on the first rehabilitation pe-
riod only (lasting about 2 weeks) and included a 4-monthfollow-up. The participants filled out a set of questionnairesbefore the intervention actually started (on the 2nd day after
their arrival at the rehabilitation center, baseline measure-
ment) and again 4 months after the first rehabilitation period(short-term follow-up measurement). This first period lastedfor 12 days in the Vitality program and 13 days in the
Working Ability program. In the former rehabilitation pro-
gram, the follow-up questionnaires were filled out at therehabilitation center when the clients started their second
rehabilitation period (on the day of their arrival) approxi-
mately 4 months after the first period (M 105 days, SD24 days). In the latter program, the follow-up questionnaires
were mailed to the clients approximately 4 months after thefirst rehabilitation period (M 109 days, SD 2 days),because the second rehabilitation period of this program
was not scheduled as the Working Ability program. All
questionnaires were code-numbered in the rehabilitation
center and sent to the researchers for statistical recording.
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Description of the Employee Rehabilitation
Intervention
The aims and contents of the two intervention pro-
gramsVitality and Working Abilitywere basically sim-ilar during the first rehabilitation period, the focus in thepresent study. Both programs aimed at maintaining andimproving the participants working ability and prerequi-sites for continuing working. In addition, both interventions
are based on a multidisciplinary and holistic approach; that
is, the interventions include a comprehensive evaluation of
participants physical, psychological, and social conditions.On the basis of these evaluations, all of the participants
receive a personal rehabilitation plan, which they follow
throughout the rehabilitation process and, it is hoped, after
the rehabilitation process has ended.
Individuals suffering from physical or psychological
problems participated in both programs. Although, in par-ticular, the Vitality program is aimed at burned-out individ-
uals, the Working Ability program may also include clients
with burnout symptoms. Employees are referred to a spe-cific rehabilitation program on the basis of their primarydiagnosis. Both programs consist mostly of a fixed set ofprogrammatic activities, but some activities based on indi-
vidual needs, such as physical exercise, are also available.
The focus in both programs is primarily on the individualand partly on the individual organizational interface (seeLe Blanc, de Jonge, & Schaufeli, 2000; Schaufeli &
Enzmann, 1998). Generally, individual-level interventions
aim at increasing the individuals awareness and ability to
cope with stress, whereas interventions aiming at the indi-vidual organizational interface focus on increasing the em-ployees resistance to specific job stressors in the context ofhis or her working environment.
The Vitality program is aimed at employees who areunder 50 years of age and have become exhausted by their
work. They may suffer from one or more of various job-
related psychological health problems, such as work stress,burnout, and decreased self-esteem. The participants send
their medical report and rehabilitation application to the
local office of the Social Insurance Institution of Finland,from where the papers are delivered to a rehabilitation
center. The selection of the participants to the Vitality
intervention program is made by the physicians of the
rehabilitation center. Participants go through the rehabilita-tion process in groups of 8 to 10 clients. The purpose of this
intervention is to restore, maintain, and improve individu-als physical, psychological, and social resources by findingpractical solutions to the problems of coping in working life.
The idea of this intervention is that the employee finds waysin which to recognize and evaluate his or her own resources
and working situation to be able to monitor and recognize
the warning signs of impending psychological health prob-lems or to find ways of helping himself or herself in therecovery process. During the first period of this program (12days), various individual (e.g., physical exercises) andgroup-based activities (e.g., discussions on work-related
issues) are engaged in, which mainly focus on improvingthe individuals coping resources. In this program the reha-bilitation activities are more group-based and the partici-
pants psychosocial functioning is usually at a lower levelthan that of the participants in the Working Ability program
(Pekkonen, Mannikko, Sorensen, & Alen, 2002). The con-
tent of this rehabilitation program is shown in more detail inTable 1.
The Working Ability rehabilitation intervention is tar-geted at employees who are 40 to 60 years of age and whoseworking ability has generally been reduced or threatened bydisease, disability, or other disorder. The participants usu-ally seek rehabilitation when the actions taken by theiremployer and by occupational health care services to im-prove their situation have failed. When the client has re-ceived sickness allowance at least for 60 days, the SocialInstitution of Finland is under law required to assess aclients need of rehabilitation. Based on this fact and theclients medical report and rehabilitation application, thedecision of the selection to the Working Ability interventionis made by medical experts in the local offices of the SocialInsurance Institution of Finland.
The fact that the participants working ability has alreadydiminished or is threatened for one reason or another is the
most distinctive difference between the two employee re-habilitation intervention programs. The main purpose of theWorking Ability program is to help the participants to findways of supporting their possibility to continue in theirwork. Also in this program rehabilitation occurs in groups,in this case comprising from four to six clients, and includesindividual (e.g., physical exercises) and group-based activ-ities (e.g., discussions on work-related issues). However, theactivities during the first period of this program (13 days)are more individual-centered and multidisciplinary-orientedthan in the Vitality program, and the participants physicalfunctioning is at a lower level compared with the partici-pants in the Vitality program (Pekkonen et al., 2002; seeTable 1 for more details).
Measures
Job burnout. The MBIGS was used to assess occupa-tional burnout (Maslach et al., 1996). The MBIGS consistsof 16 statements and three subscales: exhaustion, cynicism,and professional efficacy. High scores on exhaustion (5items; Time 1 .95, Time 2 .94) and cynicism (5items; Time 1 .86, Time 2 .83) and low scores onprofessional efficacy (6 items; Time 1 .80, Time 2 .85) are indicative for burnout. The items were rated on a7-point frequency-based scale (0 never, 6 every day).
