JAN ORIGINAL RESEARCH

Burnout: co-workers’ perceptions of signs preceding workmates’

burnout
Eva Ericson-Lidman & Gunilla Strandberg

Accepted for publication 18 May 2007

Correspondence to: E. Ericson-Lidman: E R I C S O N -L I D M A N E . & S T R A N D B E R G G . ( 2 0 0 7 ) Burnout: co-workers’ per-

e-mail: eva.ericson-lidman@nurs.umu.se
Eva Ericson-Lidman RNT
Postgraduate Student
Department of Nursing, Umeå University,
Umeå, Sweden
Gunilla Strandberg PhD RNT
Assistant Professor
Department of Nursing, Umeå University,
Umeå, Sweden
ceptions of signs preceding workmates’ burnout. Journal of Advanced Nursing
60(2), 199–208
doi: 10.1111/j.1365-2648.2007.04399.x
Abstract
Title. Burnout: co-workers’ perceptions of signs preceding workmates’ burnout
Aim. This paper is a report of a study to describe co-workers’ perceptions of signs
preceding workmates’ burnout.
Background. Burnout engenders emotional and economic suffering, both individual
and societal. It is therefore important to learn to recognize early signs to prevent
burnout and co-workers, who have opportunities to recognize such signs, are
valuable resources in this context.
Method. Fifteen interviews were conducted with nursing and medical staff in
Sweden who had worked with a person who developed burnout. The interviews
took place in 2004 and were analysed using a thematic content analysis. The
narratives were obtained when co-workers already knew that their workmates
were on sick leave because of burnout or had left their employment after sick
leave because of burnout.
Findings. The findings show that co-workers retrospectively recalled a multiplicity
of signs. They perceived that the people concerned were struggling to manage
alone, showing self-sacrifice, struggling to achieve unattainable goals, becoming
distanced and isolated, and showing signs of falling apart.
Conclusions. Some of the signs preceding workmates’ burnout may be difficult to
interpret as signs of burnout, because they may be regarded as qualities which are
to some extent encouraged in the prevailing culture. The findings provide a
complex picture of these signs that will hopefully increase our awareness of and
ability to recognize such signs to facilitate the possibilities of our helping in time.
The sub-themes and themes in the present study may also serve as a basis for
supervisors involved in supporting clinical staff.

Keywords: burnout, co-worker, interviews, medical staff, nursing, perceptions,

signs, thematic content analysis

conscience and burnout (Lützén et al. 2006, Glasberg et al.

Introduction
2007, Ericson-Lidman et al. 2007). In the project, burnout is
This study is part of an ongoing project, the ‘Stress of studied from various perspectives, including personal experi-
Conscience Study’, about the connection between stress of ence of becoming and being burnout and the perspectives of

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 199
E. Ericson-Lidman and G. Strandberg
others who have had close contact with those suffering
from burnout, such as co-workers and healthcare managers.
According to the National Board of Health and Welfare
(NBHW 2003), the work-related mental ill health is a
growing problem both in Sweden and the rest of the western
world. The dramatic increase in the number of people on
sick leave since 1997 can be partially explained by mental ill
health, including burnout. A longitudinal study, extending
over 8 years, indicates the chronic nature of the condition
(Toppinen-Tanner et al. 2002) and underlines why the
emotional and economic costs of burnout are too high to
ignore (Maslach & Leiter 1997). The consequences of
burnout affect not only the person with symptoms, but also
patients and co-workers; burnout threatens quality of care
and patient safety (Michie & Williams 2003, Laschinger &
Leiter 2006), and studies have provided evidence of burnout
contagion in the workplace (Bakker et al. 2001, 2005). It is
of great importance when encountering people at risk of
developing burnout to recognize the early signs to prevent
harmful effects (Ekstedt & Fagerberg 2005). By exploring
co-workers’ perceptions of signs preceding workmates’
burnout, we hope to contribute to increased awareness
and ability to recognize signs so that help can be given in
time.
