Literature reviews of interventions

A review of research on medical resident burnout found that only 9 of the 160 articles on the topic focused on interventions. “Interventions included workshops, a resident assistance program, a self-care intervention, support groups, didactic sessions, or stress-management/coping training either alone or in various combinations” (McCray, Cronholm, Bogner, Gallo, & Neill, 2008, p. 626). Procedural shortfalls in all of the reviewed studies limited the potential validity and generalizability of these findings. Another

review came to a similar conclusion about burnout studies in a broad range of human service professions: intervention studies were rare, their samples were generally small, and their research designs were flawed (Buljac-Samardzic, Dekker-van Doorn, Van Wijngaarden, & Van Wijk, 2010). In addition, some cases of intervention resulted in no changes in burnout, but this maintenance of the status quo in the face of adverse events was a more positive outcome in comparison to control groups who got worse over time (e.g., Innstrand, Espnes, & Mykletun, 2004; Le Blanc, Hox, Schaufeli, Taris, & Peeters, 2007).

A comprehensive literature review of 63 stress-oriented interventions (van den Bossche & Houtman, 2003) used a 2X2 framework (Kompier & Kristensen, 2001) of Focus (work environment vs. individual or group) by Prevention (primary vs. secondary/tertiary). Only three of these studies reported changes in burnout. Individual interventions generally sought to increase employees’ resiliency to endure the pressures of work life. These programs included relaxation (e.g., van der Hek & Plomp, 1997) or meditation (e.g., Murphy, 1996). Other programs utilized cognitive behavioral therapy (CBT) or stress inoculation therapy (SIT). The review identified one individually oriented study that reported decreases in exhaustion (Lindquist & Cooper, 1999), and one that reported improvements in all three aspects of burnout ( Ewers, Bradshaw, McGovern, & Ewers, 2002). Another study found a decrease in exhaustion associated with participation in a workshop teaching cognitive strategies to address inequity perceptions in conjunction with relaxation techniques (Van Dierendonck, Schaufeli, & Buunk, 1998). However, no studies were found in Van den Bossche and Houtman’s review (2003) that addressed burnout through interventions focusing on the individual/organizational interface or organizational interventions. The authors recognized valuable contributions in the existing literature, but found the amount of intervention research, its scope, and experimental rigor to be inadequate to the task of developing, implementing, and evaluating methods for addressing stress and burnout.

Cognitive behavioral therapy

Individual interventions to address burnout often focus on strengthening both physical and psychological resiliency. Cognitive behavioral therapy (CBT) has been included in the intervention strategy of several studies. One study found decreases in burnout, as measured by the single-factor exhaustion-oriented Melamed Burnout Scale (Melamed, Kushnir, & Shirom, 1992), following participation in an individually oriented intervention that combined CBT with physical activity training (Stenlund et al., 2009). Another CBT study found reductions in exhaustion and in the time required for participants to recover sufficiently to return to work, for 168 employees on disability leave (Lagerveld et al., 2012). A study that contrasted 10 forensic nurses with a control group found that a coping skills intervention produced improvements in all three dimensions of burnout at the end of the six-month training. There were no corresponding changes in the control group (Ewers et al., 2002).

However, several other studies have not found any positive effects of CBT interventions. For example, de Vente et al. (2008), finding no reduction in burnout, concluded: “this study adds to the evidence that CBT-based interventions as currently practiced are not successful in treating patients with clinical levels of work-related stress” (p. 214). Butow et al. (2008) also failed to find an impact on burnout for their communication skills intervention, although it did increase participants’ confidence in their communication abilities. Vuori et al. (2012) found no change in exhaustion in response to their career development workshops despite its beneficial effects on depression and intention to retire early. Ossebaard (2000) found no enduring impact of biofeedback training on exhaustion. Visser et al. (2008) found no effect on burn-out for a peer support program for 52 health care providers working with dementia patients. Elo et al. (2008) found no change in exhaustion in an otherwise successful program focusing on understanding the psychosocial work environment for 625 Finnish public service employees.

Mindfulness

Another approach to addressing burnout, especially within health care, has been mindfulness (Kabat-Zinn, Lipworth, & Burney, 1985). Mindfulness is defined as a “non-elaborative awareness of present-moment experience” (Chambers, Gullone, & Allen, 2009, p. 561) that involves intentional, nonjudgmental, present-focused attention (Thomas & Otis, 2010). The potential of mindfulness to address burnout may lie in its use as a relaxation technique, which could reduce exhaustion or improve emotion-focused coping with distressing events at work and help people feel a greater sense of efficacy and confidence. Also, its use of a nonjudgmental psychological detachment might help prevent the development of cynicism. Future research is needed to identify what the actual mechanisms might be.