Job conditions. For the subjective evaluation of work-ing conditions, one job demand factor (time pressures atwork) and three job resources factors (job control, work-place climate, and supervisor satisfaction) were measured.Time pressures at workwere assessed with four items (Time1 .74, Time 2 .66). Job control was measured bynine items in which respondents were asked to evaluatetheir possibility to control certain aspects of their work (e.g.,workload, quality of work, and working pace; Time 1 .89, Time 2 .89). The quality of the workplace climate
was measured with five items, which described the atmo-sphere in the workplace (Time 1 .84, Time 2 .88).These three measures have been widely used in Finnish
occupational studies and validated by the Finnish Instituteof Occupational Health (Bergstrom et al., 1997; Elo, Lep-panen, Lindstrom, & Roponen, 1990). Supervisor satisfac-tion was assessed using three items (Time 1 .87, Time2 .89) from the Finnish version of the Job DiagnosticSurvey (Vartiainen, 1989). All of the working conditions
225BURNOUT PATTERNS IN REHABILITATION
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items were rated by using a 5-point Likert-type responsescale (1 strongly agree, 5 strongly disagree).
Personal resources. The 21-item shortened version ofthe Coping Inventory for Stressful Situation (Endler &
Parker, 1990) was used to measure task-oriented coping (7items; Time 1 .83, Time 2 .86), emotion-orientedcoping (7 items; Time 1 .83, Time 2 .82), andavoidance-oriented coping (7 items; Time 1 .72, Time
Table 1
Focus and Contents of the Two Employee Rehabilitation Intervention Programs
Employee rehabilitation
intervention
Target group and durationof the first intervention
period Focus on individual
Focus onindividualorganizational
interface
Vitality and energy forworking life (Vitality)
Employees under 50years of age with job-related psychologicalproblems
Duration: 12 days
Tests and examinationsby physician andphysiotherapist (e.g.,ECG, medical andphysiotherapyexaminations, physicalcapacity tests)
Group discussions andlectures by physician(e.g., medicaltreatment),psychologist (e.g.,stress management;burnout), psychiatrist(e.g., depression,psychotherapies), andphysiotherapist (e.g.,ergonomics, physicalexercise)
Physiological andoccupational therapy
Physical exerciseactivities andrelaxation
Group discussions onwork-related issues
Individual counselingsession with psychologist(2 60 min) (e.g., stressmanagement, work andprivate life interface,time management) 3content according toindividual needs
Maintaining and promoting
working ability(Working ability)
Employees about 4060
years of age whoseworking ability isthreatened or hasalready decreased
Duration: 13 days
Tests and examinations
by physician andphysiotherapist (e.g.,ECG, medical andphysiotherapyexaminations, physicalcapacity tests)
Social evaluation (112hr) by a social worker
Group discussions andlectures by physician(e.g., medicaltreatment),psychologist (e.g.,workload),physiotherapist (e.g.,ergonomics, workload)and physical educationinstructor (e.g.,physical exercise)
Physical exerciseactivities andrelaxation
Physiotherapeutictraining
Group discussions on
work-related issues Individual counseling
session with psychologist(112 hr) (e.g., stressmanagement,psychosocial factors atwork) 3 contentaccording to individualneeds
226 HATINEN, KINNUNEN, PEKKONEN, AND ARO
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2 .68). The extent to which each strategy has been usedin a stressful situation at work was rated on a 5-pointLikert-type scale (1 not at all, 5 very much). SOC wasoperationalized by the shortened 13-item Orientation to Life
Questionnaire (Antonovsky, 1987). Participants were askedto select a response on a 7-point semantic differential scalewith two anchoring phrases. The SOC scale includes 5 itemsabout comprehensibility (1 very often, 7 very seldom
or never), 4 about manageability (1 never happened, 7
always happened), and 4 about meaningfulness (1 veryseldom or never, 7 very often). The three intercorrelated
components form the composite measure of the strong SOC(Time 1 .88, Time 2 .88).
Depression. The Beck Depression Inventory (BDI;Beck et al., 1961) was used to measure depression. TheBDI is a 21-item questionnaire asking about the degree towhich the respondent is experiencing negative thoughts,feelings, and behavior. The items cover a range of gen-
eral self-evaluations unrestricted to ones work or workenvironment. Specifically, the inventory was composedof 21 symptom-attitude categories: mood, pessimism,sense of failure, lack of satisfaction, feeling of guilt,sense of punishment, self-hate, self-accusations, self-pu-nitive wishes, crying spells, irritability, social with-drawal, indecisiveness, body image, work inhibition,sleep disturbance, fatigability, loss of appetite, weight
loss, somatic preoccupation, and loss of libido. In eachcategory the respondent had to choose one statement(from four to six statements), which was scored from 0 to3. The higher the BDI score (range from 0 to 63) the moresevere the level of depression (Time 1 .89, Time 2
.90). The means, standard deviations, and intercor-relations for all the measures at Time 1 and Time 2 arepresented in Table 2.
Statistical Analysis
We used cluster analysis to identify natural groupings orpatterns of burnout within the rehabilitation clients. Thismultivariate technique is a statistically sound means bywhich to form homogeneous groups that contain highlysimilar entities (Aldenderfer & Blashfield, 1984). This clus-ter procedure is especially useful when we do not havenation-specific and clinically validated cutoff points indi-cating levels of burnout, as is the case at present in Finland.Using other countries cutoff points is not recommendedbecause burnout levels vary across countries (Maslach et al.,1996).
