Safety Science 118 (2019) 898–906

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/safety

Work ability and burnout: What comes first? A two-wave, cross-lagged study T
among early childhood educators☆
⁎
Sara Viotti, Gloria Guidetti, Ilaria Sottimano , Mara Martini, Daniela Converso
Department of Psychology, University of Turin, Italy

A R T I C LE I N FO A B S T R A C T

Keywords: Although previous evidence suggests an association between work ability and burnout, no study has been
Burnout specifically dedicated at establishing which is the directionality of the relationship between these two important
Work ability constructs either in educational or in other occupational contexts. Studies shedding light on the directionality of
Conservation of resource theory this relationship are essential, as their results may address organizational management and occupational health
Cross-lagged associations
practitioners in choosing the most proper interventions capable of early interrupting a possible loss spiral in-
itiated by decreased work ability or increased burnout. In view of that, the aim of the present study was to
examine the cross-lagged association between work ability and burnout (i.e., exhaustion, enthusiasm toward the
job, and cynicism) at a distance of one year. In total, 349 early childhood educators completed a self-report
questionnaire at two-time points. Data analyses were performed employing cross-lagged structural equation
model (SEM). The findings indicated that work ability positively predicts enthusiasm toward the job and ne-
gatively predicts exhaustion. Conversely, work ability did not significantly affect cynicism. Moreover, none of
the three-burnout sub-dimensions were found to significantly affect work ability measured at one years of
distance. The main contribution of the present study was to have clarified the directionality of the association
between work ability and burnout and to have identified the burnout sub-dimensions specifically affected by
work ability. From a practical point of view, the present study highlighted the importance of investing in pro-
moting work ability in order to prevent job burnout.

1. Introduction parents’ expectations (Hall-Kenyon et al., 2014; Whitaker et al., 2015).

In many industrialized societies, public educational services are
essential in helping families to take care of and support the physical,
cognitive, and emotional development of children during the pre-kin-
dergarten stage (typically ages 0–3). Early childhood educators play a
key role in carrying out these services, as they are responsible for the
development of educational programs and the coordination of the daily
activities of welcoming, dining, sleeping, and personal hygiene.
According to the literature, early childhood educators are exposed
to many risks that may jeopardize their occupational health and well-
being. One of the most relevant is occupational burnout, a syndrome
typically developed in caregiving and service occupations where the
core of the job involves a relationship between provider and recipient
(Rentzou, 2012; Blöchliger & Bauer, 2018). According to previous
studies, early childhood educators’ risk of burnout can be linked to the
great responsibility involved in caring for not-yet-self-sufficient minors
and the difficulties associated with meeting both children’s needs and
The development of this syndrome represents an important risk not
only for workers but also for their recipients, since it is well established
in the literature that burnout negatively affects the quality of services
provided (De Simone et al., 2018). According to Maslach (2003),
burnout is a psychological response to chronic work-related stress of an
interpersonal and emotional nature. Scholars agree in defining burnout
as a syndrome characterized by three main symptoms: psychological
exhaustion, reduced enthusiasm for the job, and cynicism (Maslach,
2003; Gil-Monte and Figueiredo‐Ferraz, 2013). Psychological exhaus-
tion is the energy-related dimension of the syndrome, describing as it
does a process of energy depletion. Enthusiasm is the motivational
component of the syndrome; it is ordinarily a positive dimension, and
its reduction accounts for the process of disengagement from work
(Bakker and Demerouti, 2008). Similar to the construct of work en-
gagement, enthusiasm refers to the motivation and passion that drive
workers to achieve work goals as a source of personal pleasure (Gil-
Monte and Figueiredo‐Ferraz, 2013). The third burnout dimension –

☆
No specific funds was received for the present study.
⁎
Corresponding author at: Department of Psychology, University of Turin, Via Giuseppe Verdi 8, 10124 Turin, Italy.
E-mail addresses: sara.viotti@unito.it (S. Viotti), ilaria.sottimano@unito.it (I. Sottimano).

