Combined Interventions to Reduce Burnout Complaints and Promote Return to Work: A Systematic Review of Effectiveness and Mediators of Change

Abstract

Burnout has adverse effects on the health and work-related outcomes of employees. Nevertheless, little is known about effective ways of reducing burnout complaints and facilitating full return to work, which defines rehabilitation. This study consists of a systematic review of the effects of combined interventions (i.e., both person-directed and organization-directed). It also includes the identification and description of mediators of change, thereby explaining how combined interventions do or do not work. Seven electronic databases were searched for English peer-reviewed publications: the Psychology and Behavioral Sciences Collection; PsycARTICLES; Web of Science; Scopus; SocINDEX; PubMed; and PsycINFO, using various combinations of search terms (e.g., burnout AND intervention). Out of 4110 abstracts published before 29 September, 2019, 10 studies (reporting the effects of nine combined interventions) fulfilled the inclusion criteria, which were defined using PICOS criteria (participants, interventions, comparators, outcomes and study design). Although the risk of bias of the included studies is high, all combined interventions were effective in facilitating rehabilitation. Results suggest that involving employees in decision-making and enhance their job control and social support, while eliminating stressors, explain the effectiveness of the intentions. With caution, workplace health promotion practitioners are encouraged to use these findings to tackle burnout among employees.

Full text

International Journal of
Environmental Research
and Public Health
Review
Combined Interventions to Reduce Burnout
Complaints and Promote Return to Work:
A Systematic Review of Effectiveness and
Mediators of Change
Roald Pijpker * , Lenneke Vaandrager, Esther J. Veen and Maria A. Koelen
Department of Social Sciences, Wageningen University & Research, 6700 EW Wageningen, The Netherlands;
Lenneke.Vaandrager@wur.nl (L.V.); Esther.Veen@wur.nl (E.J.V.); Maria.Koelen@wur.nl (M.A.K.)
*Correspondence: Roald.Pijpker@wur.nl; Tel.: +31-6-20187620
Received: 1 November 2019; Accepted: 17 December 2019; Published: 19 December 2019


Abstract:
Burnout has adverse effects on the health and work-related outcomes of employees.
Nevertheless, little is known about effective ways of reducing burnout complaints and facilitating
full return to work, which defines rehabilitation. This study consists of a systematic review of
the effects of combined interventions (i.e., both person-directed and organization-directed). It also
includes the identification and description of mediators of change, thereby explaining how combined
interventions do or do not work. Seven electronic databases were searched for English peer-reviewed
publications: the Psychology and Behavioral Sciences Collection; PsycARTICLES; Web of Science;
Scopus; SocINDEX; PubMed; and PsycINFO, using various combinations of search terms (e.g., burnout
AND intervention). Out of 4110 abstracts published before 29 September, 2019, 10 studies (reporting
the effects of nine combined interventions) fulfilled the inclusion criteria, which were defined using
PICOS criteria (participants, interventions, comparators, outcomes and study design). Although the
risk of bias of the included studies is high, all combined interventions were effective in facilitating
rehabilitation. Results suggest that involving employees in decision-making and enhance their job
control and social support, while eliminating stressors, explain the effectiveness of the intentions.
With caution, workplace health promotion practitioners are encouraged to use these findings to tackle
burnout among employees.
Keywords:
burnout; combined interventions; mediators of change; occupational health; PRISMA;
resources; rehabilitation; return to work; systematic review; workforce
1. Introduction
In the countries of the Organization for Economic Co-operation and Development (OECD),
work-related stress is the leading cause of absenteeism [
1
], with significant financial consequences for
society [
2
]. The best-known occupational syndrome—burnout—has adverse effects on the health and
wellbeing of employees (e.g., increasing physical illness [3]), in addition to affecting their attitudes at
work (e.g., decreasing organizational involvement [
4
,
5
]). For instance, burnout has shown to be an
important correlate of musculoskeletal disorders (e.g., chronic back pain), which, in turn, are associated
with a further increase in burnout complaints, daily productivity loss and form a major cause of
occupational leave and prolonged recovery time [
6
,
7
]. Moreover, burnout and its adverse effects on
the health and wellbeing of the workforce, is associated with high rates of sick leave and replacement
costs [
8
,
9
]. It is therefore of the utmost importance to tackle burnout, both for employee health and
wellbeing and for organizational development and performance.
Int. J. Environ. Res. Public Health 2020,17, 55; doi:10.3390/ijerph17010055 www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2020,17, 55 2 of 20
Burnout is predominantly described as an outcome of “a prolonged response to chronic emotional
and interpersonal stressors on the job, defined by the three dimensions of exhaustion, cynicism and
professional efficacy” [
10
] (p. 397). Emotional exhaustion refers to a feeling of being depleted and
overextended by one’s emotional and physical resources. Cynicism and depersonalization refer to a
detached response to various aspects of the job. Reduced efficacy and accomplishment refer to a sense
of incompetence and lack of productivity at work [
11
]. Burnout complaints can occur in employees
who are currently still working. Over time, however, burnout can lead employees to take sick leave
and become unable to work [12].
According to several theories, burnout develops in a non-linear manner [
13
]. Models that are
well-supported by empirical evidence include the Job Demand-Control Model [
14
], Conservation
of Resources theory [
15
] and the Job Demands-Resources Model [
16
]. These models emphasize
that the development of burnout is fostered through a complex interplay between factors within
employees (e.g., low self-esteem) and factors within the organizational context (e.g., work overload).
Based on these theories, interventions should target both employees and their working contexts, in
order to facilitate rehabilitation (i.e., reducing burnout complaints and promoting full return to work
(RTW)) [
17
]. Examples of person-directed interventions include psychotherapy and mindfulness
sessions. Examples of organization-directed interventions include changing working schedules and
team building.
1.1. Scientific Gap
To date, most systematic reviews and meta-analyses have focused separately on either
person-directed or organization-directed interventions, both of which have proven suboptimal in
facilitating rehabilitation [
18
]. Their lack of effectiveness has consequently been attributed to the
single-level approach (either person-directed or organization-directed interventions) [
18
]. There is
thus a need to synthesize the effectiveness of existing combined interventions (both person-directed
and organization-directed). Although existing theories suggest that combined interventions could be
effective in facilitating rehabilitation, it would also be interesting to examine why and how interventions
do or do not work. This has yet to be sufficiently understood [
18
–
20
]. In studies on interventions
aimed at reducing stress-related complaints in general (and not specifically burnout), job control has
been found to mediate changes in such complaints [
21
]. It would therefore be worthwhile to explore
the role of possible mediators of change in combined interventions.
1.2. Study Objective
Based on studies with experimental designs, the present study aims to assess the effectiveness
of combined (both person- and organization-directed) interventions for employees with burnout
complaints (currently either working or not working) on facilitating rehabilitation. Complementary,
this review aims to identify and describe mediators of change that could explain how combined
interventions do or do not work.
2. Methods
The systematic review was structured according to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines [
22
]. More specifically, we used the PRISMA checklist
to guide the design and reporting of the systematic review (supplementary materials, Table S1). Since
we did not aim to conduct a meta-analysis of the combined interventions, not all elements of this
checklist were relevant for this review (e.g., statistical measures of consistency).
2.1. Inclusion Criteria
Five inclusion criteria were applied to the identified studies, based on the PICOS criteria
(participants, interventions, comparators, outcomes and study design). First, to reduce heterogeneity
between studies, those focusing on employees were included, while those focusing on students [
23
],