In one study, 84 health care providers who participated in an eight-week mindfulness meditation program showed a reduction in exhaustion, but not the other two aspects of burnout; however, the study did not have a control group (Galantino et al., 2005). Similarly, a reduction in exhaustion was found for 11 health care providers participating in an eight-week mindfulness course (Cohen-Katz et al., 2005). Another study contrasted 18 intervention participants with a control group to find improvements in all three aspects of burnout (Shapiro et al., 2005). More recently, a study found improvement in burnout among 93 health care providers who met for eight 2.5-hour weekly sessions plus a day-long retreat focusing on mindfulness meditation (Goodman & Schorling, 2012).

Workplace interventions

Interventions that have focused directly on the employees’ workplace seem to have a more consistent impact on burnout. For example, a program for nurses, which targeted workplace equity issues using guided imagery and group discussions, had a positive impact on both exhaustion and efficacy (Dierendonck, Schaufeli, & Buunk, 2001). A program based on discussions of work-life quality among psycho-geriatric care providers also found improvement in exhaustion, although not efficacy (Van Weert et al., 2005). A reduction in exhaustion, relative to control groups, was found for a program that provided workplace coaching sessions to 76 participants over a six-month period (Duijts et al., 2008). Improvement in all three burnout dimensions was found for 10 nurses participating in a program teaching a method of managing extreme behavior in a developmental disabilities ward (Long et al., 2008). A skills development workshop resulted in improvements on all three dimensions of burnout for 25 social workers (Cohen & Gagin, 2005). A study that assessed employees’ burnout scores before, immediately after, and four weeks after returning from vacation, found that burnout (as measured by the one-dimensional Burnout Measure; Pines, Aronson, & Kafry, 1981) decreased from baseline immediately after vacation but returned to baseline at the four-week follow-up (Westman & Etzion, 2001).

Long-term interventions

Some studies have found success for prolonged intervention methods. For example, Salmela-Aro et al. (2004) found reductions in burnout for nurses participating in one of two 16-week intervention groups: (1) a psychodrama group based on work-related themes and (2) an analysis of work issues from a psychoanalytic perspective. There were 32 nurses in each intervention group and 34 nurses in a control group. When assessed with the Bergen Burnout Indicator (Matthiesen, 1992), a unidimensional measure of exhaustion, both intervention groups showed decreased exhaustion, in contrast to the control group. Bresó et al. (2011) found increases in work engagement along with decreases in exhaustion and cynicism among 23 students who completed a four-month individual cognitive behavioral intervention, in contrast to a control group that did not improve. Psychotherapy patients with burnout diagnoses (n = 74) in a Dutch clinic were found to have improved on all three aspects of burnout after 8.5 months of treatment, with these gains remaining constant six months later (Mommersteeg et al., 2006). However, the latter study did not use a control group.

Organizational interventions

Progress has occurred in exploring organizational interventions in recent years. Halbesleben et al. (2006) reported an innovative approach to applying action research as a means to reduce burnout. This descriptive study drew upon a group problem-solving exercise to address problems that managers and employees identified in their work as firefighters. They found reductions in exhaustion and cynicism over the intervention period. In another study, the active involvement of participants (20 white-collar workers) in designing their individual rehabilitation treatment plan led to a stronger impact on exhaustion and cynicism than was found in a control group using traditionally structured therapy sessions (Hätinen et al., 2007). Another organizational intervention was a small-scale (n = 20) study of nurses that found a decrease in exhaustion when implementing an individualized patient care model within a Swedish hospital (Berg, Hansson, & Hallberg, 2008). Le Blanc and Schaufeli (2008) argue that by encouraging participants’ active involvement in the planning, design, and implementation of interventions, an action research approach increases the potential for success. The sense of agency, as well as the access to local knowledge resulting from such collaborations, is fundamental to the impact and long-term sustainability of interventions.

Person-centered vs. situation-centered interventions

One major theme in the literature review is the contrast between interventions that focus on the individual and those that focus on a group or team or organizational unit. Clearly, much more attention has been given, for many years, to individual approaches (and there are many). However, there is not a lot of strong, consistent evidence that supports the effectiveness of these individual strategies. Even though there have been fewer attempts to implement and evaluate intervention strategies at the level of the work context (the job, the organizational unit, or the organization as a whole), the current evidence suggests that these sorts of strategies are more likely to have a positive impact.