https://doi.org/10.1016/j.ssci.2019.06.027
Received 5 October 2018; Received in revised form 1 June 2019; Accepted 18 June 2019
Available online 24 June 2019
0925-7535/ © 2019 Elsevier Ltd. All rights reserved.
S. Viotti, et al.
cynicism – denotes the presence of negative attitudes of indifference
toward the job and the service recipients (Taris et al., 2005).
Another important emerging risk in the educational context, and
one which is capturing the attention of occupational health scholars
and practitioners to a great extent, is the progressive reduction of work
ability across the work-life span (Converso et al., 2015; Grabara et al.,
2018). Generally speaking, as a consequence of the aging workforce
evident in many European countries due to sociodemographic changes
and pension reforms, the proportion of workers reporting poor work
ability is increasing considerably (Milczarek et al., 2007). When con-
sidering the educational system, Italy is one country in which the aging
workforce trend is particularly worrying; between 2002 and 2011, the
number of over-50 teachers increased from 31.5% to 48.7% (Argentin,
2013; OECD, 2014). A recent study (Converso et al., 2015) involving a
representative sample of Italian early childhood educators confirmed
this alarming situation in the pre-school context; it found that the
average age of the sample was 50-years old, and that about 40% of the
sample reported inadequate work ability. Work ability refers to the
functional capacity to meet the requirements of the job (Ilmarinen
et al., 1997). According to Airila et al. (2014), work ability can be seen
as a health-related resource, which sustains workers’ adaptation to
work environments and fosters an individual’s sense of ability to control
and successfully affect their environment (Hobfoll et al., 2003;
Xanthopoulou et al., 2007).
Job burnout and work ability represent two important constructs in
understanding the fitness of workers to do their job, both accounting for
the level of worker energy and the resources available to invest in the
job. However, whereas work ability is a health-related resource and
primarily refers to physical energy, burnout relates strongly to the
emotional/affective domain, and mostly reflects the availability of
psychological energy. Accordingly, literature has identified different
families of interventions to prevent burnout and foster work ability.
Burnout prevention literature has provided evidence of the effective-
ness of interventions aimed at developing psychosocial job resources
(e.g. social support) that may sustain workers and work teams in better
managing the relationship with their recipients (Awa et al., 2010).
Furthermore, burnout can be reduced through interventions aimed at
developing psychological personal resources (e.g. self-efficacy) that are
helpful in managing negative emotions and reducing interpersonal
strain reactions related to recipients (e.g. counselling or psychosocial
skill training) (Innstrand et al., 2004; Bresó et al., 2011; Siu et al.,
2014). Conversely, work ability is improved more effectively using in-
tervention programs focused on health, functional capacity, and ergo-
nomics. For instance, Pohjonen and Ranta (2001) highlighted that
worksite physical exercises are beneficial for increasing work ability.
Later, De Boer et al. (2007), in a prospective controlled intervention
study, found work ability significantly increased among workers who
received individual counselling focusing on optimizing work func-
tioning. Several studies have also demonstrated that programs specifi-
cally designed for workers with chronic diseases (e.g. cancer, multiple
sclerosis, or cardiovascular diseases), and aimed at fitting the ergo-
nomic and psychosocial environment around workers’ health needs,
helped to enhance their ability to continue working (Khan et al., 2009;
Tamminga et al., 2010).
Although previous literature suggests an association between work
ability and burnout (Hakanen et al., 2006; Glise et al., 2010; Airila
et al., 2012; Mache et al., 2013), no study has been specifically dedi-
cated to establishing the directionality between these two important
constructs in an educational or any other occupational context. This
research gap has associated consequences from a practical point of
view, as this lack of information may impede the designing of effective
interventions to improve the quality of working life in the workplace. In
considering the different approaches required to intervene in work
ability and burnout, studies shedding light on the directionality of the
relationship between these two constructs are essential, as the results
may assist organizational management and occupational health
899
Safety Science 118 (2019) 898–906
practitioners in choosing the most suitable interventions to interrupt at