Int. J. Environ. Res. Public Health 2020,17, 55 3 of 20
athletes [
24
] and volunteers [
25
] were excluded. Second, combined interventions (both person-directed
and organization-directed) were included. Third, we did not define a comparison exposure, which
means that experimental studies that did not include a control group were included. Fourth, studies
using the Maslach Burnout Inventory (MBI) to assess burnout were included, as the MBI is regarded
as the gold standard for measuring burnout [
26
], thereby enhancing comparability between studies.
With respect to return to work (RTW), all operationalizations were included. Fifth, randomized
controlled trials, quasi-experimental and pre-test/post-test study designs were included, as these
designs provide more robust evidence than do cross-sectional or other non-experimental designs [
27
].
Finally, only studies published in English between 1970 and 29 September 2019 were included.
2.2. Data Sources and Search Terms
Seven electronic databases were searched for peer-reviewed publications: the Psychology and
Behavioral Sciences Collection; PsycARTICLES; Web of Science (all databases); Scopus; SocINDEX;
PubMed; and PsycINFO. Search terms were based on the three dimensions of burnout—emotional
exhaustion, depersonalization or cynicism, personal accomplishment or professional efficacy, Maslach
Burnout Inventory or MBI—and combined with and “intervention”. To ensure substantial breadth and
depth in the electronic databases, the search strategy was pilot tested before the search was conducted.
The first author conducted the electronic search.
2.3. Search Strategy
The database search yielded 4110 hits, including a large number of duplicates (n =1154).
The subsequent search strategy consisted of two stages (See Figure 1). In the first stage, titles and
abstracts were screened against the inclusion criteria and abstracts deviating from them were excluded
(
n=2638
). Where the reviewer was uncertain, the abstract was moved onto the next stage for a
full-text review. In the second stage, full-text articles were screened (n =318) against the inclusion
criteria. Studies that did not meet the inclusion criteria (e.g., non-combined interventions) were
excluded (
n=308
). The first three authors were involved in the full-text screening stage and, in case of
uncertainty, the fourth authors acted as tie-breakers for the inclusion or exclusion of the remaining
articles. The reference lists of the included articles were screened to identify any additional relevant
studies. These lists did not reveal any additional studies and 10 studies were ultimately included in
the review.
Int. J. Environ. Res. Public Health 2019, 16, x 3 of 21
studies using the Maslach Burnout Inventory (MBI) to assess burnout were included, as the MBI is
regarded as the gold standard for measuring burnout [26], thereby enhancing comparability between
studies. With respect to return to work (RTW), all operationalizations were included. Fifth,
randomized controlled trials, quasi-experimental and pre-test/post-test study designs were included,
as these designs provide more robust evidence than do cross-sectional or other non-experimental
designs [27]. Finally, only studies published in English between 1970 and 29 September 2019 were
included.
2.2. Data Sources and Search Terms
Seven electronic databases were searched for peer-reviewed publications: the Psychology and
Behavioral Sciences Collection; PsycARTICLES; Web of Science (all databases); Scopus; SocINDEX;
PubMed; and PsycINFO. Search terms were based on the three dimensions of burnout—emotional
exhaustion, depersonalization or cynicism, personal accomplishment or professional efficacy,
Maslach Burnout Inventory or MBI—and combined with and “intervention.” To ensure substantial
breadth and depth in the electronic databases, the search strategy was pilot tested before the search
was conducted. The first author conducted the electronic search.
2.3. Search Strategy
The database search yielded 4110 hits, including a large number of duplicates (n = 1154). The
subsequent search strategy consisted of two stages (See Figure 1). In the first stage, titles and abstracts
were screened against the inclusion criteria and abstracts deviating from them were excluded (n =
2638). Where the reviewer was uncertain, the abstract was moved onto the next stage for a full-text
review. In the second stage, full-text articles were screened (n = 318) against the inclusion criteria.
Studies that did not meet the inclusion criteria (e.g., non-combined interventions) were excluded (n
= 308). The first three authors were involved in the full-text screening stage and, in case of uncertainty,
the fourth authors acted as tie-breakers for the inclusion or exclusion of the remaining articles. The
reference lists of the included articles were screened to identify any additional relevant studies. These
lists did not reveal any additional studies and 10 studies were ultimately included in the review.
Figure 1. Process of study selection.
Figure 1. Process of study selection.

Int. J. Environ. Res. Public Health 2020,17, 55 4 of 20
2.4. Data Extraction and Quality Assessment
The data extraction phase consisted of two steps. In the first step, studies were described
according to the following characteristics: author(s) and country; setting and design; study aim and
outcomes; participants; controls; theoretical framework; interventions; mediators of change; duration
and frequency; pre-test, post-test and follow-up; and results. In the second step, statistically significant
effects of the combined interventions on the reduction of burnout complaints and the promotion of RTW
were described, as were the theoretical assumptions and mediators of change. All researchers were
actively involved in defining how the data should be extracted and described in an iterative process.
The theoretical assumptions underlying the combined interventions were described in order to
enhance insight into why the interventions did or did not work. For combined interventions that
were not built on any specific theory, it was deemed appropriate to describe the general assumptions
made by the authors (if described). With regard to mediators of change, in addition to reporting those
mediators that were explicitly measured and evaluated concerning change in the outcome variables,
we also described mediators of change that were identified in the theoretical (or other) assumptions
underlying the combined interventions.
Since the overarching aim of this review is to assess the effectiveness of the combined interventions
for the rehabilitation of employees with burnout, it is important to assess the risk of bias of the included
studies to determine the extent to which the reported effects can be attributed to the interventions
and not to a lack of methodological rigor. To assess this risk of bias, we used the Quality Assessment
Tool for Quantitative Studies, which is specifically developed by the Effective Public Health Practice
Project for this critical step [
28
]. The tool can be applied in any public health topic area and has
been evaluated on its validity and reliability, which proved to be strong [
28
,
29
]. The tool defines
six components to assess the risk of bias: selection bias (e.g., do the study participant represent the
target population?), study design (e.g., was a randomized controlled trial design used?), confounders
(e.g., how did the authors deal with possible differences between experimental and control groups?),
blinding (e.g., were the study participants aware of the research question?), data collection methods
(e.g., were the measurements instruments reliable and valid?), withdrawals and dropouts (e.g., were
withdrawals and dropouts reported?) [
28
]. The first author conducted the assessment and nine studies
showed a “high” risk of bias and one study was assessed as having a “moderate” risk of bias. Studies
were not excluded based on this assessment; however, the results should be interpreted with caution.
To ensure transparency, the assessment scores can be found in the Supplementary materials, Table S2.
3. Results
3.1. Description of the Studies
Descriptive information regarding the 10 studies in this review is presented in Table 1.