Thus, the three standardized burnout variables at Time 1were used as clustering variables in a hierarchical, agglom-erative cluster analysis. This cluster approach begins withthe same number of clusters as there are potential burnoutpatterns (i.e., number of individuals). At each step, clustersare joined together on the basis of their similarities, orindividuals are added into existing clusters, until finallythere is only one cluster. We used Wards method as a
linkage method, whereby the clusters are chosen in whichthe variance among the cases is as small as possible (Al-
denderfer & Blashfield, 1984), and squared Euclidean dis-tance as a similarity method, which takes both the form andthe level of the profiles into account (Bergman & Magnus-son, 1991).
According to Bergman and Magnusson (1991), the most
optimal cluster solution can be obtained by starting with
Wards method and then subjecting the solution to a K-means cluster analysis. This procedure is useful because
once agglomerative hierarchical clustering starts joining the
cases together, the cases cannot be moved from one cluster
to another, even where another cluster would finally be abetter fit. K-means clustering can correct the initial clustersolution by relocating a misfit case into the cluster thecenter of which is closest to the case.
After identifying the meaningful burnout patterns, we
tested the cluster solution by performing multivariate anal-
ysis of variance (MANOVA) with the three burnout dimen-
sions at Time 1 as dependent variables (see Aldenderfer &
Blashfield, 1984). Evidence for the validity of the burnoutpatterns was sought in the differences in the background
factors (rehabilitation program, gender, age, living with a
partner, vocational education, socioeconomic status, hours
worked per week) by using either chi-square test or one-wayanalysis of variance (ANOVA). The post hoc group com-
parisons were performed either with Scheffes (equal vari-ances assumed) or with Tamhanes (equal variances notassumed) test.
A repeated measures MANOVA was conducted to ex-
amine whether there would be any changes in burnout
symptoms between the burnout patterns after the worker
rehabilitation intervention. This analysis used the group of
burnout pattern as a between-groups variable and time as a
repeated measure, enabling us to examine between-groups
differences in burnout symptoms at both measurement
times. The same procedure was used to search for changes
in job conditions, personal resources, and depression be-tween the burnout patterns. Using these external variables
(i.e., variables that were not included in the original clus-
tering) to examine the differences between the burnout
patterns served also as a validation method for the finalcluster solution (Aldenderfer & Blashfield, 1984). In thoseinstances in which two or more than one dependent variable
within a domain correlated with each other, we analyzed the
variables with the same MANOVA. Univariate ANOVAs
were followed. Where significant main effects occurred,post hoc comparisons were performed on the dependent
variables using Bonferronis test. Additionally, the effectsizes measured with eta-square (2) are reported. According
to Cohen (1988), the effect sizes can be classified as small(0.01 to 0.04), medium (0.05 to 0.11), and large (0.12 to1.0). Missing data in the cluster and MANOVA analyses
were treated by listwise deletion.
Results
Cluster Identification and Definition
The burnout patterns were explored by cluster
analysis, using the three baseline measures (ex-
haustion, cynicism, and professional efficacy) asthe clustering variables. The number of clusters
that most accurately reflected the hierarchical
structure of the data was decided on the basis of the
dendrogram. A dendrogram is a visual representa-
227BURNOUT PATTERNS IN REHABILITATION
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tion of the steps in a hierarchical clustering solu-
tion, and it identifies not only the clusters being
combined at each step but also the distances at
which they are joined. In this study, the four-
cluster solution produced clusters that contained an
adequate number of individuals in interesting and
interpretable ways (see Figure 1). In the three-
cluster solution Groups 2 and 3 clustered in onegroup (excluding a meaningful group, Group 2),
and in the five-cluster solution Group 1 divided
into two clusters, both of which comprised indi-
viduals with rather low burnout scores and there-
fore did not differ in terms of conceptual clarity.
Because of this, these two-cluster solutions were
rejected, and the four-cluster solution was consid-
ered the best.
To define the four clusters, we performed a
MANOVA with the three burnout dimensions (at
Time 1) as dependent variables and the four burnoutpatterns as an independent variable. Due to the fact
that cluster analysis is designed to find groups that
express high intracluster homogeneity and high ex-
tracluster heterogeneity, it is not surprising that the
result showed a significant multivariate effect for the
burnout pattern, F(9, 314) 71.07, p .001, 2
.59, indicating that the level of burnout symptoms
differed significantly between the four burnout pat-
terns and the effect size was large. Univariate anal-
yses with each burnout dimension as a dependent
variable showed that these differences occurred in all
three burnout symptoms: exhaustion, F(3, 135) 144.63, p .001, 2 .77; cynicism, F(3, 135)
96.00, p .001, 2 .69; and reduced professional
efficacy, F(3, 134) 71.38, p .001, 2 .62.
The post hoc comparisons indicated that Group 3
experienced more exhaustion than Groups 1, 2, and 4
(p .001). Furthermore, Group 2 reported more
exhaustion than Groups 1 and 4 (p .001). Besides,
Group 3 experienced more cynicism compared with
Groups 1, 2, and 4 (p .001), and Group 2 more
than Group 1 (p .001) and Group 4 (p .01). In
other words, the two burnout groups that did notdiffer from each other in either the exhaustion or
cynicism dimension were Groups 1 and 4, both of
which had low scores on exhaustion and cynicism.