an early stage a possible loss spiral initiated by decreased work ability
or increased burnout. Therefore, knowing what comes first – work
ability or burnout – is crucial for organizations that prioritize the
adoption of a primary-prevention perspective in the field of occupa-
tional health.
In view of this gap, the aim of the present study is to examine the
directionality between work ability and three burnout sub-dimensions
(i.e., enthusiasm toward the job, exhaustion, and cynicism) in a sample
of Italian early childhood educators, using conservational of resource
theory (COR, Hobfoll, 1989) as a theoretical framework. To the best of
our knowledge, no previous study has employed a cross-lagged design
to assess the association between work ability and burnout on any of its
sub-dimensions. From a methodological point of view, the study em-
ploys a two-wave design and uses a cross-lagged technique for ana-
lyzing the data. Cross-lagged panel models examine the predictive as-
sociation between two variables over time, each controlling for effects
at earlier time points (Lewis-Beck et al., 2004). The main strength of
cross-lagged panel models is to provide evidence of the causal pre-
dominance between two variables (e.g., exhaustion to work ability vs.
work ability to exhaustion. See Zapf et al., 1996). In terms of the time
lag, the study focuses on a short-term measurement point of one year;
this is because establishing whether and how these constructs affect
each other in the short term may help in identifying early interventions
to prevent the strengthening of a vicious circle between work ability
and burnout. Any potential vicious circle could in turn lead to further
negative consequences for the organization in terms of absenteeism, job
turnover, and diminished quality of service (Pak et al., 2018).
1.1. The effect of work ability on burnout
An important added value of COR theory is the description of the
intrinsic energetic resource process through the use of the metaphor of
the loss cycle, which can be effectively applied to understand the re-
lationship between work ability and burnout (Hobfoll and Shirom,
2001). As Hobfoll (1989) explains, a loss cycle refers to a process of
resource expenditure that makes individual incapable of coping with
future loss, thus potentially leading to further resource loss. According
to Hobfoll and Shirom (2001), in workplace settings, resources are
those factors that help workers in achieving work goals or in reducing
physiological and psychological costs. COR theory suggests that work
ability and burnout are processes that are centered on the individual’s
intrinsic energetic state resources (Gorgievsky and Hobfoll, 2008). En-
ergetic state resources are the key to human functioning. Throughout
life, the energetic state of the body needs to be in line with the activities
that people undertake. Within the individual, there is a constant taxing
of the energetic state as well as of the effort needed to react to threats
and opportunities.
Work ability –reflecting basic personal resources, such as health and
functional capacity– is a central component of the individual’s resource
armamentarium (Airila et al., 2014). According to COR theory (Hobfoll,
1989), change in functional capacity might deeply influence the in-
dividual’s intrinsic energetic state, consequently affecting the avail-
ability of psychological and emotional resources (Gorgievsky and
Hobfoll, 2008). In the workplace, work ability contributes to the reg-
ulation/maintenance of the equilibrium between the individual’s en-
ergetic state and the job demands that he or she has to face, sustaining
him or her in achieving work goals (Viotti et al., 2017). In this view,
diminished work ability may work as an initiator of a loss spiral,
leading a worker to experiencing a disequilibrium between demands
posed by the job and the personal resources on which he or she can rely.
The mobilization of additional effort by the worker to compensate for
limited ability may be accompanied by fatigue. Studies have demon-
strated that accumulated fatigue is a precursor of burnout (Zarei et al.,
2016). If this loss process cannot be interrupted, a further gap in the
equilibrium of the individual’s energetic state may be generated,
S. Viotti, et al.
leading to the experience of burnout.
From an empirical point of view, there is some evidence suggesting
the role of work ability in negatively predicting exhaustion and low
enthusiasm. In a cross-sectional study involving over 50 kindergarten
teachers, Viotti et al. (2017) found the path from work ability to ex-
haustion significant. In a sample of firefighters, Airila et al. (2014)
observed that work ability significantly predicted engagement after
10 years. Yet, to the best of our knowledge, no previous study has ex-
amined the relationship between work ability and cynicism. Never-