Int. J. Environ. Res. Public Health 2020,17, 55 5 of 20
Table 1. Included articles (N =10).
Author/s,
Country Setting, Design Study Aim,
Outcome/sParticipants Controls Theoretical
Framework Interventions Mediators of
Change Measured Duration
Pre-Test (T1),
Post-Test (T2),
Follow-Up (T3)
Results Risk of
Bias
White-collar workers
Studies 1,2
[30,31];
Sweden
Employees on sick
leave due to
burnout; identified
from a social
insurance register;
controlled clinical
trial design
Promoting
RTW; RTW
(sick leave
percentage)
Workers
with burnout;
confirmed by
medical
examination and
questionnaire
interview (n =74)
Workers
with burnout who
were not interested
in participating in
the intervention;
no intervention (n
=74)
Job-person
(mis)match
Combined intervention: a
convergence
dialogue meeting (i.e., dialogue
between the patient and the
supervisor to find solutions to
facilitate RTW)
Partial work
resumption
expected to foster
full RTW
Half-day seminar,
1.5-hour meeting
After 18 and 30
months, the total
sick
leave↓in the
combined
intervention
group, as
compared to the
control group
After 18 and 30
months, the total
sick
leave↓in the
combined
intervention group,
as compared to the
control group
High
Study 3
[32];
Netherlands
Staffmembers of
29 oncology wards
of 18 general
hospitals;
quasi-experimental
design
Reducing
burnout
complaints;
MBI-HSS
(EE, DP)
Staffmembers at
risk of developing
burnout; randomly
selected from 9
wards (n =260)
Staffmembers;
remaining 19
wards; no
intervention (n =
404)
Not
reported
Combined intervention: a staff
support group and a
participatory approach (n =260)
Job control, social
support,
participation in
decision-making,
quantitative
demands and
patient-related
emotional
demands
6 monthly sessions
of 4 hours each
T1–before the
intervention
T2–6 months later,
directly after the
intervention ended
T3–6 months after
the intervention
ended
In the combined
intervention, EE↓at
both T2 and T3, DP↓
at T3 compared to
the control group
High
Study 4
[33]; Hong
Kong
Construction-related
professionals
engaged in
property
development,
consulting and
contracting
companies;
quasi-experimental
design
Reducing
burnout
complaints;
MBI-GS
(EE, CY,
PE)
Workers at risk of
developing
burnout; all
workers worked in
the same company
(n =55)
None Job-person
(mis)match
Combined intervention; based
on job-redesign addressing
stressors and resources in the
workplace (n =55)
None
A period of one
year. The
frequency of the
interventions
differed according
to the activity
T1–before the
intervention
T2–1 year after the
intervention
T3–none
EE↓, CY↓after the
combined
intervention; PE↔
High
Study 5
[34];
Finland
White-collar
women diagnosed
as having various
job-related
psychological
health problems
(e.g., burnout);
quasi-experimental
design
Reducing
burnout
complaints;
MBI-GS
(EX, CY, PE
scores)
Female
white-collar
workers;
diagnosed by
physicians based
on their medical
report application
(n =20 +32)
Female
white-collar
workers; awaiting
treatment (n =12).
Based on
job-person
(mis)match
Traditional intervention:
primary focus on the individual
but when necessary, also on the
individual-organizational
interface (n =32)
Combined intervention: similar
to the traditional intervention
but based on a participatory
approach (n =21)
Job control, social
support,
participation in
decision-making
One year with two
rehabilitation
periods (12 and 5
days, respectively)
T1–before the
intervention
T2–after the first
part of the
intervention, 4
months after T1
T3–after the
second part of the
intervention, 8
months after T2
In the combined
intervention, EX↓
between T1 and T2
and between T1 and
T3; CY↓between T1
and T2; PE↔
In the traditional
intervention, EX↔,
CY↔, DP↔
In the control group,
CY
↓
between T1 and
T2; CY↔, DP↔
High

Int. J. Environ. Res. Public Health 2020,17, 55 6 of 20
Table 1. Cont.
Author/s,
Country Setting, Design Study Aim,
Outcome/sParticipants Controls Theoretical
Framework Interventions Mediators of
Change Measured Duration
Pre-Test (T1),
Post-Test (T2),
Follow-Up (T3)
Results Risk of
Bias
White-collar workers
Study 6
[35];
Norway
Staffmembers
working with
people with
intellectual
disabilities in two
municipalities; 2
groups,
pre-test/post-test
design
Reducing
burnout
complaints;
MBI-GS
(EX, CY, PE
scores)
Staffworking in
one municipality
at risk of
developing
burnout (n =79)
Staffworking in a
different
municipality; no
intervention (n =
33)
Job-person
mismatch
Combined intervention:
focusing on the individual (e.g.,
exercise in a health club) and
the organization (e.g.,
improving the working
schedule) (n =79)
None
A period of 10
months. The
frequency of the
interventions
differed
depending on the
activity
T1–before the
intervention
T2–after the
intervention, (i.e.,
after 10 months)
T3–none
In the combined
intervention EX↓
after the
intervention, as
compared to the
control group; CY↔,
PE↔
In the control group,
EX↔, CY↔, PE↔
High
Healthcare workers
Study 7
[36]; USA
General surgery
residents working
at the University
of Arizona; one
group,
pre-test/post-test
design
Reducing
burnout
complaints;
MBI-GS
(EX, CY,
PE)
Staffmembers at
risk of developing
burnout; the
intervention was
part of their formal
(on the job)
education (n =49)
None Not
reported
Combined intervention:
multiple activities (e.g.,
mindfulness sessions, team
building) (n =49)
None
A period of one
year. Monthly,
interactive
sessions were
provided
T1–before the
intervention
T2–One year after
the
implementation of
the intervention
T3–none
EE↓after the
combined
intervention; CY↔,
PE↔
High
Study 8
[37];
England
Staffworking in an
in-patient alcohol
ward; one group,
pre-test/post-test
design
Reducing
burnout
complaints;
MBI (EE,
DP, PA)
Staffmembers at
risk of developing
burnout; all staff
were invited to
participate in the
intervention (n =
19)
None
Demand-Control
Support
Job Stress
Model
Combined intervention:
managing stress at the
individual, team and
organizational level and on
understanding the causes and
consequences of aggression (n
=19)
None
Two-day training
with two weeks
between the
training
days
T1–3 months
before the
intervention
T2–1 month after
the intervention
ended
T3–none
PA↑after the
combined
intervention, EE↔,
DP↔
High
Study 9
[38]; USA
Staffrepresenting
15 departments
(e.g., nursing,
pharmacy,
housekeeping);
one group,
retrospective
pre-test/post-test
design
Reducing
burnout
complaints;
MBI-HSS
(EE, CY,
PA)
Staffmembers at
risk of developing
burnout; a
stratified random
sample reflecting
all departments (n
=51)
None Not
reported
Combined intervention: based
on experiential techniques (e.g.,
team building and enhancing
self-esteem) (n =51)
None Three sessions of
three hours each
T1–3 months
before the
intervention
T2–1 month after
the intervention
ended
T3–none
EE↓, PA↑after the
combined
intervention; CY↔
High