Finally, Groups 3 and 4 reported lower professional
Table 2
Intercorrelations of the Study Variables at Time 1 and Time 2
Variable M SD 1 2 3 4 5 6 7 8 9
Time 11. Exhaustion 2.80 1.71 2. Cynicism 2.06 1.50 .71 3. Reduced professional efficacy 1.94 1.24 .36 .42 4. Time pressures at work 3.29 0.78 .29 .06 .00 5. Job control 2.88 0.86 .19 .27 .18 .21 6. Workplace climate, good 3.13 0.88 .28 .40 .21 .04 .37 7. Supervisor satisfaction 2.93 0.97 .38 .44 .20 .11 .34 .47 8. Task-oriented coping 3.61 0.76 .28 .31 .43 .00 .01 .16 .10 9. Emotion-oriented coping 2.80 0.82 .32 .43 .21 .15 .14 .25 .16 .09
10. Avoidance-oriented coping 2.15 0 .70 .10 .09 .04 .08 .08 .09 .07 .13 .1411. Sense of coherence 4.60 1.11 .57 .58 .36 .22 .31 .44 .40 .41 .4212. Depression 12.66 8.89 .70 .57 .45 .29 .22 .24 .37 .29 .39
Time 213. Exhaustion 2.12 1.46 .68 .50 .19 .35 .14 .19 .30 .23 .1914. Cynicism 1.82 1.40 .55 .68 .40 .12 .21 .25 .27 .30 .2515. Reduced professional efficacy 1.97 1.32 .35 .43 .69 .06 .35 .21 .17 .41 .2316. Time pressures at work 3.19 0.57 .30 .13 .08 .69 .22 .13 .20 .08 .1017. Job control 3.01 0.76 .15 .24 .22 .14 .75 .29 .22 .01 .2418. Workplace climate, good 3.11 0.90 .19 .24 .20 .07 .30 .65 .37 .15 .1319. Supervisor satisfaction 2.93 0.92 .26 .27 .15 .12 .20 .33 .61 .07 .1120. Task-oriented coping 3.42 0.81 .18 .15 .44 .02 .02 .04 .01 .72 .1421. Emotion-oriented coping 2.54 0.74 .52 .50 .22 .17 .19 .19 .16 .14 .5422. Avoidance-oriented coping 2.03 0.60 .27 .17 .11 .07 .04 .21 .17 .02 .0523. Sense of coherence 4.61 1.06 .48 .47 .38 .20 .27 .30 .25 .42 .3424. Depression 9.50 8.78 .53 .45 .28 .07 .25 .30 .34 .28 .36
Note. r .18, p .05. r .24, p .01. r .31, p .001.
228 HATINEN, KINNUNEN, PEKKONEN, AND ARO
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efficacy than Groups 1 and 2 (p .001), of which
Group 2 scored higher on reduced professional effi-
cacy than Group 1 (p .01). The only two groups
that did not differ in the reduced professional efficacy
dimension were Groups 3 and 4, both of which had
high scores on reduced professional efficacy.
The four burnout patterns were defined on the
basis of the above-described MANOVA resultsas follows (see Figure 1): (a) Participants who
did not feel the various burnout symptoms were
named as not burned out (n 55). (b) The ex-
hausted-and-cynical pattern (n 36) comprised
those who felt exhaustion and cynicism more of-
ten than on the average. (c) The pattern of burned
out (n 26) comprised those suffering from all
three burnout symptoms more often than on the
average. (d) Those who suffered mainly from
a decline in feelings of competence were named
as low professional efficacy (n 18); this symp-tom was experienced more often than on the
average.
We validated the cluster solution with regard to the
background variables. Only the rehabilitation pro-
gram and the burnout pattern were significantly re-
lated to each other, 2(3, N 135) 23.80, p
.001. Those belonging to the burned-out pattern par-
ticipated more often in the Vitality intervention pro-
gram than the Working Ability program (89%
vs.11%), whereas the participants who were labeled
as not burned out participated more often in the
Working Ability intervention program than Vitalityprogram (67% vs. 33%). This provides further sup-
port for the cluster solution because the Vitality in-
tervention program was especially targeted at em-
ployees suffering from job-related psychological
health problems, such as work stress and burnout. In
the further analyses, the rehabilitation program was
used as a covariate. Besides this, because the two
interventions are targeted at the workers of different
ages and health problems, we added age (in years)
and self-reported prolonged illnesses (asked by a
single question How many prolonged illnesses di-agnosed by the physician do you have at the mo-
ment? at the baseline) as continuous variables into
the analyses as covariates. The three covariates did
not correlate with each other.
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
.04 .01 .67
.09 .43 .54 .03 .51 .53 .71 .02 .45 .44 .32 .47
.13 .28 .29 .37 .20 .06 .01 .27 .23 .08 .24 .38 .14 .06 .30 .19 .26 .34 .30 .12 .43 .08 .24 .33 .35 .32 .23 .23 .30 .59
.10 .25 .22 .25 .30 .51 .06 .19 .14 .04
.01 .43 .52 .43 .47 .20 .09 .17 .12 .12 .04
.56 .12 .20 .23 .12 .01 .14 .06 .17 .16 .02 .26
.06 .73 .64 .51 .57 .54 .21 .30 .30 .23 .43 .49 .05
.11 .56 .70 .68 .60 .43 .10 .17 .26 .23 .26 .55 .12 .69
229BURNOUT PATTERNS IN REHABILITATION
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Short-Term Changes in Perceptions of Burnout
Symptoms, Job Conditions, Personal Resources,
and Depression Within the Burnout Patterns
We performed 4 (burnout pattern) 2 (time)
multivariate analyses of covariance (MANCOVAs)
using the type of rehabilitation program, age, and
prolonged illnesses as covariates to analyze the short-
term changes in burnout symptoms, job conditions,
personal resources, and depression after employee
rehabilitation. In those instances in which the vari-
ables in a domain correlated with each other, we
analyzed them simultaneously. The results of these
analyses are shown in Table 3.