theless, the plausibility of the significance of this path has been sug-
gested in cross-sectional and longitudinal studies that have provided
evidence regarding the predictive role of various types of job and per-
sonal resources in cynicism (Janssen, Schaufeli, & Houkes, 1999;
Huang, Wang, & You, 2016).
Accordingly, we formulated the following hypotheses:
(H1) Work ability at Time 1 negatively predicts exhaustion at Time
2.
(H2) Work ability at Time 1 positively predicts enthusiasm toward
the job at Time 2.
(H3) Work ability at Time 1 negatively predicts cynicism at Time 2.
1.2. The effect of burnout on work ability
The opposite path, which suggests that burnout leads to work
ability, is also compatible with the COR principle of loss spiral, which
states that the strategy that people employ to offset loss may lead to
secondary losses (Hobfoll, 1989). Generally speaking, COR theory de-
fines burnout as a process of excessive work involvement that leads to
the depletion of motivational and energetic resources, which in-
dividuals feel may not be replenished (Hobfoll and Shirom, 2001). The
inability to replenish lost energy resources in an attempt to cope with
demands may lead to impair the normal functioning in daily work life
(Gorgievsky and Hobfoll, 2008). In this view, burnout represents a
process of resource loss that gradually develops over time, depleting
functional capacity and health resources (Gorgievsky and Hobfoll,
2008). In particular, the arisen of psychical complaints may be related
to acute responses from endocrine chances induced by the autonomic
nervous system, making individuals more susceptible to developing
illnesses (Hobfoll & Shirom, 2001).
Empirically, the plausibility of the influence of burnout on work
ability has been suggested in both cross-sectional and follow-up studies,
although not employing a cross-lagged design, that have postulated this
path directionality. For instance, in a large sample of workers employed
in two manufacturing organizations, Rongen et al. (2014) found that
work engagement predicted work ability level at a six-month distance.
In an eight-year cohort study among forest industry workers, Ahola
et al. (2009) reported that exhaustion and cynicism measured at the
baseline predicted work ability measured at the follow-up.
In addition, Airila et al. (2014) suggested that the relationship be-
tween burnout and work ability might be bidirectional rather than
unidirectional, finding that work engagement measured at Time 2
mediated the relationship between work ability measured at Time 1 and
work ability measured at Time 2 (ten years later).
Accordingly, we formulated the following hypotheses:
(H1r) Exhaustion at Time 1 negatively predicts work ability at Time
2.
(H2r) Enthusiasm toward the job at Time 1 positively predicts work
ability at Time 2.
(H3r) Cynicism at Time 1 negatively predicts work ability at Time 2.
900
Safety Science 118 (2019) 898–906
2. Method
2.1. Data collection and participants
A two-wave study was conducted on the Educational Services of the
Municipality of medium-size city in North Italy, which serves 8759
children. Questionnaires were distributed to early childhood educators
working in 10 subdivisions of the educational services system in the
municipality of Turin (dedicated to infants aged 0–3) as part of a larger
project aimed at monitoring work sustainability across the working life
span. In the current study, only data concerning work ability and
burnout were used. The data were collected at two time points, with a
one-year distance (Time 1: March/May 2016; Time 2: March/May
2017). At both time points, questionnaires were administered during
the compulsory annual medical examination (in compliance with
Italian law n. 81/08) with an occupational physician on health and
safety in workplaces. In accordance with the directional staff of the
educational services and the occupational physician in charge of ex-
ecuting occupational health surveillance, prior to the appointment with
the occupational physician, a researcher proposed that each educator
complete the self-report questionnaire. The medical examination and
questionnaire completion were undertaken during working hours in
facilities provided by the Educational Services. Each participant signed
an informed consent form regarding the purposes of the study. They
were also assured of their anonymity and confidentiality. The research
protocol received the approval by the Bioethical committee of the
University.
In 2016 (Time 1), 435 early childhood educators employed in the 10
subdivisions within the municipal educational system were asked to fill
out a self-report questionnaire. A total of 405 (93.1%) workers re-
sponded to the survey. Of the 405 workers who responded at Time 1, a
total of 380 were eligible to take part in the second wave. This dis-
