Employee Burnout: Prevention, Recovery, and Outdoor Therapy A Salutogenic Perspective

Background Burnout is a major societal issue that adversely affects employees' health and performance, which over time results in high sick leave costs for organizations. Contradictory to the knowledge of the predictors, correlates, and consequences of burnout, still very little is known about how employees successfully recover after burning out. Moreover, theoretically-grounded and evidence-based interventions for employees with burnout are rarely designed and studied. Simultaneously, the growing recognition of the importance of nature for our health and well-being has led to numerous scientific studies that provide evidence on a wide range of outcomes, including improvements in physical health, self-reported health, subjective well-being, and mental well-being. These health-promoting effects of nature are increasingly used to prevent and treat mental health problems, such as providing therapies outdoors in nature for employees with burnout. Although evidence of the effectiveness of outdoor therapy is slowly accumulating, theories explaining whether and how outdoor therapy may facilitate the burnout recovery process are often lacking. Study Aim and Research Questions The central aim of my thesis is to examine the value of outdoor therapy for the recovery process of employees with burnout. Given the salutogenic perspective of this thesis, I examined the mechanisms protecting against burnout and underlying the burnout recovery process (Research Phase 1; Research Questions 1-3) and whether and how outdoor therapy supports the burnout recovery process (Research Phase 2; Research Questions 4-5). Accordingly, I focus on the following research questions: Burnout Prevention  Research question 1: Which mechanisms in employees' non-working time protect employees against the development of burnout? Burnout Recovery  Research question 2a: How effective are existing combined (both person- and organization-directed) burnout interventions?  Research question 2b: Which mechanisms influence the effectiveness of existing combined (both person- and organization-directed) burnout interventions?  Research question 3: Which mechanisms explain a successful recovery after burnout? The Value of Outdoor Therapy for Employee Burnout  Research question 4: How and to what extent does outdoor therapy builds on the mechanisms underlying successful recovery after burnout?  Research question 5a: What is the perceived impact of outdoor therapy on the recovery process of employees with burnout?  Research question 5b: Which mechanisms explain the perceived impact of outdoor therapy on the recovery process of employees with burnout? Methods In this thesis, I adopted a mixed-methods design, with one longitudinal quantitative study, one systematic review, two qualitative studies, and one retrospective (both quantitative and qualitative) study, resulting in a rich understanding of burnout prevention, burnout recovery, and outdoor therapy for employee burnout. More precisely, I used multiple data collection methods to extract relevant data from various sources, including longitudinal questionnaires (RQ 1), a systematic literature study (RQ 2), in-depth interviews (RQ 3), semi-structured interviews, and content analysis (RQ 4), and a retrospective questionnaire and interviews (RQ 5). By employing mixed methods, I was able to assess the relation between outdoor therapy and the burnout recovery process quantitatively (focusing on outcomes) and qualitatively (focusing on which mechanisms explain this relation). I first used questionnaires among the working population and a systematic literature search, and in-depth interviews focusing on burned-out employees. This allowed me to inductively explore the mechanisms underlying burnout prevention and burnout recovery in general (Chapters 4-6), followed by deductively investigating the perceived impact and underlying mechanisms of outdoor therapy among former clients with burnout (Chapters 7 and 8) Results In Chapter 4, I present the findings of the longitudinal study focusing on the role of off-job crafting (OJC) for burnout prevention during the COVID-19 crisis, thereby enhancing insights into the mechanisms that protect against burnout (RQ 1). The study was based on a longitudinal research design, comprising one wave collected before the onset of the pandemic in March 2019 and one wave collected during the first lockdown of the crisis in April 2020 (total paired sample: N = 658). We showed that all six OJC dimensions (i.e., Detachment, Relaxation, Autonomy, Mastery, Meaning, Affiliation) and burnout correlated negatively cross-sectionally and longitudinally. Furthermore, employees who are able to "switch off" from their work-related thoughts (OJC for Detachment) and experience being closely related to others (OJC for Affiliation) before the crisis reported reductions in burnout during the crisis. In Chapter 5, I show the results from the systematic literature review, first focusing on the observed effects of nine included combined (both person- and organization-directed) interventions (RQ 2a). I found that the combined interventions led to greater improvement in exhaustion and cynicism in both the short term (after 4 months) and the long term (after 12 years) than in professional efficacy. In terms of promoting a return to work (RTW), the combined interventions showed long-term effects on the promotion of full RTW. I also found that a full or partial RTW does not mean that employees do not experience burnout complaints anymore. Overall, combined interventions seem more effective in reducing burnout complaints and supporting the RTW process than only using person- or organization-directed interventions. Concerning the mechanisms underlying the effectiveness of these interventions (RQ 2b), I found 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 the RTW process and reduce burnout complaints. However, the risk of bias in the included studies was considerably high, so the results of these studies have to be treated with caution. In Chapter 6, focusing on nine employees who have recovered from their burnout, I inductively found that the recovery process comprises four phases (RQ 3). For each recovery phase, various