Burnout symptoms. The three burnout symptomsserved simultaneously as dependent variables in the
MANCOVA analysis. After adjusting for covariates,
a significant Group Time interaction effect was
identified for the burnout dimensions, F(9, 263)
5.34, p .001, 2 .13. Thus, the burnout symp-
toms differentiated between the burnout pattern
groups over time. There was also a significant mul-
tivariate main effect found for burnout pattern, F(9,
263) 30.19, p .001, 2 .44, as the definition
of the patterns already showed. At the univariate
level there was a significant Group Time effectidentified for each burnout symptom: exhaustion,
F(3, 110) 10.74, p .001, 2 .23; cynicism,
F(3, 110) 4.85, p .01, 2 .12; and professional
efficacy, F(3, 110) 4.26, p .01, 2 .10. These
interactions meant (see Table 3) that, first, exhaustion
showed a decreasing trend especially in the burned-
out and exhausted-and-cynical patterns compared
with the two other patterns. Second, there was adecreasing trend in cynicism in the burned-out pat-
tern. Finally, reduced professional efficacy showed
an increasing trend in the exhausted-and-cynical
group, whereas in the low-professional-efficacy pat-
tern the trend was decreasing.
Job conditions. After adjusting for the three co-
variates, the MANCOVA for time pressures at work
showed neither a significant interaction nor main
effects (see Table 3 for means). All job resources (job
control, workplace climate, supervisor satisfaction)
correlated with each other, and thus they all servedsimultaneously as dependent variables in the analy-
sis, in which the effects of the three covariates were
also controlled. The Burnout Pattern Time inter-
action effect was not significant. However, signifi-
cant multivariate main effect for burnout pattern, F(9,
248) 1.93, p .05, 2 .05, was observed. At the
univariate level there was a main burnout pattern
effect for job control, F(3, 104) 2.97, p .05,
2 .08; workplace climate, F(3, 104) 3.31, p .
05, 2 .09; and supervisor satisfaction, F(3,
104) 2.98, p .05, 2
.08. In the pairwisecomparisons any differences between job control and
supervisor satisfaction were not detected, but those
who were burned out reported worse quality of work-
place climate (p .05) compared with those who
Figure 1. Mean z scores of the three burnout dimensions (Time 1) within the four burnout
patterns. Ex exhaustion; Cy cynicism; Pe professional efficacy.
230 HATINEN, KINNUNEN, PEKKONEN, AND ARO
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Table3
Short-TermChangesinPsychologicalHealth,
JobConditions,andPersonalRe
sourcesAccordingtotheFourB
urnoutPatterns
Outco
mevariable
(1)Notbur
nedout
(n
55)
(2)Exhaustedand
cynical(n
36)
(3)Burnedout
(n
26)
(4)Low
professional
efficacy(n
18)
Fvalue
Time1
M
Time2
M
Time1
M
Time2
M
T
ime1
M
Time2
M
Time1
M
Time2
M
Groupeffecta
Time
effect
Group
Time
Psychologicalh
ealth
Exhaustion(n
117)
1.4
6
1.5
3
3.9
0
2.9
2
4.5
3
3.0
6
1.8
1
1.5
0
41.2
6***
4.0
3*
10.7
4***
2,
3
1,
4
Cynicism(n
117)
0.9
5
1.1
4
2.4
7
2.2
5
4.4
8
3.4
2
1.5
4
1.6
8
45.1
2***
0.3
1
4.8
5**
2,
3
1,
4
3
2
Reducedprofessionalefficacy
(n
117)
0.9
8
1.1
2
1.6
6
2.2
0
3.4
4
3.1
6
3.3
4
2.9
2
52.8
3***
1.0
0
4.2
6**
3,
4
1,
2
2
1
Depression(n
98)
7.3
1
5.9
3
15.3
9
12.6
3
19.0
1
12.4
3
10.6
8
9.3
0
9.6
6***
10.4
9**
2.2
3
2,
3
1
Jobconditions
Timepressures(n
120)
3.2
5
3.1
3
3.3
7
3.3
2
3.3
5
3.2
4
3.0
8
3.2
1
0.5
3
0.1
4
0.8
7
Jobcontrol(
n
111)
3.0
7
3.1
4
2.5
7
2.8
9
2.5
8
2.6
2
2.7
2
2.8
3
2.9
7*
3.9
7*
1.3
3
Workplaceclimate,good
(n
111)
3.3
5
3.2
3
2.9
3
2.8
7
2.5
8
2.6
7
3.1
9
3.3
3
3.3
1*
0.5
8
0.6
5
1
3
Supervisorsatisfaction(n
111)
3.1
8
3.1
0
2.5
9
2.7
5
2.6
0
2.4
9
3.0
4
3.1
5
2.9
8*
0.1
0
0.7
3
Personalresour
ces
Task-orientedcoping(n
117)
3.9
0
3.6
9
3.5
9
3.4
0
3.4
8
3.2
5
3.1
7
2.9
1
6.0
9**
0.3
0
0.0
5
1
4
Emotion-orie
ntedcoping
(n
117)
2.5
5
2.3
4
2.9
1
2.7
2
3.3
2
3.1
6
2.5
7
2.2
9
7.1
2***
1.9
3
0.0
8
3
1,
4
Avoidance-orientedcoping
(n
117)
2.1
1
1.9
4
2.2
2
2.2
0
2.1
5
2.2
4
1.9
5
1.8
9
1.1
5
0.1
5
0.7
9
Senseofcoh
erence(n
123)
5.1
8
5.0
2
4.2
2
4.4
8
3.7
2
3.8
0
4.6
3
4.6
2
10.5
1***
2.4
5
1.8
3
4
3
1
2,
3
Note.