crepancy was due to the fact that 11 of those who responded at Time 1
were transferred out of the study subdivisions, and 14 retired. Of the
380 workers, 349 (91.8%) completed the second questionnaire.
Therefore, the sample used for the present study consisted of 349 tea-
chers, and the total dropout rate from Time 1 to Time 2 was 13.8%
(n = 56). All participants (100%) were women aged between 25 and
63 years old (m = 48.57, SD = 7.39). Average job seniority as an early
childhood educator was 22.46 years (SD = 9.67) and ranged from less
than one year to 40 years. The sample rated their health on a scale from
1 (“very problematic”) to 4 (“very good”); 62.2% of the sample rated
their own health as good (3), 31.5% as very good (4), 4.9% as pro-
blematic (2), and 0.6% as very problematic (1). The average body mass
index (BMI) was 23.31 (SD = 4.16; min = 16.02, max = 38.67), and
7.2% obtained a rate higher than 30, falling in the obesity category
(Okorodudu et al., 2010).
2.2. Measures
Whereas the study’s major variable scales (i.e., work ability and
burnout) were collected at both time points, the control variable scales
were collected at Time 1 only.
2.2.1. Perceived work ability (WA)
This was measured using a modified version of the Work Ability
Index (Tuomi et al., 1998), specifically aimed at assessing perceived
work ability, as suggested by McGonagle et al. (2014, 2015). It contains
five items: (1) current work ability compared with lifetime best (score
range: 1–10); (2) work ability in relation to mental and physical de-
mands (score range: 2–10); (3) estimated work impairment due to
diseases (score range: 1–6); (4) self-prognosis of work ability for the
next two years (score range: 1–4 or 7); and (5) mental resources (score
range: 1–4).
S. Viotti, et al.
2.2.2. Burnout
This was measured using three subscales from the Spanish Burnout
Inventory (Guidetti et al., 2018): psychological exhaustion (4 items,
e.g., “I feel emotionally exhausted”); enthusiasm toward the job (5
items, e.g., “I see my job as a source of personal accomplishment”); and
cynicism (5 items, e.g., “I don’t like taking care of some children”). The
responses were given on a five-point scale ranging from 0 “Never” to 4
“Every day.”
2.2.3. Control variables
The literature identifies perceived health, BMI, age, and job tenure
as potential confounders for both work ability (e.g., Ilmarinen et al.,
2005; McGonagle et al., 2014; Rongen et al., 2014; Van den Berg et al.,
2009) and burnout (Maslach et al., 2001). In addition, it has been
widely recognized that job demands significantly affect both work
ability and burnout (McGonagle et al., 2014; Sottimano et al., 2017). A
single-item scale was used to measure mental demands (i.e., “is your
work mentally demanding?”) and physical demands (i.e., “is your work
physically demanding?”) from Copenhagen Psychosocial Questionnaire
(COPSOQ, Kristensen et al., 2005); responses given on a 5-point scale
(0 = strongly disagree; 5 = strongly agree).
2.3. Analysis strategy
The data analysis was performed using IBM Statistical Package for
the Social Sciences 24 (SPSS) and Mplus 7.3. The descriptive statistics
included dropout analyses, means, standard deviations, and correla-
tions among the major study variables within each wave and across the
two waves. Associations between the major study variables, measured
at both time points with potential confounders collected at Time 1,
were assessed using the t-test for dichotomous variables (i.e., obesity
and health status) and Pearson’s r correlations for continuous variables
(i.e., mental demands, physical demands, age, and job seniority).
To ensure that no other latent structures, excepting the one hy-
pothesized, underlined the data and that the scales measured separate
and well-identified constructs, a series of confirmatory factor analyses
(CFAs) involving items of the major study variables were performed
separately for the two measurement points. More specifically, four
competing models, which included from one to four factors, were
compared:
– The one-factor model (M1) assumed that all items loaded on a un-
ique big factor. According to Podsakoff et al. (2003), a poor fit of the
one-factor model indicates that common method variance is not a
major problem.
– The two-factor model assumed that items assessing burnout loaded
on one factor, while items measuring work ability loaded on the
other factor (M2). This model assumed that the best factor structure
underlying burnout is a one-factor solution (see Mészáros et al.,
2014).
– In the three-factor model, work ability and enthusiasm items loaded
each on its corresponding factor, whereas the exhaustion and cy-
nicism items loaded on the same factor (M3). This model, according
to Green et al. (1991) assumed that the best factor structure un-
derlying burnout is a two-factor solution consisted of a negative