Int. J. Environ. Res. Public Health 2020,17, 55 7 of 20
Table 1. Cont.
Author/s,
Country Setting, Design Study Aim,
Outcome/sParticipants Controls Theoretical
Framework Interventions Mediators of
Change Measured Duration
Pre-Test (T1),
Post-Test (T2),
Follow-Up (T3)
Results Risk of
Bias
Self-employed
Study 10
[39];
Netherlands
Self-employed
individuals on sick
leave due to
work-related
psychological
complaints (e.g.,
burnout);
controlled clinical
trial design
Reducing
burnout
complaints,
promoting
RTW;
MBI-NL
(EX, DP, PE
scores),
RTW
(mean
number of
days to
partial and
full return
to work)
Self-employed;
screened by
psychologists (n =
40 +40)
Self-employed;
asked to postpone
their treatment for
four months (n =
42)
Not
reported
Person-directed intervention:
CBT; focused on cognitive
restructuring (n =40)
Combined intervention:
CBT-based stress management
and meetings with labor
experts aimed at changing the
work context (n =40)
None
11 bi-weekly
sessions of
approximately 45
minutes per
session
5 to 6 sessions of
approximately 1
hour, twice per
week
T1-before the
intervention
T2-4 months after
the onset of the
intervention
T3-10 months after
the onset of the
intervention
EE↓, DP↓; PE↔,
regardless of the
intervention
Shorter time to
partial and full RTW
for participants in
the combined
intervention, as
compared to those in
the person-directed
intervention and
control group
Moderate
↑=significant increase; ↔=no significant change; ↓=significant decrease
Abbreviations: CCT =Controlled Clinical Trial; MBI =Maslach Burnout Inventory; MBI–GS =Maslach Burnout Inventory–General Survey; MBI–HSS =Maslach Burnout Inventory–Human
Services Survey; MBI–NL =Maslach Burnout Inventory–Netherlands; RTW =Return to Work; EX =Exhaustion; CY =Cynicism; DP =Depersonalization; PA =Personal Accomplishment;
PE =Professional Efficacy.

Int. J. Environ. Res. Public Health 2020,17, 55 8 of 20
3.1.1. Countries, Settings and Research Designs
The articles were based on studies conducted in eight countries: USA (n =2), Sweden (
n=2
),
the Netherlands (n =2), Norway (
n=1
), Finland (
n=1
), Hong Kong (n =1) and England (
n=1
).
The settings were highly heterogeneous, ranging from self-employed individuals to white-collar
workers and healthcare workers. The research designs also varied, ranging from a controlled clinical
trial to pre-test/post-test designs. This was also the case for the time between pre-tests and follow-up
measurements, which ranged from four months (Study 5) to 30 months (Studies 1 and 2).
3.1.2. Measures of Burnout and RTW
Most of the studies concerned interventions aimed at reducing burnout complaints (Studies 3, 4, 5,
6, 7, 8 and 9), although three aimed to promote full RTW (Studies1, 2 and 10). Multiple versions of the
MBI were used across the studies, including the MBI—General Survey (measuring exhaustion, cynicism
and professional efficacy) and the MBI—Human Survey Index (measuring exhaustion, cynicism and
personal accomplishment). Studies 1, 2 and 10 measured RTW, which was operationalized as the mean
number of days to partial and full RTW (Study 10) and the sick leave percentage (Studies 1 and 2).
3.1.3. Combined Interventions, Theories and Mediators of Change
The combined interventions were all different in terms of content. More specifically, none of the
studies evaluated the same person-directed and organization-directed interventions. The duration
and frequency of the interventions also differed sharply across the studies, depending on the activities
on which the interventions were based. For example, Study 9 was based on three sessions of three
hours each, while Study 3 was based on six monthly sessions of four hours each. Multiple theoretical
frameworks were identified, with most focused on job-person mismatch (Studies 1, 2, 4, 5 and 6).
Study 8 used the Demand-Control-Support Model and Studies 3, 7, 9 and 10 did not report any
theoretical framework.
Abbreviations: CCT =Controlled Clinical Trial; MBI =Maslach Burnout Inventory; MBI–GS =
Maslach Burnout Inventory–General Survey; MBI–HSS =Maslach Burnout Inventory–Human Services
Survey; MBI–NL =Maslach Burnout Inventory–Netherlands; RTW =Return to Work; EX =Exhaustion;
CY =Cynicism; DP =Depersonalization; PA =Personal Accomplishment; PE =Professional Efficacy.
3.2. Effectitivness of the Combined Interventions
3.2.1. Studies 1 and 2
•Effectiveness
A controlled clinical trial design was conducted among Swedish employees on sick leave due to
burnout. The authors conclude that, after 18 months, 89% of the employees in the experimental group
had RTW to a certain extent, whereas only 73% employees in the control group had RTW. The effect of
the combined intervention remained stable after 30 months, where 82.4% of the employees where back
at work, which was still a higher percentage compared to the control group (77.9%).
•Underlying Principles
The combined intervention was based on a convergence-dialogue meeting (CDM), which was
intended to cultivate a dialogue between the employee and the supervisor to identify opportunities in
order to facilitate RTW.
•The combined Intervention
To facilitate RTW, an outline of the employee’s perspective was compiled according to multiple
sources (e.g., questionnaire replies, the course of events leading to burnout, the employee’s own views
of changes required for RTW). Based on this outline, the supervisor was interviewed at the workplace,

