Burnout Syndrome in Europe: Towards a Harmonized Approach in Occupational Health Practice and Research

Industrial Health 2019, 57, 745–752 Research Strategy

Burnout syndrome in Europe: towards a harmonized approach in occupational health practice and research

Irina Guseva CANU1*, Olivia MESOT1, Christina GYÖRKÖS1, Zakia MEDIOUNI1, Ingrid Sivesind MEHLUM2 and Merete Drevvatne BUGGE2

1Center for primary care and public health (Unisanté), University of Lausanne, Switzerland 2National Institute of Occupational Health (STAMI), Norway

Received August 25, 2018 and accepted January 29, 2019 Published online in J-STAGE February 27, 2019

Abstract: Health practitioners and decision makers in the medical and insurance systems need knowledge on the work-relatedness of burnout. To gather the most reliable information regarding burnout diagnosis and recognition in Europe, we used an 8-item standard questionnaire sent by e-mail to occupational health specialists identified via the Network on the Coordination and Har- monization of European Occupational Cohorts (OMEGA-NET) within the European Cooperation in Science and Technology (COST) Action. Participation rate was 100%, and the questionnaire was completed for 37 countries. In 14 (38%) countries burnout syndrome can be acknowledged as an occupational disease. However, only one country included burnout on the list of occupational diseases. The results showed a high variability in burnout diagnosis, in assessment of its work- relatedness, and in conditions allowing compensation of patients. These results reflect a lack of graded evidence on burnout and its determinants. The ongoing research on burnout conducted in the frame of the OMEGA-NET COST Action should be helpful through facilitating standardization of both existing and new data on burnout, a priority outcome requiring harmonization.

Key words: Burnout, Diagnosis, Epidemiology, Harmonization, Occupation, Work-relatedness