component (“core dimension”) and a positive component.
– The four-factor model, including four latent variables –work ability,
exhaustion, enthusiasm, and cynicism– in which each items loaded
on its respective corresponding factor (M4, the hypothesized
model).
The study hypotheses were examined by means of cross-lagged
modeling techniques (structural equation modeling, i.e., SEM). In par-
ticular, four models were compared with each other: the stability model,
which included the autoregressive paths between the same latent
variables measured at the different time points, the synchronous
901
Safety Science 118 (2019) 898–906
correlations between the latent variables measured at the same time,
and the longitudinal correlations between the residuals of the identical
items measured at different time points (M1); (2) the causality model,
which included all the paths of the stability model, plus the regressive
path(s) referred to in H1, H2, and H3 (M2); the reverse causation model,
which included all the paths of the stability model, plus the regressive
path(s) referred to in H1r, H2r, H3r (M3); the reciprocity model, which
included all the paths in the previous three models (M4). Once the
model with the best fit was identified, we adjusted for the effects of the
three variables that were shown to have an effect on one of any major
study variable measured at any time point (i.e., physical demands, age,
and health status). In particular, control variables measured at Time 1
were regressed on the three major study variables measured at both
Time 1 and Time 2.
Since the data for this study had a nested structure, with early
childhood educators belonging to 10 subdivisions of the educational
services, for the analyses conducted in MPLUS, this nesting effect was
controlled by using a sandwich estimator via the TYPE = COMPLEX
command and by identifying “subdivision” as a cluster variable. This
sandwich estimator adjusts standard errors for the effects of clustered
data and provides more appropriate tests of statistical significance.
Even if, according to the interest focus of our hypothesis, the constructs
under study are measured only at a single level, failure to account for
the nested structure may expose the risk of bias in the coefficient esti-
mation at the individual level (Bliese, 2000). This may also occur in the
event there is little evidence for the clustering of the variables within
divisions, such as in the present study, in which the interclass corre-
lations (ICC(1)) for all the study variables were equal to or below 0.06.
Robust maximum likelihood (MLR) was employed as an estimation
method. The chance of Comparative Fit Index (CFI) (Meade, Johnson, &
Braddy, 2008) and the Satorra-Bentler Scaled Chi-square Difference
Test (SBΔχ2) were used to determine the presence of invariance. A
significant difference in χ2 and a difference higher than 0.002 in the CFI
value between the less constrained and the more constrained model
suggest a lack of invariance (Meade, Johnson, & Braddy, 2008). Re-
garding the study hypotheses, the SBΔχ2 was used to compare the
models. In addition, the goodness-of-fit of the model was assessed using
the ratio of χ2 to the degrees of freedom (df), the Comparative Fit Index
(CFI), the Tucker-Lewis Index (TLI), the Standardized Root Mean
Square Residual (SRMR), and the Root Mean Square Error of Approx-
imation (RMSEA). According to Kline (2005), a χ2/df ratio of 3 or less
indicates a good model fit, and less than 2 indicates an excellent model
fit. For the TLI and CFI indices, values higher than 0.90 are considered
indicators of good model fit (Bentler, 1995). A SRMR value of less than
0.08 indicates good fit (Hu and Bentler, 1999), and a RMSEA value
lower than 0.09 indicates an acceptable model fit (Byrne, 1998). In
addition, the Akaike Information Criterion (AIC) and the Bayes In-
formation Criterion (BIC) were used to compare the alternative (non-
nested) measurement models (Kline, 2005). For the AIC and BIC,
smaller values are indicative of better fitting models.
3. Results
3.1. Descriptive analyses
Table 1 reports on the dropout analyses. To control for potential
selection bias associated with dropout at Time 2, statistical differences
regarding the background variables, job demands, and study variables
were assessed by comparing the group of respondents (n = 349) and
dropouts (n = 56) at Time 2. As reported in Table 1, analysis high-
lighted (t-test for continuous variables and χ2 for dichotomous vari-
ables) no significant differences between the group of respondents
(n = 349) and dropouts (n = 56).
Table 2 reports on the univariate analysis of the study and control
variables. All the variables considered in the study showed acceptable
stability over time, as all pairs reported relatively high r values
S. Viotti, et al. Safety Science 118 (2019) 898–906