Rehabilitationprogram,age,andnumberof
prolongedillnessesservedascovaria
tesinallanalyses.
a
PairwisecomparisonswithBonferronistest.
*p
.05.
**
p
.01.
***p
.001.
231BURNOUT PATTERNS IN REHABILITATION
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were not burned out. Finally, a main time effect at the
univariate level was found for job control, F(1,
104) 3.97, p .05, 2 .04. Participants in every
pattern experienced that their job control increased
during the 4-month follow-up.Personal resources. All individual resources
(three coping strategies and SOC) were analyzed in
separate MANCOVAs. After adjusting for the co-
variates, no significant Burnout Pattern Time in-
teraction effect was identified for any of the coping
strategies (task-oriented, emotion-oriented, or avoid-
ance-oriented coping). However, a significant multi-
variate main effect for burnout pattern, F(3, 110)
6.09, p .01, 2 .14, was observed for task-
oriented coping. Participants who were not burned
out used more task-oriented coping than those whoexperienced low professional efficacy (p .01). For
emotion-oriented coping, a significant multivariate
main effect was also observed for burnout pattern,
F(3, 110) 7.12, p .001, 2 .16. In the pairwise
comparisons, burned-out participants used more
emotion-oriented coping compared with those who
belonged to the patterns of low professional efficacy
(p .01) and not burned out (p .001). No signif-
icant effects were observed for avoidance-oriented
coping. For SOC, neither a significant Group Time
interaction effect nor multivariate main effect fortime was identified. Instead, a significant main effect
for burnout pattern was observed, F(3, 116) 10.51,
p .001, 2 .21. The pairwise comparisons re-
vealed that the not-burned-out group experienced
stronger SOC compared with the exhausted-and-cyn-
ical (p .01) and burned-out (p .001) groups. In
addition, participants who reported low professional
efficacy had a stronger SOC than the participants
who were burned out (p .05).
Depression. No significant Burnout Pattern
Group Time interaction effect was obtained fordepression. Instead, significant main effects for time,
F(1, 91) 10.49, p .01, 2 .10, and burnout
pattern, F(3, 91) 9.66, p .001, 2 .24, were
identified. The level of depression declined at a fol-
low-up 4 months later in every pattern. According to
the pairwise comparisons, those belonging to the
exhausted-and-cynical (p .001) or burned-out pat-
tern (p .001) experienced more depression than
those who were not burned out.
Discussion
The results showed that the employees in the two
rehabilitation programs manifested burnout symp-
toms in different ways. We identified four homoge-
neous and meaningful burnout patterns: not burned
out, exhausted and cynical, burned out, and low pro-
fessional efficacy. These burnout patterns differed in
terms of job and personal resources, as well as de-
pression. Additionally, after adjusting for the covari-ates (type of rehabilitation program, age, and number
of prolonged illnesses), the changes observed in the
rehabilitation clients burnout during the 4-month
period depended on the burnout pattern membership.
The levels of exhaustion and cynicism showed a
decreasing trend in the burned-out pattern, whereas
the levels of exhaustion and professional efficacy
showed a decreasing trend in the exhausted-and-cyn-
ical pattern. Professional efficacy showed in turn an
increasing trend in the low-professional-efficacy pat-
tern. Furthermore, depression decreased and job con-trol increased during the 4 months after the employee
rehabilitation.
One burnout pattern was characterized by high
levels in all the burnout symptoms (i.e., the burned-
out pattern) and one by low levels in all the burnout
symptoms (i.e., the not-burned-out pattern). How-
ever, no burnout patterns were identified in which the
participants would have experienced only exhaustion
or cynicism. Instead, we identified two further burn-
out patterns, which can be interpreted in the light of
the developmental models of burnout. Leiters (1993)process model suggests that emotional exhaustion is
the first reaction to demanding work. Consequently,
when other coping strategies have failed to reduce
stress, one tries to cope with the situation by deper-
sonalization. These two symptoms may, therefore,
have clustered in these data as the exhausted-and-
cynical pattern, describing the situation in which
people have resorted to defensive coping (deperson-
alization) as a consequence of the depletion of their
emotional resources. In addition, Leiter proposed that
personal accomplishment develops rather indepen-dently of the two other burnout symptoms depending
on the available resources, and this may explain the
existence of the pattern of low professional efficacy.
Altogether, the burnout patterns found in our study
were in line with our hypotheses.
Our cluster solution can also be interpreted in the
light of the phase model of burnout development
(Golembiewski & Munzenrider, 1988). Applying this
model to the four burnout patterns found in this
study, not burned out (Phase I) and low professional
efficacy (Phase III) represent the early phases ofburnout development, whereas exhausted and cynical
(Phase VI) and burned out (Phase VIII) represent
progressed phases of burnout. Parallel to the phase
model, the COR theory contributes to the understand-
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ing of burnout development by suggesting that when
resource loss occurs and if resources cannot be re-
plenished, cycles of losses may follow and this, in
turn, eventually leads to burnout (Hobfoll & Shirom,
2001). The implication for the development of burn-out is that only one type of burnout symptom may
appear at first, expanding over time finally to include
all the symptoms of burnout (Taris et al., 1999). In
other words, the more the burnout symptoms, the
later the phase in burnout development and the more
severe the burnout condition.