Background
The concept of burnout has different meanings in the
scientific world. In Sweden, the use of the term ‘burnout’
has been criticized because it has associations with irrevoca-
ble damage and is not a medical term. A more accurate term
might be ‘exhaustion syndrome’. The concept of burnout and
exhaustion syndrome may be differentiated; burnout is
characterized as a crisis reaction to work and exhaustion
syndrome is characterized by clinical symptoms and mal-
function (NBHW 2003). Åsberg et al. (2005) emphasize that
burnout/exhaustion syndrome is not only a work-related
issue, but can also relate to issues such as unemployment or
sickness in the family. The NHBW (2005) has recently added
exhaustion syndrome as a supplementary diagnosis to the
Swedish version of classification systems of diseases and
health problems. Although we are aware of the different
meanings, we use the term ‘burnout’ here as it is most
commonly used in the literature.
The most commonly-used definition of burnout includes
exhaustion, cynicism and ineffectiveness (Maslach et al.
2001). People whose occupation involves a lot of contact
with, and responsibility for, other people (NBHW 2003), and
those working in settings which are inconsistent with their
character (Maslach & Leiter 1997) are particularly at risk.
200  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Explanations of burnout are related to organizational factors
(NBHW 2003), deterioration in relations with co-workers
(Buunk & Schaufeli 1993, Eriksson et al. 2003), and
personality characteristics (Beer & Beer 1992, Schmitz
et al. 2000). Research indicates that strain in daily life can
contribute to or aggravate burnout (Etizon 1984), and to the
understanding that a person’s whole life is involved (Ekstedt
& Fagerberg 2005).
To prevent burnout, it is important to identify the first
signs. Co-workers may assist the person become aware of
what is happening and then help to do something about it
(Maslach 2003). Ideally, development of a continuous,
comprehensive, integrated programme on burnout preven-
tion is needed, which should include courses on assessment,
education, supportive networks, skills training, interactive
managerial leadership for specific needs and an open channel
of communication in the healthcare system (Cheng 2005).
There is no consensus about how to treat burnout effectively
(Åsberg & Nygren 2003) and interventions are often made
only when workers are already experiencing problems such as
emotional exhaustion (Freddy & Hobfoll 1994, compare
Burke & Richardson 2001).
The person with burnout needs and appreciates social
support from co-workers (Baruch-Feldman et al. 2002) and,
indeed, a supportive workplace can even guard against
burnout (Garrett & McDaniel 2001). However, help from
co-workers does not always seem to reach the person
developing burnout because attempts to help are not
always recognized or accepted (Ericson-Lidman et al.
2007). A phenomenological study by Ekstedt and Fagerberg
(2005) shows that in the period preceding burnout, people
gradually cut off everything that impedes their struggle, and
do not realize what is happening to them. People in need of
support for various kinds of mental strain report that they
needed people around them to help them become aware of
their problems (Hedin 1994). Researchers emphasize the
importance of people in the immediate surroundings
recognizing early signs of burnout (Forney et al. 1982,
Pfifferling & Dyck 2003), especially co-workers (Maslach
2003).
During the time preceding burnout, however, it has been
shown that co-workers often fail to grasp the seriousness of
the situation (Ericson-Lidman et al. 2007). Therefore, it
seems important to explore co-workers’ perceptions of signs
preceding workmates’ burnout retrospectively, knowing that
their workmate is on sick leave because of burnout.
Drawing on the work of Peirce (1960), Kugelmann (2003)
elaborates the structure of a sign: signs signify something to
someone, and a sign is a sign if, and only if, it is interpreted.
Questions therefore arise about what co-workers see in the
JAN: ORIGINAL RESEARCH
period where a workmate is becoming burnt out, and how,
retrospectively, they perceive and interpret those signs. Our
literature review shows that research on burnout has
concentrated on people affected. Co-workers’ perspectives
may deepen knowledge about burnout, and consequently
strengthen the possibility of helping in time.
The study
Aim
The aim of our study was to describe co-workers’ perceptions
of signs preceding workmates’ burnout.
Design
We used a qualitative approach with narrative interviews
with co-workers who had worked with people who had
developed burnout. When knowledge of the issue under study
is limited, qualitative research is a suitable method (Morse &
Field 1998).
Participants
We carried out the research in inpatient and primary care
settings in northern Sweden where employees had been
officially certificated on sick leave as a result of burnout. A
convenience sample of co-workers was selected by the
supervisor of each unit using the criterion that co-workers
selected should have worked with a person who developed
burnout and was on sick leave, or had finished their
employment after sick leave due to burnout. Fifteen
co-workers (n = 15) agreed to participate and four declined.
