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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

221BURNOUT PATTERNS IN REHABILITATION


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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-

222 HATINEN, KINNUNEN, PEKKONEN, AND ARO


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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



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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



8/18

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-



9/18

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.



10/18

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



11/18

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.



12/18

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.



13/18

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-



14/18

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



15/18

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,



16/18

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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