The four-cluster solution was also supported by
differences in one background factor. Burned-out
individuals participated more often in the Vitality
intervention program, whereas the respondents who
were not burned out participated more often in theWorking Ability intervention program. Because the
Vitality intervention program is designed especially
for those employees who suffer from job-related psy-
chological health problems, such as burnout, the clus-
ter analysis succeeded in placing the rehabilitation
clients in the correct groups. Additionally, the four
burnout patterns differed in terms of job resources,
personal resources, and depression, indicating the
validity of the cluster solution (see Aldenderfer &
Blashfield, 1984).
This study confirmed the previous findings thatexhaustion could be the easiest symptom to alleviate
by interventions (e.g., Cooley & Yovanoff, 1996;
Schaufeli, 1995; van Dierendonck et al., 1998). Ex-
haustion decreased in both the burned-out and ex-
hausted-and-cynical patterns. Also, the level of cyn-
icism seemed to decrease in the burned-out pattern,
and professional efficacy showed an increasing trend
in the low-professional-efficacy pattern. However,
contrary to our expectations one negative trend was
detected: Professional efficacy was reduced in the
exhausted-and-cynical pattern 4 months after thepostintervention. This negative tendency in burnout
development may nevertheless indicate that dimin-
ishing professional efficacy is, as a matter of fact, one
part of the recovery process. In the intervention study
of van Dierendonck et al. (1998), personal accom-
plishment diminished 6 months after a 5-week group-
based burnout intervention program, returning, how-
ever, to the baseline level after 1 year. The authors
suggested that this temporary decrease in personal
accomplishment might actually be a positive effect,
because the intervention program may have sensi-tized the participants to a greater awareness of their
professional situation, leading to a critical perception
of their personal accomplishments. This awareness
can be regarded as a positive outcome, because peo-
ple who suffer from burnout may not acknowledge
their own situation (Freudenberger, 1974). Unfortu-
nately, we still cannot rule out the fact that the
reduced professional efficacy in the exhausted-and-
cynical pattern may also imply that these individualsare on their way to becoming totally burned out.
Finally, the question remains as to whether the two
burnout symptoms that decreased after rehabilitation
would in any case have decreased without treatment.
However, as such, untreated burnout symptoms have
turned out to be quite stable across time (Schaufeli &
Enzmann, 1998), and therefore they are not likely to
disappear without any treatment.
Our expectations in relation to differences between
the various burnout patterns in job conditions and
personal resources over time were partly met andconsistent with the ideas of the COR theory. How-
ever, contrary to our hypothesis, there were no dif-
ferences in the perceptions of job demands between
the four patterns over time, as main effects either for
group or for time. This implies that time pressures at
work operated as a work stressor to some extent for
all the rehabilitation clients. Furthermore, as the COR
theory suggests, burned-out individuals have experi-
enced major losses in their lives and therefore have
few resources left (Hobfoll & Freedy, 1993; Hobfoll
& Shirom, 2001). In this study, resource losses wereindeed apparent in those burnout groups in which two
or three symptoms dominated. As we hypothesized,
burned-out participants had fewer job resources
(lower supervisor satisfaction) and fewer personal
resources (lower SOC) than not-burned-out partici-
pants; however, the exhausted-and-cynical partici-
pants also experienced a lower level of personal
resources (SOC) compared with the not-burned-out
participants.
More specifically, when studying the relationships
between burnout and coping strategies, employeeswho suffered from low professional efficacy reported
less use of task-oriented coping than employees who
were not burned out. The relationship between task-
oriented coping and personal accomplishment has
been found in other studies as well (Greenglass &
Burke, 2000; Lee & Ashforth, 1996; Leiter, 1991;
Sears et al., 2000). According to Lee and Ashforth
(1996), a problem-focused, active response to prob-
lems and a positive evaluation of the self may rein-
force each other. Following this line of thought,
participants who experienced low professional effi-cacy may have felt that they were incompetent and
inefficient in handling problems proactively, and
therefore did not engage in task-oriented coping.
Furthermore, previous studies have proposed that
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emotion-focused coping has been associated with
high levels of burnout (Sears et al., 2000), which was
also confirmed in this study: Burned-out clients re-
ported more use of emotion-oriented coping than
clients in the low-professional-efficacy and not-burned-out patterns.
Previous studies have also demonstrated the asso-
ciations between low SOC and burnout (Soderfeldt et
al., 2000). A person with a high SOC can handle
stressors better than one with a low SOC (An-
tonovsky, 1987; Feldt, 1997; Soderfeldt et al., 2000).
It is not surprising therefore that the not-burned-out
participants experienced a stronger SOC than the
exhausted-and-cynical and burned-out participants,
or that participants in the low-professional-efficacy
pattern experienced a stronger SOC than those whowere burned out. Although Antonovsky (1987) as-
sumed that SOC is a relatively stable characteristic in
adults, there are research results to show that the level
of SOC can change in adulthood (Feldt, Leskinen,
Kinnunen, & Mauno, 2000). For example, Feldt et al.
indicated that alterations in the work environment
may change individuals SOC. Therefore, it would be
important to target rehabilitation activities on im-
proving working conditions to promote SOC, which
in turn can promote the recovery from burnout.