Table 1 Cronbach’s alphas (α) confirmed the good internal consistency of

Descriptive and dropout analyses. the scales at both times, as follows: work ability, 0.67 (Time 1) and 0.71
Two-wave Dropouts t-Test/X2 (Time 2); exhaustion, 0.83 (Time 1) and 0.83 (Time 2); enthusiasm,
sample (n = 56) 0.85 (Time 1) and 0.83 (Time 2); and cynicism, 0.67 (Time 1) and 0.70
(n = 349) (Time 2).
M(ds)

1. Work ability Time 1 28.22(3.92) 27.44(5.66) 1.21 ns

2. Work ability Time 2 27.91(3.91) – – 3.3. Cross-lagged associations
3. Psychological exhaustion Time 1 7.41(3.28) 7.60(3.74) −0.38 ns
4. Psychological exhaustion at 7.46(3.17) – – Table 4 reports on the goodness-of-fit indices for the cross-lagged
Time 2
SEMs, which were performed to test the causal relationships among the
5. Job enthusiasm Time 1 14.65(3.43) 15.16(3.44) −0.93 ns

6. Job enthusiasm Time 2 14.88(3.29) – – variables under study. M1, the stability model, showed acceptable va-
7. Cynicism Time 1 2.73(2.38) 2.76(2.41) −0.10 ns lues on the goodness-of-fit indices. In this model, all paths had sig-
8. Cynicism Time 2 2.76(2.34) – – nificant values (γworkability T1→T2 = 0.67, p = .001; γexhaustion
9. Mental demandsa 3.23(0.52) 3.27(0.62) 0.10 ns
T1→T2 = 0.66, p = .001; γenthusiasmT1→T2 = 0.55, p = .001;
10. Physical demandsa 3.35(56) 3.38(0.59) 0.49 ns
11. Agea 48.57(7.39) 47.88(10.30) 0.46 ns
γcynicism→T2 = 0.59, p = .001). From the stability model to the normal
12. Job tenurea 22.46(9.67) 21.98(11.53) 0.24 ns causality model, the adding of three paths resulted in a significant in-
13. BMI > 30 (1 = Obesity)a 7.2% 1.8% 2.16 ns§ crease in the chi-square (SBΔχ2 = 7571.16, p = .001). The path from
14. Perceived Health 93.7% 87.5% 4.14 ns§ work ability to exhaustion (γ = -0.17, p = .03) and enthusiasm
(0 = problematic/very
(γ = 0.16, p = .01), respectively, were found to be significant. Con-
problematic; 1 = good/very
good)a versely, the path from work ability to cynicism was found not to be
significant (γ = −80.09, p = .46).
Notes: aMeasured at Time 1 only. §As BMI and perceived health were treated as The reverse model did not report a significant delta chi-square
a dichotomous variable, χ2 was employed; ns = not significant. (SBΔχ2=0.90, p = .82), compared with the stability model, M1
(SBΔχ2 = 9.84, p = .02). In this model, the TLI value was found to be
(0.53 ≤ r ≤ 0.62). All the correlations among the major study variables slightly below the cut-off (TLI = 0.89), and no cross-lagged association
showed significant associations in the expected direction. Regarding the was found to be significant (γexhaustion→workability = 0.008, p = .90;
control variables, physical demands were found to be negatively asso- γenthusiasm→workability = 0.03, p = .52; γcynicism→workability = 0.005,
ciated with work ability at Time 1 and psychological exhaustion at both p = .55).
time points. Age was significantly associated with all major study In comparison with the causality model (Δχ2M2-M4 = 1.02, p = .79),