defined by means of the dimensions of exhaustion, cynicism Introduction and lack of efficacy from the “Maslach Burnout Inventory- General Survey” (MBI-GS)4). Some authors who studied Although the term burnout has been described since burnout in relation with specific working conditions, speci- 19741), neither the Diagnostic and Statistical Manual of fied it as occupational5), professional6) or job burnout7), Mental Disorders (DSM)2), nor the International Classifica- though no consensus exists on this terminology. tion of Disease (ICD)3) has recognized it as a distinct disor- Burnout has negative consequences for individuals, order. In the 10th revision of ICD, burnout is defined as a state ganizations as well as society. At the individual level, burn- of vital exhaustion and is classified under problems related out can cause emotional and mental stress, leaving profes- to life management difficulty (Z73). Most often burnout is sionals feeling unsatisfied in their careers8) and employees who were once enthusiastic and excited about their career 9) *To whom correspondence should be addressed. drained, cynical, and ineffective . At the organization and E-mail: [email protected]; [email protected] society levels, burnout causes high healthcare costs and ©2019 National Institute of Occupational Safety and Health productivity loss, due to increased turnover intentions and This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/) 746 I GUSEVA CANU et al. decreased performance7). Shanafelt et al. estimated that a as their substitutes. Upon approval at the national level, US healthcare system with 500 physicians, at the average participants of the network may attend OMEGA-NET MC national burnout rate of 54%, can expect to spend US $12 meetings and scientific events, such as training courses, million every year just to replace physicians who leave the workshops and conferences, thanks to the EU funding re- organization due to burnout10). In Germany, burnout annual lied to this Action. The OMEGA-NET participants are all cost in lost productivity was estimated 9 billion euros11), active as occupational health scientists and professionals, while in Switzerland, work-related stress and exhaustion specialized in occupational health, including occupational cost between CHF 5 and CHF 5.8 billion a year12). medicine, occupational psychology and ergonomics, Diagnosis and treatment of patients with burnout in oc- occupational epidemiology, occupational hygiene, and cupational health practice are challenging due to different exposure assessment19). Work-related psychosocial de- etiological theories, numerous burnout conceptualization terminants of mental health are one of six research areas attempts and a variety of assessment tools13–16). These chal- OMEGA-NET has decided to focus on. Therefore, the lenges have repercussions for the recognition of burnout OMEGA-NET network corresponds to a perfect setting as an occupational disease and its compensation when and opportunity for accurately completing the results of appropriate. To evaluate these challenges, an exploratory the exploratory study on burnout by Lastovkova et al17). study was conducted among European Union (EU) coun- In this report, we aimed at completing the first map tries17). This study allowed mapping the evaluation systems of the evaluation system of burnout syndrome in Europe of burnout syndrome in the EU, possible compensation of extended to the 37 COST Association member countries, this disorder and preventive measures used. However, the and presenting the ongoing research on burnout conducted authors reported several methodological limitations of their within the framework of the OMEGA-NET COST Action. study, including the potential for selection, misclassification and missing data bias17). In fact, the data were unavailable Participants and Methods for five out of 28 countries, due to lack of response from the corresponding experts. Some of these limitations, namely During the second OMEGA-NET meeting in Barcelona the respondent selection and missing data problems, may, (February 2018), we prioritized research tasks focused on however, be addressed using European Cooperation in Sci- mental health and burnout. After the meeting, we contacted ence and Technology (COST, www.cost.eu). occupational health specialists from OMEGA-NET par- Funded by the EU Horizon 2020 Program, COST is ticipating countries by e-mail and each specialist identified the longest running European platform where researchers a competent person in their country to complete a survey. can jointly develop their ideas and initiatives through the The identified experts were then asked to provide the most trans-European networking of nationally funded research. reliable information regarding eight domains of interest8) as COST activities are largely arranged as COST Actions. follows: (1) the presence of an official national list of occu- In 2017, a COST Action entitled “The Network on the pational diseases, (2) the possibility to acknowledge burnout Coordination and Harmonization of European Occupa- and compensate patients, (3) evaluation criteria for compen- tional Cohorts (OMEGA-NET)” was launched18). This sation, (4) number of subjects with acknowledged burnout four-year (2017–2021) Action seeks to optimize the use syndrome over the past year, (5) number of compensated of occupational, industrial and population cohorts at the subjects over the past year, (6) proportion of companies European level by advancing (1) collaboration of cohorts having an action plan to limit stress at work, (7) proportion with extensive contemporary information on employment of companies where employees participate in psychosocial and occupational exposures, (2) co-ordination and harmo- risk assessment, and (8) proportion of companies collaborat- nization of both new and existing occupational exposure ing with psychologists. To collect these data, they received assessment efforts, and (3) facilitation of an integrated an electronic questionnaire and instructions, stating that the research strategy for occupational health in Europe, with responses were expected by e-mail a month later. The data the aim to extend globally18) (http://omeganetcohorts. were extracted and tabulated for summarizing and statistical eu/). In 2018, 37 countries have joined OMEGA-NET, analyses, using Microsoft Excel software. each country usually represented by one or two research As in the previous exploratory study, the Eurobarometer organizations, allowing registration of two occupational Working conditions survey20) statistics were used to assess health researchers as OMEGA-NET Management Com- the proportions for the last three domains, reflecting the mittee (MC) members and two additional researchers implementation of prevention strategies in each country.