We hypothesized that especially personal re-sources would increase in the 4 months following
rehabilitation. However, there were no changes iden-
tified in these outcome variables. Contrary to our
expectations, of job resources, job control did in-
crease to some extent during the 4-month follow-up,
suggesting that the rehabilitation succeeded in pro-
moting clients abilities to control certain job char-
acteristics. No improvements in workplace climate
and supervisor satisfaction were identified after the
rehabilitation programs. The reason for this may be
due to the short follow-up but may also be due to thenature of the first rehabilitation period, which was
carried out in the rehabilitation center away from the
employees workplace, and which did not focus on
changing actual jobs or job conditions. It must be
remembered that the total rehabilitation process is far
longer, including three to four rehabilitation periods,
and that later on, as the rehabilitation process pro-
ceeds, the focus of intervention will be shifted more
onto the organizational level.
According to the COR theory, depression appears
at an advanced stage in the burnout process (Hobfoll& Shirom, 2001), which was evident in the fact that
the burned-out pattern had the highest scores for
depression. The relationship between burnout and
depression has been found in previous studies as well
(Glass et al., 1993; Landsbergis, 1988; McKnight &
Glass, 1995). Because depression is considered to be
a consequence of burnout (Burke et al., 1996; Cooper
et al., 2001; Glass et al., 1993; Leiter & Durup,
1994), alleviating depressive symptoms in burned-out individuals would be a sensible first step when
starting the rehabilitation process. The employee re-
habilitation interventions in this study seemed to be
successful in this regard.
Four months after the employee rehabilitation in-
tervention, both positive and negative changes were
detected in the participants psychological health. To
be able to affect burnout and the underlying causes of
burnout more efficiently, intervention programs
should focus more on changing the situational and
organizational factors that may have had a greaterrole in the development of burnout than the individ-
ual ones (Maslach, 2000; Maslach et al., 2001). The
COR theory also suggests that interventions should
place greater emphasis on the objective job factors
that more permanently shape individuals perception
of job stressors (Hobfoll & Freedy, 1993). Meta-
analyses and reviews on work stress and burnout
interventions have also stressed that individually ori-
ented interventions do not include sufficient actions
to take care of the causes that underlie burnout de-
velopment (Ganster & Murphy, 2000; Murphy, 1996;van der Klink et al., 2001). This does not mean that
interventions should concern themselves solely with
changing job or job conditions, but instead that in-
terventions that combine both an individual and or-
ganizational level focus could be the most beneficial
solution in reducing and preventing burnout
(Maslach, 2000; Maslach et al., 2001). Nevertheless,
in this study, burnout symptoms decreased regardless
of the fact that no actions were thus far taken in
clients workplaces during the follow-up.
From the practical point of view, the most impor-tant implication in this study relates to the four pat-
terns of burnout, which occupied different positions
during the rehabilitation process, that is, patterns
characterizing people who are differently burned out
in terms of job resources, personal resources, and
psychological health. Recognizing the different pat-
terns of burnout and knowing how these patterns are
related to various job- and individual-related out-
comes will enable rehabilitation professionals to fo-
cus their intervention activities more effectively. Al-
though there were no positive changes detectedduring the follow-up in the job resources (except for
job control) or personal resources, we consider that it
is very important to study whether this treatment
strategywhich is costly for the society, employers,
234 HATINEN, KINNUNEN, PEKKONEN, AND ARO
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as well as employeesis actually successful. This
study revealed that to some extent the rehabilitation
intervention (which lasted for 2 weeks) was already
efficient; this concerned especially the burned-out
clients. As mentioned before, these interventions willcontinue, and we shall be able to study their long-
term effects in the future. Employees may need
longer treatment period to regain their resources and
working ability. Besides, burnout usually develops
gradually, over many years; therefore, it is natural to
expect that the recovery process also requires several
years.
The employee rehabilitation intervention seemed
to be most useful for the burned-out clients, who had
the greatest lack of personal resources and suffered
most from psychological health problems comparedwith the other patterns. For burned-out clients the
first step in rehabilitation is to alleviate burnout
symptoms and depression. After that the target of the
intervention should also focus on the organizational
level due to the fact that the burned-out employees
reported worse interpersonal relations (poor work-
place climate and dissatisfaction with supervision), a
situation that can only be remedied by organization-
al-oriented intervention activities. Furthermore, for
individuals who suffer from reduced professional ef-
ficacy, supporting and guiding them in proactiveways of handling problems at work could be the most
useful rehabilitation strategy.
There are a number of limitations concerning the
present study. First, the sample size was small and
the grouping of rehabilitation clients was based on
cluster analysis. To test whether the same cluster
solution has any generalizability, one should repli-
cate the solution repeatedly across other samples in
the same general population (Aldenderfer & Blash-
field, 1984). The second limitation concerns the fact
that there was no control group. We cannot be surewhether the differences in outcome variables that
occurred during the 4 months are due to the interven-
tion programs, although at least burnout and depres-
sive symptoms have turned out to be stable without
treatment. Third, because the sample for this study
consisted of employees whose need for rehabilitation
services had been established by a physician, the
results of this study can only be generalized to the
working rehabilitation population. On the other hand,
this study is valuable, particularly on account of the
nature of this sample, which comprised a group ofindividuals who had sought rehabilitation particularly
because of burnout; therefore, the healthy worker
effect was partly avoided. In addition, those differ-
ences between the burnout patterns and the changes
over time found in our study can be considered
reliable, because we were able to control for con-
founding factors in our analyses.
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