Generalized Resistance Resources (GRRs) and Specific Resistance Resources (SRRs) are addressed: 1. Facing the Crisis (GRR: accepting the situation, SRR: label being sick, GRR: resting, SRR: financial security) 2. Addressing Root Causes (GRR: daily structure, GRR: physical activity, GRR: Nature, SRR: therapies/professionals, GRR: connectedness) 3. Seizing and Realizing the Opportunity (GRR: approval, GRR: reflecting, GRR: courage, SRR: openness) 4. Staying at Work: (SRR: meaningfulness, GRR: awareness, GRR: confidence) Finally, essential overarching GRRs facilitating successful recovery after burnout included receiving social support from family, friends, and colleagues, as well as having a feeling of control over the recovery process. In Chapter 7, I developed an intervention and evaluation model of outdoor therapy for employee burnout, thereby showing how outdoor therapy builds on the mechanisms underlying the burnout recovery process (RQ4). For doing so, I used qualitative data collected through semi-structured interviews with outdoor psychologists and former clients, a content analysis of the intervention protocol, and reflective meetings with the intervention developers and health promotion experts. I identified six key outdoor intervention elements: 1) being more active in nature (physical activity); 2) doing mindfulness and meditation exercises in nature (reconnecting body and mind); 3) using natural elements as a mirror for reflection (nature metaphors); 4) using nature to support the relationship between client and therapist (creating relationships); 5) having the client interact with nature (observing nature interactions); and 6) using natural elements for specific exercises (experiential learning). I further showed that the implementation of these elements may facilitate the recovery process after burnout in which proximal (e.g., feeling at ease), intermediate (e.g., feeling of control), and distal outcomes (e.g., a stable RTW) emerge. This implementation process depends on the context of the therapist (e.g., number of clients per day), therapy (e.g., privacy issues), and the clients (e.g., affinity to nature). In Chapter 8, I retrospectively focused on the perceived impact of outdoor therapy on the burnout recovery process among six former clients (RQ 5a). I found that all participants perceived outdoor therapy as very positive for their burnout recovery process in general. Concerning the perceived impact of outdoor therapy on the proximate outcomes, I found that all participants expressed having perceived a high impact on all of these outcomes, resulting in feeling relaxed and physically well, in addition to coming close to their own feelings. With regards to the perceived impact of outdoor therapy on the intermediate and distal outcomes, four participants scored high or very high, indicating that outdoor therapy had helped them to feel healthy and have fewer burnout complaints. However, two participants indicated that outdoor therapy had a low impact on various intermediate and distal outcomes, such as having a feeling of control over the recovery process, suggesting that outdoor therapy did not play a role in those outcomes. With regards to the mechanisms explaining the perceived impact of outdoor therapy (RQ 5b), my findings suggest that some interventions elements (i.e., physical activity, creating relationships, observing nature interactions) are yielding a bigger perceived impact than others (i.e., reconnecting body and mind, nature metaphors, experiential learning) – the latter depending on preferences for certain exercises and whether the therapists apply all intervention elements. Conclusions and Recommendations My thesis complements the existing body of knowledge concerning 1) burnout prevention, 2) burnout recovery, and 3) the value of outdoor therapy for employee burnout. First, enabling employees to switch off from their work-related thoughts and tasks, in addition to being closely and emotionally connected to others in their non-working time, are promising buffering mechanisms to prevent severe burnout complaints. Second, when employees do develop burnout, the recovery process entails four phases, all addressing various GRRs/SRRs – strongly suggesting that pathways and meaning of recovery differ among employees. Most importantly, when employees experience a feeling of control over their recovery process and receive support from friends, family, professionals, employers, and occupational doctors, they are able to return to work in a stable and meaningful way. Third, outdoor therapy comprises six promising intervention elements that support – to a certain extent – the burnout recovery process. Likely dependent on the context of the clients, therapy, and therapist, some intervention elements (i.e., physical activity, creating relationships, observing nature interactions) yield a larger perceived impact on the burnout recovery process than others (i.e., reconnecting body and mind, nature metaphors, experiential learning). Besides outdoor therapy, interventions in the workplace to strengthen GRRs – autonomy, social support, participation – while reducing stressors are crucial too for the recovery process. Recommendations for future studies are to build on my context-sensitive evaluation model to longitudinally examine the effects and mechanisms of outdoor therapy for employees with burnout, preferably employing both quantitative and qualitative methods. Additionally, since the outdoors can potentially be either a health-promoting or a resources-depleting setting for outdoor therapists, I would find it worthwhile to study whether working outdoors is indeed health-promoting for therapists. Finally, research should focus on how to increase the use of outdoor therapy in mainstream mental healthcare settings and how to tackle the structural causes of burnout. Recommendations for practice are to combine outdoor therapy with interventions in the workplace by involving (if possible) the employer and occupational doctor in the recovery process. Finally, since the recovery process and meaning of recovery seem to differ among clients, it is important to tailor interventions to the specific recovery goals and needs of clients and not only focus on symptom reduction and the RTW as primary outcomes.