Int. J. Environ. Res. Public Health 2020,17, 55 9 of 20
in addition to outlining the perceived causes of the employee’s absenteeism and the changes required
in order to facilitate RTW. In general, the intervention focused on solutions and changes aimed at the
identification of converging perspectives and goals between employees and supervisors.
The CDM started by highlighting the agreements and disagreements between the supervisor and
the employee with regard to the causes of the sick leave and the improvements required in order to
facilitate RTW. Each session lasted for about 1.5 hours, resulting in agreements concerning short term
and long-term goals and solutions. Thereafter, the employees were invited to a seminar, along with
4–6 other employees who had participated in the intervention. The seminar consisted of discussions
and lectures on the topic of work-related (and other) stress. These discussions and lectures were also
arranged separately for the supervisors involved. For the employees, the seminar aimed to help them
reflect on how they could prevent a similar occurrence of sick leave in the future. For the supervisors,
the focus was on how to prevent sick leave related to work stress among their employees.
•Mediators of Change
The expectation that facilitating partial RTW would predict full RTW was not supported by
empirical evidence. The principles underlying the combined intervention (e.g., an actual change in the
work environment) were not evaluated.
3.2.2. Study 3
•Effectiveness
A quasi-experimental study design was employed to investigate Dutch oncology staffwith a
risk of developing burnout. The authors conclude that, compared to the two control wards, the
combined intervention resulted in significantly less exhaustion after both 6 and 12 months and in less
depersonalization after six months.
•Underlying Principles
No specific theoretical framework was reported. Instead, the combined intervention was inspired
by a participatory approach, in which the interventions were context-specific and based on an
accurate assessment of both individual and organizational factors, rather than relying on pre-packaged,
context-independent programs based on a uniform and theory-based approach. The combined
intervention was developed in collaboration with external counselors and it combined a support
group with the participatory approach. Before the intervention, intake interviews were held with
the managers of the ward (e.g., discussing possible intervention effects), in order to enhance their
motivation to implement the interventions.
•The Combined Intervention
The combined intervention consisted of six monthly meetings of three hours each, which were
supervised by both of the team counselors. The first session started with education on job stress
(although no details were provided) and the results concerning the employees’ work situations
(e.g., workload, emotional demands, job control, social support, participation in decision-making), as
measured at T1, were fed back to the employees. During this first meeting, the participants selected
a number of stressors to be addressed (e.g., lack of social support). Each of the remaining meetings
consisted of two parts: education and action. The educational part focused on the emergence and
persistence unwanted behavior (Meeting 2); feedback and communication (Meeting 3); creating a
social support network (Meeting 4); and balancing job-related investments and outcomes (Meeting 5).
The action part focused on enhancing the abilities of the workforce to cope with stressors effectively.
Outcomes of these sessions included restructuring the weekly work meetings in order to allow more
staffparticipation in decision-making.

Int. J. Environ. Res. Public Health 2020,17, 55 10 of 20
•Mediators of Change
The authors conclude that the combined intervention significantly increased participation in
decision-making, which subsequently led to a decrease in exhaustion. Similar results were reported
for social support and job control: increases in both social support and job control were significantly
related to simultaneous reductions in exhaustion and depersonalization. Even though participants in
the combined intervention reported fewer burnout complaints than did those in the control group,
both exhaustion and depersonalization had increased after one year. This result can be explained by
an increase in the perceived workload (although it is not clear what contributed to this increase).
3.2.3. Study 4
•Effectiveness
A quasi-experimental study design was employed to investigate construction-related professionals
engaged in property development, consulting and contracting companies in Hong Kong. One year
after the combined intervention, employees reported significantly fewer feelings of exhaustion and
cynicism than they had before the intervention.
•Underlying Principles
The combined intervention was conducted from the perspective of job-person mismatch, using
job-redesign to reduce mismatches (i.e., stressors) identified through a cross-sectional study measuring
job-related variables among employees (i.e., working hours, quantitative workload, role conflict,
control over work pace, satisfaction with supervisor).
•The combined Intervention
The person-directed interventions included in-house training courses to enhance the
ability of employees to cope actively with stressors (e.g., improving time management skills).
The organization-directed intervention included a change in working hours (one additional day
offevery two weeks), which was expected to reduce the incidence of long working hours. The authors
did not describe how the combined intervention was implemented or by whom.
•Mediators of Change
The mediators of change (possible stressors) were measured only in order to inform the
development of the combined intervention. They were neither tested nor evaluated with regard to the
change in burnout complaints reported by employees.
3.2.4. Study 5
•Effectiveness
A quasi-experimental study design was employed in Finland to investigate white-collar workers
(e.g., stafffrom social services and health departments) who were currently on sick leave due to burnout.
The authors conclude that the combined intervention produced a significant reduction in feelings of
exhaustion after both four and eight months and in cynicism after four months. Although no changes
occurred in the person-directed intervention (Control group 1), cynicism decreased significantly in the
no-treatment group (Control group 2).
•Underlying Principles
The theoretical framework was based on job-person mismatch. During the intervention process,
participants collaborated with representatives from their workplaces and with the rehabilitation staff
to reduce mismatches and improve their working environment.