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For concerns of internal consistency, we sent a pre- similar. completed table with proportions from this survey to the As shown in Table 1 and extensively commented by specialists and requested to check the accuracy of data for Lastovkova et al.17), there is a high variability in burnout their respective countries. We also asked the participating diagnostic criteria, in assessment of its work-relatedness, specialists to identify national occupational health spe- and in conditions allowing compensation. This reflects a cialists in countries beyond OMEGA-NET participants. lack of graded evidence on burnout and its determinants. The identified specialists were in turn contacted with the Although several systematic reviews and meta-analyses same request as those participating in OMEGA-NET. This have tried to assess the evidence of the relationship be- strategy allowed us to receive responses from all contacted tween work-related determinants and burnout21–23), none countries (n=14) and update the information from the has addressed the complete panel of possible burnout exploratory study for all of the 37 European COST Full determinants in workers, including both individual and Members countries (Table 1). work-related factors. The majority of studies have only measured some factors (predominantly work-related) and Results and Discussion some outcomes (i.e., some dimensions of burnout), and the results from these studies cannot be easily compared. In As can be seen in Table 1, thirty five (92%) countries addition, interrelationships between different determinants have an official list of occupational diseases. The only two have rarely been investigated. countries not having such a list are the Netherlands and The absence of a standardized definition of burnout, Sweden. In 14 (38%) countries (Bosnia and Herzegovina, the lack of a reference method for its diagnosis in medical Cyprus, Denmark, Estonia, France, Hungary, Iceland, practice, and the need for harmonization of this outcome Latvia, Malta, Netherlands, Portugal, Slovakia, Sweden measurement in occupational health research are important and Turkey), burnout syndrome can be acknowledged concerns for this study. Although we tried to control for as an occupational disease. However, Latvia is the only the participant selection bias (based on the OMEGA-NET country where burnout is explicitly listed on the list of oc- adherence procedure and national expert identification cupational diseases. In Bosnia and Herzegovina, Denmark, process) and missing data issues, potential outcome mis- Estonia, Hungary, Malta, Portugal, Slovakia and Turkey, classification bias is still difficult to circumvent. Because burnout can be acknowledged as a chronic stress-related of limited resources, it was impossible to make an inven- occupational disease through the “open item” in the list tory and scrutinize all sources of data within this study, as of occupational diseases. It is noteworthy to mention that well as to extend it beyond the eight domains of interest, in Turkey, the court of justice can acknowledge burnout defined by Lastovkova et al.17) Moreover, we have not as an occupational disease based on the decision made by reassessed the data collected in the first survey8), assuming the health insurance board. In Iceland, the Netherlands the accuracy of these data. Therefore, this study should be and Sweden, any disease or injury can be acknowledged considered as an update of the previous survey, extended as occupational, assuming sufficient proof of the causality to 28 European and nine European neighbor countries. is provided. France uses the “Additional occupational dis- OMEGA-NET could be helpful through facilitat- ease recognition system”. In Cyprus, the examining physi- ing standardization of new exposure and outcome data cian can acknowledge burnout as an occupational disease harmonization of existing data. In particular, OMEGA- if it is related to the working conditions of the affected NET intends to provide an opportunity to investigate the person. There are no specific evaluation criteria but the causes of variability in research findings between studies Department of Labour Inspection can advise the examin- and eventually address those related to methodological ing physician reporting or suspecting a burnout case. inconsistencies18). OMEGA-NET considered burnout as a The EU membership status of the country does not seem priority health outcome for such a standardization effort, to influence the possibility to acknowledge burnout as an and a dedicated task-group was created in February 2018 occupational disease. However, the proportion of countries (http://omeganetcohorts.eu/). Since this date, two meetings with such a possibility among non-EU countries (33%) is have been organized between task-group members to de- slightly lower than among Member States of the EU (39%). fine the priority concerns and research agenda with respect The possibility to acknowledge burnout as an occupational to burnout measurement in epidemiological studies. This disease among COST Members States (38%), Members agenda currently encompasses several studies on burnout, of OMEGA-NET (41%), and Member States of the EU is as summarized in Table 2. 748 I GUSEVA CANU et al.

- b 4 5 8 9 9 11 12 10 38 67 12 28 59 67 Use of ments) (% establish psychologists b

55 43 61 77 42 68 51 69 55 57 62 73 55 68 Participation of psychosocial risks (% establishments) employees to address b 7 7 20 15 51 24 33 26 20 38 26 51 38 22 lishments) limit stress at Action plan to work (% estab - 7 0 0 0 1 0 0 2 42 99 NA NA NA 592 (yr) No of (2015) (2015) (2015) subjects (2014-2016) (2013–2015) (2005–2015) compensated - 0 0 0 1 0 0 2 0 42 NA NA 329 738 1989 (2015) (2015) (2015) (2013–2015) (2005–2015) (2014–2016) syndrome (yr) with acknowl edged burnout No of subjects ------NA Evaluation criteria nation Committee evaluation, Individual psychiatric and occupational exami tional examination nation tional examination Individual psychiatric and occupa tional examination, duration of the disorder for one year at least and minimum 6.66% loss of income Committee evaluation, associated with Depression (F 32.9, F 33.0), adjustment disorder (F 43.2), anxi ety disorder (F41.9) Individual occupational examination Committee evaluation, the rate of incapacity minimum 25%, associat ed with diagnosed mental disorders Individual occupational examination Individual psychiatric and occupa Committee evaluation. Individual psychiatric and occupational exami Individual psychiatric and occupa Committee evaluation after indi vidual psychiatric diagnosis Occupational examination tional examination (ILO guidelines) Individual occupational examination (according to NCOD guidelines) Individual psychiatric and occupa