The participants were all women and included eight regis-
tered nurses (RNs), five enrolled nurses (ENs), one physician
and one medical secretary. They ranged in age from 27 to 59
(Md = 50) years and had worked from 6 to 30 (Md = 25)
years in healthcare. Five of the co-workers could not
remember how many years they had worked with the person
developing burnout, but the shortest period of time men-
tioned was 2 years and the longest 30 years.
Data collection
The interviews were carried out by EE-L between March and
June 2004 in the healthcare units, the interviewer’s office, or
the interviewees’ homes, depending on what they preferred.
To encourage narration, the interviews began with an open-
ended question (Mishler 1986): ‘Please tell me about your
experience of working with a person who developed
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Co-workers’ perceptions of workmates’ burnout
burnout’, and probing questions were asked as the interview
progressed. All interviews were tape-recorded and trans-
cribed verbatim, including indications of sighs, laughter,
crying and silences.
Co-workers initially concentrated on their experiences of
working with a person developing burnout (Ericson-Lidman
et al. 2007). However, they also spontaneously reflected on
what they now, wise after the event, recalled as signs
preceding burnout. In this paper, we critically examine those
parts of the text about perceptions of signs preceding
workmates’ burnout. Some of the interviewees had worked
with two or more people developing burnout and therefore
used ‘they’ in the narrations. The person developing burnout
is referred to as the workmate.
Ethical considerations
The study was approved by the appropriate ethics commit-
tee. The selected co-workers received an information sheet
and, a week later, they were contacted and asked for
informed consent. Confidentiality for interviewees was
assured by using codes to refer to them in transcriptions
which were kept in locked files only available to EE-L and
through the fact that we did not work in the study setting. In
addition, where participants refer to a workmate in the
singular, we have always used the pronoun ‘she’ and have
changed any distinguishing marks, such as the name of a
workplace.
Participants themselves were the catalysts for examining
the signs of burnout, discussing how they now realized that
they had noticed these signs, but did not always understand
them or relate them to burnout. Many of them felt bad
about this and their failure to help in time, and wanted to
share their experiences of what they had learned. We
considered it important to learn from their experiences in
order to deepen knowledge of the signs preceding burnout.
However, talking about such signs has an ethical dimension
as it can be seen as exposing workmates. Therefore, it was
important to protect the anonymity of the people partic-
ipants were describing. We therefore asked them not to
mention any names in the interviews to protect their
workmates’ anonymity. In addition, we assured partici-
pants that, if they did mention a name, it would be erased
during transcription. Anonymity was further assured by the
fact that we did not know the identity of the people the
participants were speaking about, and by the fact that most
situations had occurred several years previously. In addi-
tion, participants often spoke about more than one
workmate, which protected the anonymity of individual
people.
201
E. Ericson-Lidman and G. Strandberg
Data analysis
We analysed the text using thematic content analysis, inspired
by framework of Burnard (1991, 1996). This method focuses
on textual data, aiming to group together similiar types of
utterances and ideas (Burnard 1996). The method has been
developed from analysis of the written word (Cavanagh
1997) to include verbal communication and interactions
(Graneheim et al. 2001, Hörnsten et al. 2004). We read the
interviews several times to create an awareness of the ‘life
world’ of the interviewees. We then divided the text into
meaning units which we condensed, coded and sorted into
groups on the basis of similar content (Burnard 1991) and
abstracted into sub-themes (Graneheim & Lundman 2004).
Finally, we abstracted sub-themes into themes, which are
threads of meaning running through the text on an interpreta-
tive level (Baxter 1991, Graneheim & Lundman 2004).
Rigour of the study
In this study, our intention has been to follow the criteria for
establishing trustworthiness elaborated by Lincoln and Guba
(1985): credibility, transferability, dependability and confir-
mability. To achieve this, we have made an effort to describe
carefully the analysis, including the process, as well as how
interpretations have been made (e.g. by illustrating the
findings with quotes). Another important issue was to identify
themes which accurately answered the research question. We
have had regular discussions with one another and held peer
debriefing sessions throughout the study to ensure consistency
of findings. We have also involved senior researchers from the
project group as critics during the analysis process.
Findings
We identified five themes and 12 sub-themes from our
analysis (Table 1). The themes comprised:
• struggling to manage alone;
• showing self-sacrifice;
• struggling to achieve unattainable goals;
• becoming distanced and isolated;
• showing signs of falling apart.