It is interesting to note that the preference for individual interventions does not parallel the research on burnout, which has consistently found more evidence for the impact of social and organizational factors, than for personal ones. Why should there be such a focus on what to do with the individual, either in terms of treatment or prevention? One answer has been that individual strategies tend to be less costly for the organization, at least immediately, than interventions that target organizational change. However, there is not a lot of evidence to test this assumption, in terms of all the costs that are involved (such as absenteeism and poor job performance), as well as whether cheaper individual interventions are as effective as group or organizational ones.

A better answer may lie in the fact that burnout has been defined and described in terms of the individual experience (exhaustion, cynicism, inefficacy). This individualistic concept is not unique to burnout – indeed, it is characteristic of definitions of various forms of mental illness and stress – but the fact that a person’s psychological and physical experience is the starting point may frame the question of “what do we do about burnout?” into the form of “what do we do about the person?” This person-centered framing dovetails with the philosophy of North America’s individualistic society, which not only sees people as responsible for their own outcomes, but which celebrates the triumph of the individual over any obstacle. From this point of view, stressors are to be overcome, not eliminated. It is believed that a person’s ability and character can be assessed by how well he or she deals with stress, and this assumption is reflected in the value placed on “stress interviews” or “stress tests” as necessary challenges to separate out the better employees from the weaker ones.

There are other implications of this person-centered framework. First, it is often presumed that the source of burnout lies more within the individual employee than the work setting. Even when lip service is paid to the presence of a stressful work environment, it is not uncommon to target the individual’s personal qualities as the more important factor (e.g., “it may be a tough job, but his real problem is that he is such a workaholic” or “that she has anger management issues”, etc.). Second, regardless of the source of burnout, it is often presumed that it is the responsibility of the person, not the organization, to do something about the problem. Again, even when lip service is paid to a stressful work environment, the focus will more often be on the failure of the person to deal with that reality (e.g., “if you can’t take the heat, you should stay out of the kitchen”). Employees who complain about the workplace stressors are often viewed as weak and whiny, and as people who are behaving in inappropriate ways and abdicating all responsibility for taking care of themselves.

This is not to say that individual interventions are not useful – they certainly can be. But they are not the only way to think about the burnout experience, given that the person is behaving within, and responding to, a larger environmental context. In other words, the individual experience should not constrain our thinking to simply the individual form of interventions. Moreover, the widespread tendency to frame the philosophical issue in an “either-or” form – is it the person or is it the organization – prevents a “both-and” approach that may be more realistic. In other words, both the person and the organization have a role to play in improving the workplace and people’s performance within it.

Employee participation in the design and implementation of the intervention

Another key theme that has emerged from the literature review is the importance of getting direct input and feedback from employees at all levels within an organization. The people who work there can point to key issues and perspectives that might not be as apparent to researchers. Employees may be able to better identify the kind of interventions that will yield more meaningful benefits to them, or will be easier to implement, or will be better supported by the other workers. The priorities for the employees – in terms of what are the more important problems, and what would be the most meaningful improvements in the workplace – are not necessarily the same ones identified by the researchers (which are more likely to be based on their review of the literature, and/or their personal research preferences). Getting a “reality check” on the extent to which research hypotheses are in accord with employee experience is probably a critical step on the path to formulating an effective intervention for burnout.

A related theme is the importance of worker collaboration and ownership of the intervention. No matter how brilliant the plan for reducing or alleviating burnout, it will not be successful if it is not adopted and put into practice. Prior consultation with employees at all levels, including front-line and managerial, is essential for any intervention to succeed. First, such consultation may yield modifications of the intervention, which will increase the likelihood of it being effective. Second, if people are on board with the proposed intervention, are willing to put in the necessary time and effort to make the changes and to maintain them, and are committed to achieving the eventual outcome, then the intervention will have a much greater chance of success.

The importance of employees’ active participation in interventions is reflected in the self-determination theory (SDT) of Deci and Ryan (1991) that proposes autonomy, competence, and relatedness as core motivations. An active role in a workplace intervention fulfills employees’ autonomy motivation in that they experience themselves as deciding on their participation rather than feeling manipulated by authority figures. An active role also confirms a sense of efficacy through its implication that employees have the capacity to contribute to improving their experience at work rather than being entirely dependent on others. Working together with colleagues on a shared intervention confirms relatedness by identifying burnout as a shared workplace concern rather than an individual affliction. Aligning interventions with employees’ core motives increases their chances of success.