burnout syndrome Possibility to acknowledge YES, open item YES YES, open item YES, open item YES, additional system YES, open item YES, listed YES, open item YES, open item YES, open item YES, open item YES YES, but not notifiable YES - NO NO YES YES YES YES YES YES YES YES YES YES YES YES Existence of list of occupa tional diseases a 1, 2 1, 2 2, 3 2, 3 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 status Country pdated* summary the of evaluation systems burnout of syndrome, possible compensation and preventive measures used in Europe Country Slovakia* Sweden* Denmark* Estonia* France* Hungary* Latvia* Malta Netherlands* Portugal* Turkey Bosnia and Herzegovina Cyprus Iceland 1. Table u

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- b 5 7 5 6 8 7 11 11 11 11 20 36 28 60 10 24 22 43 23 24 16 12 NA Use of ments) (% establish psychologists b

42 77 63 51 56 58 71 66 68 63 63 46 61 53 80 46 68 48 56 63 59 59 NA Participation of psychosocial risks (% establishments) employees to address b 9 8 24 22 36 33 36 20 14 43 49 24 14 12 40 14 14 31 32 21 57 52 NA lishments) limit stress at Action plan to work (% estab - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (yr) No of subjects compensated - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 syndrome (yr) edged burnout with acknowl No of subjects NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Evaluation criteria . 10)

burnout syndrome Possibility to acknowledge NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO - YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES Existence of list of occupa tional diseases . a 17) 2 2 1, 2 1, 2 1, 2 2, 3 2, 3 2, 3 1, 2 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 status et al Country - Country Albania Austria* Belgium* Bulgaria Croatia* Czech Republic* Finland* Germany* Greece Ireland* Italy* Lithuania* Luxembourg Montenegro Norway Poland* Republic of Mace donia Data from The Eurobarometer survey on Working conditions (2014) Working The Eurobarometer survey on Data from Serbia Slovenia* Spain* Switzerland United Kingdom* Romania* 1=Member State of the European Union, 2= Full Member of European Cooperation in Science and Technology (COST) Association, 3=Member of the OMEGA-NET COST Action. COST Association, 3=Member of the OMEGA-NET (COST) Technology 1=Member State of the European Union, 2= Full Member Cooperation in Science and Continuted Table 1. Continuted Table NCOD: Netherlands Center for Occupational Diseases; NA: not applicable. a b *Data from Lastovkova 750 I GUSEVA CANU et al. - - Source of funding COST Action COST CA16216 (contribution for tools ac quisition, working group meetings and publication costs), University of IST/ Lausanne and University of Bern BNF – National Qualification Program (contribution for review salary) ers’ As above Swiss National Science Foundation (SNSF), grant Swiss COST Action related to COST CA16216 (under review)

Study partners OMEGA-NET OMEGA-NET Burnout working group The Vaud University The Vaud Hospital Center (CHUV), Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine University Hospital Zurich completing expected date of Start of study and April 2018–June 2020. Publication of results expected by December 2020 June 2018–October 2019. Publication of results expected by March 2020 2019–2021. Publication of results expected by July 2022 -