Int. J. Environ. Res. Public Health 2020,17, 55 11 of 20
•The combined Intervention
The combined intervention entailed one year, with two rehabilitation periods (12 and 5
days, respectively). Person-directed interventions involved activities including physiological and
occupational therapy, which was intended to enhance the abilities of employees to cope with
stress and to promote awareness of stress-evoking situations and how people react to stress.
The organization-directed intervention included a link to the workplaces of the rehabilitation
clients. More specifically, the employee’s supervisor, a member of the occupational health and safety
organization, plus a representative from occupational health care were invited to the rehabilitation center
for one day during each rehabilitation period. The inclusion of representatives from the workplace in
the rehabilitation process was intended to involve the employer and to create an obligation for the
employer to implement the actions agreed upon in order to remedy defects in the workplace.
In the first rehabilitation period, the workplace-related representatives collaborated with
the participants and the rehabilitation team to identify ways to improve job conditions for the
participants, based on a memorandum that the participants had prepared in advance of this meeting.
The memorandum included issues that the participants considered essential to enhancing personal
job-related wellbeing and health. In the second rehabilitation period, the same individuals met at the
rehabilitation center again and discussed whether the agreed upon remedies had been implemented
and whether any problems had been related to them. This was expected to reduce burnout complaints.
The purpose of these two meetings was to increase the control that employees had over issues relating
to their jobs and to improve their job conditions.
•Mediators of Change
The intervention assumed that a change in burnout complaints (feelings of exhaustion) would
be mediated by a decrease in time pressure at work. The changes in two other burnout symptoms
(cynicism and reduced professional efficacy) were expected to be mediated, particularly by an increase
in perceived job control. Theoretically, the change in these symptoms was also expected to be mediated
by improvements in the workplace climate and satisfaction with the supervisor. The results support that
the combined intervention significantly increased employee job control and that this increase resulted
in lower levels of exhaustion and cynicism over the 12-month rehabilitation process. Workplace climate
had only a minimal (non-significant) mediating influence on exhaustion and no effect on cynicism.
3.2.5. Study 6
•Effectiveness
A two-group pre-test/post-test design was employed to investigate community healthcare staff
caring for people with disabilities in two municipalities in Norway. In that country, responsibility
for people with disabilities was transferred from the county to municipal level in 1991. The authors
conclude that the combined intervention significantly reduced feelings of exhaustion after 10 months,
whereas no changes in burnout complaints were observed in the control group.
•Underlying Principles
The combined intervention was conducted from the perspective of job-person mismatch. Rather
than trying to eliminate all stressors (i.e., “mismatches”), the intervention assumed that focusing on
mismatches that, if resolved, could potentially generate and allow the implementation of concrete
solutions that would be most effective in reducing burnout complaints. It was also argued that the
involvement of multiple stakeholders (i.e., the manager, two senior leaders, two employees, researchers
and the human resource manager—the working group) and the support of the supervisor were critical
success factors for any intervention in the workplace.

Int. J. Environ. Res. Public Health 2020,17, 55 12 of 20
•The Combined Intervention
Employees discussed stressors and potential solutions and this resulted in priority lists concerning
actions aimed at improving working conditions. Based on this list, the working group agreed upon
a set of intervention strategies to be implemented at both the individual and organizational levels.
For example, the person-directed interventions entailed a voluntary exercise program, in which
the study participants were expected to exercise to improve fitness. Three organization-directed
interventions were implemented: the introduction of performance appraisals, the re-organization of
working schedules to promote larger positions (i.e., more working hours each week) and stability
among the staffand the improvement of routines for new employees (e.g., better on the job training).
Specific goals were formulated for each of the interventions. For example, the purpose of the exercise
program was to improve the health and wellbeing of employees, thereby buffering the adverse effects of
burnout. The organization-directed interventions were intended to provide feedback to both employees
and supervisors, in addition to promoting job security, which is assumed to reduce burnout complaints.
•Mediators of Change
Neither the underlying principles (e.g., enabling employees to participate in decision-making) nor
the goals of the intervention (e.g., promoting job security) were evaluated with regard to the change in
burnout complaints.
3.2.6. Study 7
•Effectiveness
A one group pre-test/post-test design was employed to investigate general surgery residents
working at the University of Arizona (USA). The authors conclude that the combined intervention
significantly reduced feelings of exhaustion after 12 months.
•Underlying Principles
Although the combined intervention was not based on any specific theoretical framework,
multiple assumptions were described. The intervention assumed that enhancing the self-awareness
and emotional intelligence of employees would teach them to respond effectively, rather than reacting
to the stress inherent in their lives and environments, thereby reducing burnout complaints.
•The Combined Intervention
The person-directed interventions entailed activities aimed at improving the work-life
balance of employees and promoting healthy diet and exercise (none of which were explained).
One organization-directed intervention was implemented, which entailed a range of team building
activities (none of which were explained). The overall aim of the person-directed and organization-directed
activities was to improve the mental, physical and social health and wellbeing of employees and this was
assumed to reduce burnout complaints. The employees were asked to evaluate the program based on
certain predefined indicators (which were not based on the underlying principles). The results indicated
that, in general, the employees perceived the program as positive. For example, 96% strongly agreed that
the program created cohesiveness and a sense of community among the workforce.
•Mediators of Change
None of the underlying principles (e.g., enhancing employee self-awareness) was evaluated with
regard to the change in burnout complaints, nor were the goals of the intervention (e.g., improving
their health) or the predefined outcomes (e.g., promoting a sense of community).

Int. J. Environ. Res. Public Health 2020,17, 55 13 of 20
3.2.7. Study 8
•Effectiveness
A one group pre-test/post-test design was employed to investigate staffworking in an alcohol
ward in England. The authors conclude that the combined intervention led to a significant increase in
personal accomplishment after one month.
•Underlying Principles
The combined intervention was based on the Demand-Control Support Job Stress Model, with
an emphasis on enhancing social support among the workforce in order to improve their ability to
cope with stress. Social support was assumed to act as a buffer against the possible adverse health
effects of excessive psychological demands or stressors. Employees were involved (although it was not
clear how) in identifying stressors, which were then used as a foundation for developing the combined
intervention (although it was not clear how). The stressors identified by the staffincluded group work,
dealing with complex clients and client aggression. The practice of working with whole teams was
assumed to have a positive effect on the entire team culture, in addition to introducing bottom-up
working practices aimed at reducing stress (none of these aspects were explained).
•The Combined Intervention
Although the combined intervention focused on working with the whole team, elements in
the training also addressed both individual and organizational issues. In practice, the combined
intervention consisted of two days of training, with two weeks between the training days. The focus
of the first day of the training was on “Managing stress at the individual, team and organizational
level,” and the second day was devoted to understanding “the causes and consequences of aggression.”
One aspect of the training consisted of identifying the common antecedents of episodes of violence
from a comprehensive perspective, including client-related, environmental, team and organizational
factors, although none of these factors were explained. The team members then received assistance in
undertaking a comprehensive risk assessment (although it was not clear what was being assessed) and
strategies for implementing interventions to address the risks (these were also not explained).
•Mediators of Change
None of the underlying principles (e.g., the role of social support or employee participation) was
evaluated with regard to the change in burnout complaints.
3.2.8. Study 9
•Effectiveness
A one group retrospective pre-test/post-test design was employed in the USA to investigate staff
representing multiple healthcare professions (e.g., nursing, pharmacy, housekeeping). The authors
conclude that the combined intervention resulted in a significant decrease in exhaustion and a significant
increase in professional accomplishment.
•Underlying Principles
No specific theoretical framework was mentioned, nor was any rationale underlying the
combined intervention.
•The combined Intervention
The combined intervention consisted of three sessions (workshops) of three hours each, focusing
on team building (positive human connections), communication skills, building self-esteem and stress
management. Building self-esteem and stress management are person-directed interventions, while
team building is an organization-directed intervention. For example, the team building exercises