Models of change processes

There is much more to successful change than simply practice, because the change process is complex and involves a number of distinct phases. The successful management of these different stages of change requires a lot of time, which is another reason why long-term interventions are likely to be more effective in reaching their change goal than short-term interventions. Several models of change have proposed a basic three-stage process. The first stage focuses on overcoming people’s natural resistance to change and on preparing them to move. The second stage involves the actual transition to a different position or situation. The third stage solidifies and maintains the new change. These three stages have been described as “unfreezing, transition, and (re)freezing” by Lewin (1951, p. 231). A more modern version of the Lewinian model talks about the three stages in terms of “disconfirmation, cognitive restructuring, and refreezing” (Schein, 2004 p. 328). Another model by Bridges (2003) describes the three stages as a) Ending. Losing, Letting Go; b) Neutral Zone; and c) New Beginning.

Kotter (1996) proposed an elaborated, multi-stage model of organizational change. This is an eight-step model that is framed in terms of how leaders can manage change successfully within their organizations. The first step is to establish a sense of urgency about accomplishing a particular change, because people must understand why the change is needed and must be convinced that it is important to take immediate action. The second step involves the creation of a powerful coalition to lead the change effort, and the support to help this group work as a team. The third step is the development of a vision for change, and of strategies for achieving that vision, so that it will help direct the change effort. The fourth step is communication of the vision, in a clear and effective way, so that everyone will understand and buy in to it. The fifth step focuses on empowering broad-based action, by removing obstacles to change and by encouraging innovation and risk-taking. The sixth step is to generate short-term wins, by planning for immediate and visible achievements, and by rewarding those who accomplish them. The seventh step builds on the initial changes by never letting up on the implementation of the vision and by reinvigorating the change process. Finally, the eighth step incorporates the changes into the organizational culture, by connecting the new behaviors to organizational success and future progress.

All of these change models underscore the necessity of a long-term process to achieve some new organizational goals. Clearly, there are parallels and shared themes between all of these models. However, it has been argued that the Kotter model is a better framework for actual change implementation, because it goes beyond descriptions of processes by delineating specific action steps that can be clearly applied throughout the organization (Stragalas, 2010).

A new change model for burnout interventions

Our earlier review of published intervention studies reflected a variety of approaches, evaluation frameworks, and basic assumptions about the methods for addressing burnout. Admittedly, the current state of the research does not identify the definitive intervention format for burnout, but it does point towards qualities that characterize the most informative research on the issue. These qualities are compatible with Kotter’s (1996) perspectives on the design and implementation of change initiatives (also see Lowe, 2008; NIOSH, 2008; Peersman, Harden, & Oliver, 1998).

• Urgency: Successful change initiatives have a sense of addressing issues of critical importance to participants. They have a goal that describes the preferred end state and how it differs from the current state. Reducing burnout presents serious challenges due to its stability over long periods.
• Targeted and Strategic: Successful change initiatives focus on the key leverage points for effecting change. A large body of research identifying the primary antecedents of job burnout provides direction for focusing interventions. Successful change initiatives identify strategies that encompass a variety of specific tactics, any or all of which have a potential to make a difference. A clear focus on an identified target has been recognized as a success factor for organizational interventions that are subject to “mission-creep” (a term that refers to the expansion of project objectives beyond the original goal, or mission, of the program design) (Dejoy, Wilson, Vandenberg, McGrath-Higgins, & Griffin-Blake, 2010).
• Collaborative: Employee participation throughout the intervention process improves chances of success. People do not take kindly to being told what to do. Successful change initiatives begin with, and maintain throughout, a dialog characterized by close listening, continuous learning, and ongoing adaptation of implementation. This point was emphasized by Halbesleben et al. (2006) and also by Dejoy et al. (2010).
• Sustained: Addressing burnout requires an ongoing commitment. Burnout is an enduring condition closely linked with the structure of the work environment. Long-term success requires sustained efforts to maintain gains. Without such effort, the original baseline conditions may become re-established. The interventions reviewed earlier generally lasted for many months of individual or group sessions (e.g., Mommersteeg et al., 2006; Salmela-Aro et al., 2004).
• Evaluated: Successful change initiatives measure progress. Assessment provides a vital flow of information to guide implementation. The adage that “one attends to what is measured” fits well for intervention programs. Clear measurement of primary constructs is essential both to diagnose the situation and to determine if action has had the desired impact (Moulding, Silagy, & Weller, 1999).

Intervention qualities of CREW

The CREW intervention encompasses the six qualities of change that we propose as necessary for effective interventions. Detailed descriptions of the CREW process are available in Leiter (2012), Leiter et al. (2011, 2012), and Osatuke et al. (2009), but here we will focus just on how CREW is a good example of the new change model for burnout interventions.

First, CREW brings a sense of Urgency in responding to requests from workgroups and organizational leaders to address crises in civility and incivility. Within the VHA system and in the replication study reported by Leiter et al. (2011), CREW was implemented in response to requests from groups that acknowledged a problem with collegial relationships.