The themes and sub-themes we present below are illustra-
ted with quotations from the interviews.
Struggling to manage alone
‘Struggling to manage alone’ included the sub-themes of
‘stretching to do things well, preferably alone’ and ‘stretching
themselves to be in control of the situation’.
202  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Table 1 Sub-themes and themes in the thematic analysis
Sub-themes Themes
Stretching to do things well, Struggling to manage alone
preferably by themselves
Stretching themselves to be in control
of the situation
Pushing themselves more than can be Showing self-sacrifice
expected or demanded
Placing themselves last in the queue
Appearing weighed down by heavy Struggling to achieve
demands unattainable goals
Appearing weighed down by
insufficiency
Suffering from troubled conscience
Withdrawing from patients Becoming distanced and
Withdrawing from co-workers isolated
Withdrawing from work
Showing deteriorating bodily signs Showing signs of falling
and sleep disturbances apart
Showing themselves at the breaking
point
Stretching to do things well, preferably alone
Co-workers’ revealed that one of the signs preceding work-
mates’ burnout was that they stretched to do things well,
preferably alone. Co-workers described that their workmates
had a need to prove themselves more competent than their
co-workers, and to show they could do things best them-
selves. One co-worker said: ‘In a way she would tell us how
to do our job; it almost felt as if we did not do things as well
as she did. She took over everything’. Co-workers described
how their workmates had difficulty asking for help and
believed that they were the only ones who could carry out
certain jobs. As one co-worker said: ‘She would stay on at
work and complete some final documentation; she would
stay, as she was the only one who could manage…but nobody
has to stay on. We help each other. Nobody is indispensable’.
Stretching themselves to be in control of the situation
Another sign of impending burnout was the way workmates
stretched themselves to be in control of the situation. Co-
workers described how their workmates did not delegate
assignments and felt that demands for flexibility in both work
and private life were trying because they wanted to be in
control. Co-workers also described how their workmates
wanted to have control over details and began to over-elab-
orate. One co-worker said: ‘Everything had to be done twice,
and it took twice as long to do anything. It had become a
burden to her’ (the person developing burnout documented
both electronically and on paper). They also described how
their workmates checked on how they dealt with jobs to
JAN: ORIGINAL RESEARCH
maintain control: ‘She wanted to control how we were doing
things – what you did, where you were and where you were
not’.
Showing self-sacrifice
‘Showing self-sacrifice’ comprised ‘pushing themselves more
than can be expected or demanded’, and ‘placing themselves
last in the queue’.
Pushing themselves
Co-workers described how their workmates wanted to show
that they could manage work on their own and underlined
this by performing co-workers’ jobs, although this was nei-
ther expected nor demanded. As one co-worker related: ‘She
needed to say: ‘I’m suitable to be a carer. I manage and I’m
doing a good job’…though we did not need to hear; we knew
that she was’. They described how their workmates were
appreciated for performing others’ work tasks, even if they
obviously were in a rush: ‘They (ENs) thought she was a very
capable nurse; she ran faster and faster; she caught up with
cleaning the toilets; she caught up with taking over their job
too…’.
Placing themselves last in the queue
Another sign preceding burnout was felt to be the way
workmates cared about everyone else, both patients and
family, and did not give priority to themselves; they stepped
aside for the sake of others. One co-worker described it as
follows: ‘She was the one who gave more than she received’.
Caring for others did not only include patients, co-workers
also revealed how their workmates unconditionally put life
on hold to help their family: ‘She started an education, then
her sister got seriously ill and died. She gave up the educa-
tion…she found her mission in supporting the family and she
put aside her own needs once more’.
Struggling to achieve unattainable goals
The theme ‘Struggling to achieve unattainable goals’ con-
tained three sub-themes: ‘appearing weighed down by heavy
demands’, ‘appearing weighed down by insufficiency’ and
‘suffering from troubled conscience’.
Appearing weighed down by heavy demands
Co-workers described that workmates heading for burnout
felt that there were never-ending demands from patients,
co-workers and the work situation which, together, created
a sense of burden. As one co-worker said: ‘Having several
patients with difficulties demanded a lot (of her)’.