Int. J. Environ. Res. Public Health 2020,17, 55 14 of 20
included the construction of straw towers in small groups, a values-clarification exercise and the
preparation and performance of a musical number in which each person acted as an instrument.
Examples of stress management techniques included breathing exercises, guided visualization and a
shoulder massage with a co-worker.
•Mediators of Change
Some mediators of change were subjected to qualitative exploration and quantitative description,
expressing how often a particular theme was mentioned. For example, employees reported that the
combined intervention resulted in better communication with co-workers (24%), a better working
atmosphere (53%) and increased self-esteem (18%). However, none of these mediators was evaluated
with regard to changes in burnout complaints reported by the employees.
3.2.9. Study 10
•Effectiveness
A controlled clinical trial design was employed in the Netherlands to investigate self-employed
individuals (i.e., business owners) who were currently on sick leave due to burnout. Participants in the
combined intervention partially returned to work 17 and 30 days earlier than did their counterparts in
the person-directed intervention and the control group. For full RTW, this difference was approximately
200 days. All of these differences were statistically significant. When controlling for gender, age,
education and number of employees, however, the effect of the combined intervention was no longer
significant for partial RTW, although it did persist for full RTW.
•Underlying Principles
No specific theoretical framework was reported. The intervention had a strong focus on graded
activity. More specifically, it involved a process of gradual exposure, in which the participant’s
activation was increased through small steps. Six labor experts participated in the study. All of
these experts received training in a brief stress management intervention based on cognitive based
therapy. The stress management part of the intervention consisted of psycho-education on work
stress, the registration of symptoms and situations, relaxation, self-help books on rational emotive
behavior therapy and assignments involving writing and time management. In addition, the labor
experts advised the participants with regard to work processes and provided suggestions for reducing
workload and job demands while increasing decision latitude. These components were intended to
foster at least partial work resumption.
•The combined Intervention
The combined intervention consisted of five to six sessions of approximately one hour, twice a
week. A person-directed (based on Cognitive Based Therapy) intervention was combined with an
organization-directed intervention focusing on reducing stressors at work (e.g., reducing workload).
•Mediators of Change
None of the underlying assumptions (e.g., increasing the employees’ decision latitude) was either
empirically tested or evaluated with regard to change in RTW.
4. Discussion
4.1. Summary of Findings
This study consisted of a systematic assessment of combined interventions with regard to their
effectiveness, theoretical assumptions and mediators of change. Of the 4110 abstracts obtained in a
literature search (published before September 29, 2019), 10 studies (reporting the effects of 9 combined
interventions) fulfilled the predefined inclusion criteria. It should be emphasized that all 9 combined

Int. J. Environ. Res. Public Health 2020,17, 55 15 of 20
interventions were effective (at least to a certain extent) in facilitating rehabilitation. With regard to the
reduction of burnout complaints, the combined interventions led to greater improvement in exhaustion
and cynicism (or depersonalization), in both the short term (after 4 months) and the long-term (after 12
years), than in professional efficacy (or personal accomplishment). In terms of promoting RTW, the
combined interventions showed long-term effects on the promotion of full RTW.
Surprisingly, very few of the studies devoted much attention to evaluating potential mediators of
change that could properly explain their results and clarify why and how the combined interventions
did or did not work. Moreover, only three studies included any empirical (or other) test for mediators
of change in order to explain how the combined intervention worked. These studies suggest that
enhancing employees’ sense of job control (i.e., decision authority over their jobs), social support
(e.g., positive feedback from supervisors), participation in decision-making (e.g., selecting stressors and
mismatches) and reducing workload can facilitate rehabilitation among employees who are currently
either working or absent on sick leave. The results of the three studies involving empirical evaluation
of factors mediating change are supported by the fact that all of the studies share specific theoretical (or
other) assumptions concerning the importance of involving employees in decision-making, enhancing
their job control and social support and reducing stressors (e.g., high workload).
4.2. Scientific Implications
To our knowledge, this systematic review is the first to focus on combined interventions. Although
previous reviews have included combined interventions [
40
,
41
], the methods underlying their reviews
have exhibited many limitations (e.g., using only two or three electronic databases; limiting the
search period from 1995 to 2005; and not assessing study quality). The present review addresses
these limitations by using seven relevant databases, expanding the search to include all studies since
the emergence of the burnout concept (>1970), assessing the risk of bias and including only studies
using the MBI or RTW to ensure comparability with regard to the outcome of interest. In addition,
two of the “combined interventions” addressed in the review by Awa, Plaumann and Walter [
41
]
were organization-directed (professional supervision [
42
] and work-shift evaluations [
43
]) rather than
combined interventions and they were thus not included in the present review. Additionally, none of
these reviews attempted to identify and describe the mediators of change to explain how combined
interventions worked, which was an additional aim of this study. Hence, this systematic review
strongly builds upon and complements research on how to effectively facilitate rehabilitation, that is,
reducing burnout complaints and promoting a full RTW.
Indicated by the results of this review, the combined interventions did not lead to much
improvement in two specific dimensions of burnout: personal accomplishment and professional
efficacy. There has long been uncertainty with regard to including these two aspects as dimensions
of burnout, as they could be interpreted as either a cause or consequence of burnout [
44
]. On the
one hand, exhaustion might indicate a lack of personal accomplishment (or professional efficacy).
On the other hand, a lack of efficacy (or accomplishment) could result from poor performance due to
exhaustion [
45
]. It would therefore be interesting for future studies to provide further clarification
on the role of personal accomplishment or professional efficacy as either a cause or consequence
of burnout.
With regards to the mediators of change (whether measured directly or merely described), the
results are very much in line with central theories on burnout. For example, studies inspired by
the Job Demands-Resources Model consistently show that job resources (e.g., job control, social
support) are not only negatively related to burnout but also associated with multiple positive outcomes,
including enhanced job satisfaction and organizational commitment [
16
,
46
]. In a similar vein, a recent
cross-sectional study demonstrates that job control and social support are strongly correlated with the
ability of employees to participate and be productive in a sustainable and meaningful way [
47
]. At the
same time, the results of this review indicate that reducing workload (i.e., a job demand) can also
influence burnout complaints, thus suggesting that interventions should aim to build job resources