Second, CREW is Goal Oriented in articulating a constructive objective of improving civility. Osatuke et al. (2009) emphasize the importance of working towards constructive goals, such as increasing the frequency of civil exchanges, rather than passive goals, such as reducing bullying or incivility. In the six months of the process, participants define specific goals for each weekly CREW meeting. The CREW process regards social interaction among colleagues as both essential and inevitable in health care work. A passive goal of eliminating incivility fails to address the constructive behaviors that would replace incivility within the ongoing interactions among the employees.

CREW is Targeted in that it focuses on a pivot point that is both influential and subject to change. As noted previously, the quality of supervisory and collegial social interactions is closely associated with burnout as well as job satisfaction, commitment, and other psychological connections of employees with their work. These associations suggest that improving the quality of social discourse has the potential to prompt meaningful change. Social behavior is subject to change. Many aspects of social behavior are under conscious control. Although it may be difficult at times to overcome habitual patterns of interaction, there is ample evidence that people can learn rules of comportment when instructed.

The potential for change is more evidenced in CREW’s Collaborative format. When striving to change the course of social discourse, it helps if the participants in that discourse all share the objective of improving the quality of their social dialog. It especially helps when all of the employees in the workgroup understand and share the goal towards which they are working. The group dynamics of CREW define a distinct process in which the nature of social interactions among colleagues becomes an explicit topic of conversation. The simple act of putting social relationships on a meeting agenda identifies the strains and slights that employees experience at work, and moves these out of the realm of private complaints among friends into the formal arena of group problem-solving. For some groups, this shift may require concerted effort over multiple meetings, as it crosses a boundary to ask people to talk about a topic about which they often avoid explicit conversation. A second important dimension of CREW’s Collaborative framework is that participants play an active role in setting goals and deciding how to attain those goals. Rather than aspire to an externally imposed ideal of civil behavior, the group process calls upon participants to describe what civility and incivility mean within their work context.

CREW’s Strategic quality is evident within the overall design of the process as well as in the specifics of the exercises and topics contained within the CREW Toolkit that facilitators use to guide the structure of sessions. The structured exercises that guide CREW’s facilitators are designed to encourage participants to explore different ways of interacting with one another. The exercises cover a range of situations, such as expressing appreciation, resolving conflict, or challenging a coworker who has behaved uncivilly during a shared interaction with a service recipient.

CREW is Sustained over a six-month implementation. Ideally, the CREW process in a milder form persists after the formal CREW process, as the workgroup continues to keep civility and respect on the agenda of the workgroup’s meetings and discussions indefinitely. The design of the CREW process recognizes that changes in social behavior are likely to meet resistance when first implemented in the workplace. People have become accustomed to responding to one another in a consistent way, so initial attempts to establish new patterns of social dialog, even when the new patterns are mutually beneficial, may not meet with immediate success. Colleagues may miss the essential difference in the new behaviors, or may suspect their sincerity. A Sustained process encourages change by implicitly confirming the reality and genuineness of the new pattern of interaction.

The Evaluation quality of CREW gives it a more credible place within organizational priorities. Contemporary organizations engage in a variety of activities under the general rubric of organizational development or professional development with only the most general indicators of meaningful change. CREW includes an initial survey that serves a diagnostic function in giving facilitators an indication of the workgroup’s strengths and weaknesses. The assessment at the end of CREW provides the definitive indicator of progress: have civility, burnout, and other constructs improved over the implementation period?

Effectiveness of the CREW intervention

CREW works as an effective intervention to address burnout by improving the quality of social interactions at work. Work is a highly social activity in an information/service economy where employees with diverse knowledge, skills, abilities, and orientations integrate their work to address complex problems. The quality of collegial and supervisor relationships provides powerful leverage in addressing burnout. Supportive relationships are important for psychological well-being as well as for effective workplace performance.

From a motivational perspective, incivility and disrespect from colleagues run counter to core social motivations of autonomy, competence, and relatedness (Deci & Ryan, 1991). By changing the quality of social encounters at work such that they provide more consistent confirmation of employees’ sense of agency, efficacy, and belonging, CREW may increase employees’ overall motivation to become engaged at work.

Fundamentally, by changing the quality of social encounters among employees on an ongoing basis, CREW has an enduring impact on employees’ experience of their work life. The procedure teaches participants new ways of interacting; it encourages participants to help one another realize these changes. To the extent that these changes assist employees to improve their balance of job resources to job demands and to fulfill their core social motivations, these changes have a potential to sustain.