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Co-workers’ perceptions of workmates’ burnout
Co-workers described how their workmates felt that
demands from other occupational groups were trying as, for
example, when ENs made demands on RNs which could be
almost impossible to meet. One co-worker said: ‘She des-
cribed the discord between the ENs and the RNs as
troublesome. They said (the ENs): ‘But why aren’t you out
there more (with the patients)? There are a lot of nurses
today and you are supposed to help us with this’.
Appearing weighed down by insufficiency
Co-workers described that workmates were also dissatisfied
with themselves if they did not catch up on the shift and did
not manage to care for severely ill patients, and not only
expressed dissatisfaction with their work performance, but
actually disparaged it. Co-workers told how their workmates
often expressed a willingness to do much more than they
were capable of. One co-worker said: ‘She felt she was falling
short. She didn’t catch up with what she had planned to do
and then it became stressful and hard’. Co-workers also
described how their workmates felt that they could not come
up to others’ expectations and were frustrated because they
could not manage to perform difficult tasks: ‘I know she felt
very frustrated. She didn’t get to the seriously ill patients with
CVK (central venous pressure line). She was very frustrated
over that. She said: ‘I don’t manage to go to them. I won’t
sleep all night’.
Suffering from troubled conscience
Co-workers described that workmates felt bad when they
considered that they were not providing good enough care for
their patients. Their troubled conscience was about not doing
the right thing, as well as about not having enough time,
resulting in a sense of being drained. As one co-worker put it:
‘She felt that we did not do enough for the patients. It was not
so good for the patients on the unit; we weren’t there enough
and she felt bad about that’. Not knowing if they were acting
properly and correctly in certain situations and letting others
take over their work assignments was described as breeding a
troubled conscience, as this co-worker highlighted: ‘She
broods on it: ‘Am I forcing them too hard? Am I doing the
right thing? They should be at home. ‘It was very trouble-
some. ‘Am I unpleasant…?’ She said that she had a troubled
conscience about being the one who enforced the arrange-
ments, which were almost against their (the relatives’) will’.
Becoming distanced and isolated
‘Becoming distanced and isolated’ was composed of three
sub-themes relating to withdrawal from patients, co-workers
and work itself.
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E. Ericson-Lidman and G. Strandberg
Withdrawing from patients
Co-workers described how their workmates began to have
difficulty approaching and connecting with patients. They did
not manage to listen to their patients and tackle their prob-
lems, instead escaping to other jobs. They also described how
their workmates sometimes failed to make their house calls.
One co-worker said: ‘She was afraid of being with the patients.
I felt that she sometimes avoided being with the patients. She
looked instead for other tasks, such as cleaning the medical
room and the storeroom’. Another co-worker revealed how
their workmates sometimes did not turn up for patient visits:
‘They (the patients) didn’t receive help and they phoned and
were promised help but the person didn’t show up’.
Withdrawing from co-workers
At times, co-workers talked of how their workmates, despite
occupying the room next to them, communicated via e-mail
when they had difficulties to discuss, became taciturn and
began to cut down on the time they spent talking to others.
One remembered: ‘She sent an e-mail instead of talking face
to face. She had her room next to mine’. Others felt that their
workmates sometimes retreated to be alone, to rest: ‘Maybe
she went away a little. She felt, I suppose, that she needed to
get away and not have to talk to us’.
Withdrawing from work
Co-workers also felt that their workmates did less work than
usual, at times, for example, they talked instead of working,
did not do their paperwork, and were sometimes almost
incapable of acting. They also described how their work-
mates had problems being punctual. One co-worker said:
‘She sat down and talked about one thing and another,
instead of working’. Co-workers spoke of how their work-
mates often took extended coffee breaks, as if they were
running away from work: ‘They could not be on time, and
they sat down for coffee for a very long time. I left, and
another left, and a third, but they stayed on. It was so much
that they could not manage at last’.
Showing signs of falling apart
‘Showing signs of falling apart’ comprised: ‘showing deteri-
orating bodily signs and sleep disturbance’ and ‘showing
themselves at breaking point’.
Bodily signs and sleep disturbances
Co-workers described that many workmates either put on or
lost weight. They also developed abdominal symptoms, such
as reflux, circulatory symptoms, such as palpitations and
hypertension, and were always tired but suffered from
204  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
sleeplessness. Co-workers described how their workmates
became thinner and seemed to feel chilly: ‘She got thinner and
thinner, and sort of disappeared in her clothes’, and had
difficulty sleeping: ‘She told me that she did not sleep so well
at nights for various reasons’.