Methods Systematic search of literature in Medline/PubMed, Pschinfo and Embase via Ovid. Screening and selection of relevant studies using an Excel form tool. Risk of bias assessment using MEVORECH tool, data extraction, pooling, narrative and whenever possible analysis of quantitative summary, and grading of heterogeneity, evidence for each factor contributing to the burnout onset using GRADE approach Evaluation of the psychometric properties of burnout tools. Narrative and comparative review based on two checklists: 1) quality evaluation of diagnostic/prognostic properties in epidemiology; 2) The hypotheses will be tested using a generalized linear model where the dependent variable will be the score of MBI assessed at follow-up III with the Siegrist’s score at effort-reward-imbalance follow-up II and the pre-existing psychiatric condition/s as predic The models will be adjusted for tors. additional independent variables in order to control for potential con founders. If the number of subjects is sufficiently high, analyses will be stratified by gender. ction (2018–2021)

T A

Data to be used -NET CO Longitudinal studies on burnout adult working population published between the years 1990 and 2018 in peer-reviewed scientific journals, whatever the language used. Studies on the development and validation of tools measuring burnout, peer-reviewed validation studies published since 1981. Data of the Swiss cohort PsyCoLaus, collected at baseline (2004–2008) and during three consecutive follow-ups (follow-up I (between 2009 and 2012), follow-up II (between 2014 and 2017), and follow-up III (between 2018 and 2020).

Study design Systematic literature and meta-analysis review of literature Systematic Prospective cohorte study - - - - - Study aim ing population To identify as exhaus To tively as possible all predictors of effective burnout in adult work To identify the vali To dated tools of burnout and to examine their epidemiological meth odology To assess the research To hypothesis that 1-high workload and are over-commitment predictors of future occupational burnout and 2-pre-existing psychiatric conditions are not mandatory pre cursors of occupational burnout tudies on burnout scheduled in frame the of OMEG A Name of study Which factors contribute to the onset of burnout among workers? Comparative study of Burnout measurement tools Pre-existing psychiatric conditions, occupational stress & burnout in a prospective cohort study 1 2 3 N° Table 2. Table s

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Moreover, OMEGA-NET might be helpful in address- and Social Insurance, Cyprus; Dr. Çiğdem ÇAGLAYAN, ing another issue, pointed out by the exploratory study8): Faculty of Medicine, Kocaeli University, Turkey; Dr. the lack of harmonized registration of the occupations of Mark GAUCI, Occupational Health & Safety Authority, compensated patients. As reported by Lastovkova et al., Malta; Dr. Zhulieta HARASANI, International Labor countries do not keep records of the occupations in a simi- Organisation (ILO) National Coordinator in Albania; lar way, and frequently, only the economic activity branch/ Ms.Kim LANSER, Ministry of Health, Occupational industry is available17). In contrast with economic activity, and Environmental Health Division, Luxembourg; Dr. having three levels of standardized classification for Euro- Dragan MIJAKOSKI, Institute of Occupational Health of pean countries: national, European (the Statistical classifi- Republic of Macedonia; Evangelia NENA, Democritus cation of economic activities in the European Community, University of Thrace, Alexandroupolis, Greece; Dr. Zlatko abbreviated as NACE) and international (International POPOVIC, Health and safety inspectorate, Montenegro; Standard Industrial Classification, abbreviated as ISIC), Prof. Nurka PRANJIC, Department of Occupational there is no standardized classification of occupations on Medicine, Medical Faculty University of Tuzla, Bosnia the European level. The coding of occupations is more and Herzegovina; Dr. Kristinn TOMASSON, Administra- challenging than the coding of economic activity and can tion for Occupational Health & Safety, Iceland; Dr. Bistra lead to measurement error in subsequent exposure assess- TZENOVA and Prof. Katya VANGELOVA, National ment24). Although, several countries use the International Center of Public Health & Analyses, Department of Health standard Classification of Occupations (ISCO), the differ- at Work, National Center of Public Health and Analyses, ent versions of the ISCO codes (1988, 1998, 2008) coexist Sofia, Bulgaria. The authors also thank Prof. Brigitta and the same ISCO version may differ somewhat between DANUSER and Dr. Regina STUDER from Unisanté for countries. OMEGA-NET intends to make an inventory of their expertise and advises regarding research on burnout coding systems and existing crosswalks between coding in Switzerland. 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