title: A systematic review including meta-analysis of work environment and burnout symptoms.
abstract: Practitioners and decision makers in the medical and insurance systems need knowledge on the relationship between work exposures and burnout. Many burnout studies - original as well as reviews - restricted their analyses to emotional exhaustion or did not report results on cynicism, personal accomplishment or global burnout. To meet this need we carried out this review and meta-analyses with the aim to provide systematically graded evidence for associations between working conditions and near-future development of burnout symptoms.
  
  
  
  A wide range of work exposure factors was screened. Inclusion criteria were: 1) Study performed in Europe, North America, Australia and New Zealand 1990-2013. 2) Prospective or comparable case control design. 3) Assessments of exposure (work) and outcome at baseline and at least once again during follow up 1-5 years later. Twenty-five articles met the predefined relevance and quality criteria. The GRADE-system with its 4-grade evidence scale was used.
  
  
  
  Most of the 25 studies focused emotional exhaustion, fewer cynicism and still fewer personal accomplishment. Moderately strong evidence (grade 3) was concluded for the association between job control and reduced emotional exhaustion and between low workplace support and increased emotional exhaustion. Limited evidence (grade 2) was found for the associations between workplace justice, demands, high work load, low reward, low supervisor support, low co-worker support, job insecurity and change in emotional exhaustion. Cynicism was associated with most of these work factors. Reduced personal accomplishment was only associated with low reward. There were few prospective studies with sufficient quality on adverse chemical, biological and physical factors and burnout.
  
  
  
  While high levels of job support and workplace justice were protective for emotional exhaustion, high demands, low job control, high work load, low reward and job insecurity increased the risk for developing exhaustion. Our approach with a wide range of work exposure factors analysed in relation to the separate dimensions of burnout expanded the knowledge of associations, evidence as well as research needs. The potential of organizational interventions is illustrated by the findings that burnout symptoms are strongly influenced by structural factors such as job demands, support and the possibility to exert control.
authors.affiliation: Department of Psychology, University of Stockholm, S-10691, Stockholm, Sweden. Gunnar.Aronsson@psychology.su.se.
authors.forename: Gunnar
authors.identifier: 0000-0003-3664-1814
authors.initials: G
authors.lastname: Aronsson
authors.affiliation: Stress Research Institute, University of Stockholm, Stockholm, Sweden.|Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Töres
authors.initials: T
authors.lastname: Theorell
authors.affiliation: Health Care Centre, Norrtälje, Sweden.
authors.forename: Tom
authors.initials: T
authors.lastname: Grape
authors.affiliation: Department of Public Health and Clinical Medicine, University of Umeå, Umeå, Sweden.
authors.forename: Anne
authors.initials: A
authors.lastname: Hammarström
authors.affiliation: Division of Occupational Medicine, Institute for Environmental Medicine, Karolinska Institutet, Solna, Sweden.
authors.forename: Christer
authors.initials: C
authors.lastname: Hogstedt
authors.affiliation: Division of Psychiatry, University of Linköping, Linköping, Sweden.
authors.forename: Ina
authors.initials: I
authors.lastname: Marteinsdottir
authors.affiliation: Department of Psychiatry and Neurochemistry, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Ingmar
authors.initials: I
authors.lastname: Skoog
authors.affiliation: Division of Psychiatry, University of Lund, Lund, Sweden.
authors.forename: Lil
authors.initials: L
authors.lastname: Träskman-Bendz
authors.affiliation: Swedish Council of Health Technology Assessment, Stockholm, Sweden.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hall
mesh_terms: D000124:Achievement; D000328:Adult; D001315:Australia; D002055:Burnout, Professional / Q000523:psychology*; D016022:Case-Control Studies; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D005222:Mental Fatigue; D009520:New Zealand; D009656:North America; D016273:Occupational Exposure / Q000706:statistics & numerical data*; D015279:Organizational Culture; D011446:Prospective Studies; D012201:Reward; D012935:Social Justice / Q000523:psychology; D011795:Surveys and Questionnaires; D016526:Workload / Q000523:psychology*; D017132:Workplace / Q000523:psychology*
keywords: Burnout; Cynicism; Emotional exhaustion; GRADE system; Job control; Job demands; Meta-analyses; Personal accomplishment; Review; Social support