Showing themselves at the breaking point
Co-workers described how their workmates began to show
signs of exhaustion in the form of dejection, undue sensitivity,
touchiness and paralysis. They also described how their
workmates sometimes had problems in their private life,
which put a great strain on them. Their workmates seemed
extremely short-tempered and took it out on co-workers:
‘I experienced that irritation, aggression (gasping for breath) if
a car was wrongly booked; it was my fault… it was so
little…there was no margin’. One co-worker described a
situation when a completely exhausted workmate sat in the
dark, unable to move or act: ‘I saw that the light was on in her
room and I knew she was in there, and suddenly the light was
switched off, but no one came out. She didn’t go home until
late at night. She sat there the whole evening, in the dark’.
Discussion
Before discussing the implications of our findings, we
acknowledge that our study has limitations. With regard to
transferability, we accept that our study reflects the percep-
tions of a small group of female participants in western
society. Thus, we do not argue that the findings of this study
are necessarily applicable to men’s experiences of signs
preceding burnout or to those living in other cultures. Indeed,
research concerning gender differences in symptoms of
burnout point in different directions (Hetherington et al.
1989, Te Brake et al. 2003, Bekker et al. 2005). It is also
important to remember that the narratives were obtained
when co-workers already knew that their workmate had
fallen ill, and it is easy to be wise after the event. In
narratives, the past is constantly revised and re-interpreted in
the light of the present (Boje 1991). Narrators may have
forgotten things, became confused, or may exaggerate;
however, the narrative is still the truth of their experience
(Personal Narratives Group 1989).
The aim of our study was to describe co-workers’ percep-
tions of signs preceding workmates’ burnout. During the time
preceding burnout, co-workers failed to grasp the seriousness
of the situation (Ericson-Lidman et al. 2007). However, in
the interviews they spontaneously reflected on and narrated
their perceptions of signs preceding workmates’ burnout.
Thus, the findings spring from the narratives of co-workers
who are aware that their workmates became ill because of
JAN: ORIGINAL RESEARCH
What is already known about this topic
• Burnout engenders emotional and economic suffering,
both individual and societal, which underlines the need
for prevention.
• It is of great importance that people in the immediate
surroundings, for example the co-workers, recognize
early signs of burnout to help at an early stage.
What this paper adds
• The perceived signs preceding workmates’ burnout
were struggling to manage alone, showing self-sacri-
fice, struggling to achieve unattainable goals, becoming
distanced and isolated and showing signs of falling
apart.
• Some of the perceived signs may be hard to interpret as
signs of burnout because they may be regarded as
qualities which are encouraged.
• Co-workers could help workmates by learning to
recognize early signs of burnout, thus increasing
awareness and improving the chances of preventive
action.
burnout. The main findings show that co-workers perceived
that their workmates were struggling to manage alone,
showing self-sacrifice, struggling to achieve unattainable
goals, becoming distanced and isolated, and were showing
signs of falling apart.
As we found no studies on co-workers’ perceptions of signs
preceding workmates’ burnout, we discuss our findings in
light of the few studies with people suffering from symptoms
of burnout. People with symptoms of burnout highly value
positive outcomes from their own efforts (Hallsten 1985,
1988). They prefer to carry out tasks alone (Billeter-Koponen
& Fredén 2005), to have control over the situation and ‘want
to rule’ (Vanheule & Verhaeghe 2004). They also have a
propensity for self-sacrifice and attempt to efface themselves
for the sake of others. They may, when asked, carry out tasks
that others do not have time to do or are unable to perform;
they feel it is their duty to satisfy others (Vanheule et al.
2003)and position themselves as agents who are endlessly
devoted to others and to work (Vanheule & Verhaeghe
2005). Co-workers, however, have difficulty perceiving the
signs preceding workmates’ burnout while working with
them (Ericson-Lidman et al. 2007). The studies above are
performed when the persons were on sick leave or scored
high on a burnout instrument. This indicates, irrespective of
perspective, the difficulties in perceiving the signs of burnout
at an early stage.
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Co-workers’ perceptions of workmates’ burnout
It can be surmised that part of the difficulty of identifying
signs of burnout at an early stage, in particular the struggle
to manage alone and achieve unattainable goals, is specif-
ically related to living in a western society. Western society
is highly individualized and people are considered valuable
when they are strong, healthy, productive and independent
(compare Buber 1954/1995, compare Strandberg et al.