Int. J. Environ. Res. Public Health 2020,17, 55 16 of 20
while addressing stressors. Future intervention studies should continue to clarify the role of job
resources and stressors with respect to reducing burnout complaints.
The studies evaluated in this review also reflect the expectation that facilitating partial RTW
can predict full RTW. These expectations were not supported by empirical evidence. One possible
explanation could be that employees who failed to attain a sustainable RTW toward the end of the
follow-up period had more severe burnout complaints and therefore needed a longer period of partial
RTW. However, study 10 showed that participants in the combined intervention faster RTW than
participants in the control group while their burnout complaints did not improve. This indicates that
reducing burnout complaints and facilitating a sustainable RTW cannot be seen as a single phenomenon,
which is in line with previous studies [48].
This review assessed studies involving employees from a variety of professions (e.g., healthcare,
construction work) and therefore a variety of working contexts. Although the results suggest that
combined interventions have beneficial effects on reducing burnout complaints and promoting full
RTW for multiple professions, they do not necessarily mean that a given intervention will produce
the same effects in a different working context. Similarly, this review also includes a study involving
self-employed people, who were thus also business owners. Self-employed individuals differ from
employees in several aspects. For example, studies have demonstrated that self-employed people
are characterized by strong levels of job control, job insecurity, decision latitude, work demands,
intrinsic motivation to work and low levels of social support in their work [
49
]. Although the effect
of the combined intervention aimed at facilitating full RTW among self-employed people (Study 10)
was promising, it does not mean that employees (who are not self-employed) on sick leave would
automatically benefit from the same combined intervention.
4.3. Practical Implications
The results of this review suggest that combined rehabilitation interventions are effective (at
least to a certain extent) in facilitating rehabilitation among employees who are currently working or
absent on sick leave. In general, all of the studies share common theoretical (or other) assumptions
concerning the importance of involving employees in decision-making and enhancing their sense
of job control and social support. These assumptions are further supported by the results of three
studies that involved the empirical evaluation of such mediators of change with regard to burnout
complaints. From the perspective of promoting workplace health, it could be worthwhile to build
such resources while addressing job demands (e.g., excessive workload) in order to alleviate burnout
complaints. Reflecting on the mediators of change—particularly participation in decision-making and
social support—the results suggest that simply paying attention to employees (i.e., listening to them
and addressing their needs) is important to the facilitation of rehabilitation. This knowledge could be
applied directly in practice.
4.4. Limitations
Although all combined interventions were effective in facilitating rehabilitation, nine studies had
a high risk of bias and one study was assessed as having a moderate risk of bias. This substantial risk of
bias has a direct impact on the robustness of the findings of this review. More specifically, it is unclear
whether the effects presented in a given study were due to the combined intervention or to the study
design as such. The results of this review should therefore be interpreted with caution. It should be
emphasized that the risk of bias assessment does not judge the “quality of the included studies,” rather,
it aims to identify possible bias based on the context in which the studies were conducted, thereby
assessing the “quality of the evidence.” Future studies are challenged to enhance the robustness of the
study designs, while taking into account the complexity of the combined interventions, which is a
common challenge in (workplace) health promotion research [50].
It should also be noted that the interventions addressed in this review were only general described
in terms of content and specific theoretical (or other) assumptions. Future studies should therefore

Int. J. Environ. Res. Public Health 2020,17, 55 17 of 20
provide more in-depth information on the theories or assumptions on which the interventions are built,
as well as on how (and by whom) the interventions were developed, implemented and evaluated,
in addition to providing clear definitions for mediators of change. In addition to the quantitative
measurement and assessment of mediators of change with regard to their effects on the outcome
variables, it would be interesting to evaluate such mediators in qualitative terms. For example, the
quantitative measurement and analysis of participation in decision-making does not say anything
about how, why and under which circumstances employees were involved. In addition to evaluating
the effect of combined interventions on rehabilitation, therefore, research on burnout could benefit
from qualitative process evaluation, which could provide further information on why a combined
intervention did or did not work. Finally, the duration and intensity of the combined interventions
differed substantially, ranging from three sessions of three hours each to six monthly sessions of four
hours each. It is therefore impossible to determine exactly when a given intervention will work.
This review is subject to several limitations. Publication bias is likely to have influenced our
results. Given that studies resulting in negative or no effects are often not published, we were obviously
unable to include them in our review. Similarly, because our review includes only articles published in
English, it overlooks any relevant studies published in other languages. Also, although the MBI is used
as the golden stand for measuring burnout, it is also known to have multiple conceptual, technical and
practical issues [
45
]. For example, it does not measure all burnout symptoms (e.g., depressive feelings
and psychosomatic tension complaints), which are often the first reasons why employees seek help.
Recently, a new instrument—the Burnout Assessment Tool (BAT)—has been developed to address
the issues associated with the MBI [
45
]. For this reason, we also attempted to retrieve studies that
evaluated combined interventions using the BAT by conducting an additional search on October 10,
2019. Unfortunately, this search did not reveal any additional studies. Finally, though the tool used
for the risk of bias assessment has been evaluated as strong [
28
,
29
], we did not systematically test the
instrument for failure in similar studies and we do not have evidence to state how and where the tool
breaks down; that is, we cannot be certain on its validity and reliability.
5. Conclusions
All nine combined (both person-directed and organization-directed) interventions showed a
positive effect on facilitating rehabilitation among employees who are currently working or on sick leave
due to burnout. Although the risk of bias of the included studies is considerably high, the results show
that the mediators of change addressed—job control, social support, participation in decision-making
and workload—contribute to employees’ rehabilitation. Further studies are challenged to enhance
the robustness of the study designs while incorporating the complexity of combined interventions,
preferably by adding qualitative process evaluations besides measuring effects. In addition, research
on burnout interventions could benefit from qualitative process evaluations aimed at unravelling
how and why interventions do or do not work. Finally, with caution, workplace health promotion
practitioners are encouraged to facilitate rehabilitation by building job resources while eliminating
stressors in the workplace.
Supplementary Materials:
The following are available online at http://www.mdpi.com/1660-4601/17/1/55/s1,
Table S1: The PRISMA Checklist; Table S2: The Assessment of Bias Scores of the Included Studies.
Author Contributions:
Conceptualization, all authors; Methodology, all authors; Validation, all authors; Formal
analysis, R.P.; Writing—original draft preparation, R.P.; Writing—review and editing, all authors; Visualization,
R.P.; Supervision, L.V., E.J.V. and M.A.K.; Project administration, R.P. All authors have read and agreed to the
published version of the manuscript.
Funding:
This research and APC were funded by the internal funds of the Health and Society and by the Rural
Sociology chair groups at Wageningen University & Research in the Netherlands.
Acknowledgments:
The authors are grateful to Linda Karr for English language editing. This study is part of an
ongoing research project on understanding the mechanisms underlying the successful rehabilitation of (young)
employees with burnout. Finally, we appreciate Peter Tamas’s advice on the overall design of our review.

Int. J. Environ. Res. Public Health 2020,17, 55 18 of 20
Conflicts of Interest: The authors declare no conflict of interest.
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