2002). In such a society, self-reliance is a goal towards
which we must strive, and those who have difficulty
managing alone are considered morally and personally
deficient (compare Grubb & Lazerson 1982). We are afraid
of being a burden on others, and when we fall ill or find
ourselves in need we may, therefore, have trouble asking for
help (Becvar 2005). With this prevailing ideal image, we can
understand that it may be difficult for co-workers to realize
that such qualities may gradually lead to ill health. Instead,
co-workers may encourage one another to live up to this
ideal image. Devotion and involvement may also be hard to
interpret as related to burnout because these qualities are
highly valued and encouraged in the culture of nursing, as
well as in the wider society of today.
Becoming distanced and isolated and showing signs of
falling apart are understood as being more easily interpreted
as signs of burnout. People with symptoms of burnout may
avoid negative interactions with co-workers, for example,
and instead withdraw, which often means that their ability to
function at work deteriorates (Vanheule & Verhaeghe 2005).
They cut themselves off, which implies social withdrawal and
a gradual exclusion from activities (Ekstedt & Fagerberg
2005). Direct withdrawal from patients is also described
(Severinsson 2003, Rafii et al. 2004). Symptoms such as
sleeping problems, tiredness, palpitations of the heart, high
blood pressure (Severinsson 2003, Billeter-Koponen & Fred-
én 2005), muscular pain and infections (Ekstedt & Fagerberg
2005) are among several other physical symptoms noted.
Showing signs of falling apart includes taking incidents
personally (Vanheule & Verhaeghe 2004), losing one’s
temper, and feeling unable to act and being completely
paralysed (Ekstedt & Fagerberg 2005). The consequent need
to distance and isolate oneself is not encouraged in the
current prevailing culture, and may be the point at which
co-workers begin to suspect something is wrong.
Finally, there seem to be some differences between signs
perceived by co-workers and symptoms narrated by a person
suffering from burnout. No qualitative studies with people
suffering from burnout highlight suffering from troubled
conscience, while co-workers do not appear aware of signs
such as cognitive impairment (Ekstedt & Fagerberg 2005),
blaming others at the workplace (Vanheule et al. 2003,
Vanheule & Verhaeghe 2005) or a propensity to keep silent
205
E. Ericson-Lidman and G. Strandberg
about troubling experiences (Vanheule et al. 2003, Vanheule
& Verhaeghe 2004). Theoretically, Maslach and Leiter
(1997) and Maslach et al. (2001) describe burnout as
comprising exhaustion, cynicism and ineffectiveness.
Through our participants’ narratives, a picture of Maslach
and her companions’ description of burnout is visualized.
Separately, the perceived signs may be hard to interpret as
signs of burnout. Through our analysis of co-workers’
narratives, a pattern has emerged which generates under-
standing of a complex picture of signs preceding workmates’
burnout.
Conclusions
Understanding the complexity of the signs which precede
burnout may increase our awareness and sensitivity to them
and enable us to take action to deal with the problem at an
early stage. Some of these signs may be hard to interpret as
signs of burnout, as they may be regarded as qualities which
are encouraged in the prevailing culture. However, knowledge
generated by this study should be useful in support groups
aimed at helping people at risk of developing burnout. During
supervision sessions, sub-themes and themes in present study
may function as a platform to stimulate discussion. Interven-
tions may then be developed to help workers at risk. Further
research should concentrate on evaluation of such interven-
tions, and also on gender and cultural issues which may affect
the signs and symptoms of burnout.
Acknowledgements
This research was supported by grants from the Vardal
Foundation for Healthcare Sciences Allergy Research (E 2003
003), the Swedish Research Council (2005-66-35), Medical
Faculty, Umeå University, and the Department of Nursing,
Umeå University, Umeå. We would also like to thank the
participants in the study for sharing their experiences with us.
Finally, we express our gratitude to our research colleagues in
the ‘Stress of conscience and burnout’ project, especially
Professor Emerita Astrid Norberg, and those participants in
research seminars who have contributed with valuable
viewpoints.
Author contributions
EEL and GST were responsible for the study conception and
design and the drafting of the manuscript. EEL performed the
data collection and EEL and GST performed the data
analysis. GST and EEL made critical revisions to the paper.
GST supervised the study.
206  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
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