variables, except enthusiasm at Time 1 and cynicism at Time 2. Edu- the reciprocal model (M4, Fig. 1) did not show a better fit to the data.
cators reporting a negative rate for their overall health also perceived a An inspection of the paths revealed that the reciprocal model confirmed
significantly lower level of work ability and enthusiasm and a sig- the results obtained in the two previous models: while the paths from
nificantly higher level of exhaustion at both time points. Conversely, work ability to both exhaustion (γ = -0.16, p = .03) and enthusiasm
mental demands, job tenure, and being overweight showed no sig- (γ = 0.18, p = .01) continued to show significant values, the other four
nificant association with the major study variables. paths were not significant (i.e., cynicism→workability, exhaustion→
workability, enthusiasm→workability, cynicism→workability).
3.2. Measurement model Finally, M2 (i.e., the model showing the best fit) was adjusted for
the effect of the control variables (i.e., age, perceived health, and
Table 3 presents the fit indices of the CFA. The hypothesized mea- physical demands). The model fit was found not to be satisfactory, as
surement model, consisting of four correlated latent factors, was the the CFI and TLI values were below 0.90. The last line of Table 4 pre-
only one showing a good fit at both measurement times (i.e., M4a and sents the goodness-of-fit indices of this model (M2a). However, as
M4b). The AIC and BIC confirmed that this four-factor model fit the global fits indicated lack of fit, single paths were not interpreted.
data significantly better than the alternative models with one, two, and In accordance with the present findings, while it is possible to ac-
three factors, respectively. At both survey times, all items in the four- cept H1 and H2, the other hypotheses (i.e., H3, H1r, H2r, H3r) ought to
factor model loaded significantly on their corresponding latent factors. be rejected.
Moreover, all the latent factors showed significant correlations.

Table 2
Correlations of variables within and between waves.
Range 1 2 3 4 5 6 7 8

1. Work ability Time 1 5–37 1

2. Work ability Time 2 5–37 0.62** 1
3. Psychological exhaustion Time 1 0–16 −0.55** −0.41** 1
4. Psychological exhaustion at Time 2 0–16 −0.48** −0.52** 0.61** 1
5. Job enthusiasm Time 1 0–20 0.36** 0.30** −0.29** −0.24** 1
6. Job enthusiasm Time 2 0–20 0.32** 0.39** −0.20** −0.40** 0.55** 1
7. Cynicism Time 1 0–20 −0.33** −0.20** 0.36** 0.24** −0.24** −0.13* 1
8. Cynicism Time 2 0–20 −0.27** −0.34** 0.31** 0.41** −0.14* −0.24** 0.53** 1
9. Mental demandsa 1–4 −0.10 ns −0.03 ns 0.09 ns 0.10 ns 0.09 ns 0.09 ns 0.08 ns 0.05 ns
10. Physical demandsa 1–4 −0.15** −0.06 ns 0.36** 0.25** −0.01 ns 0.01 ns 0.11 ns 0.05 ns
11. Agea – −0.13* −0.15** 0.13* 0.14* −0.14* −0.06 ns 0.07 ns 0.12*
12. Job tenurea – −0.09 ns −0.10 ns 0.09 ns 0.11 ns −0.05 ns −0.02 ns 0.06 ns 0.10 ns
13. BMI > 30 (1 = Obesity)a – 0.97 ns 1.71 ns −0.99 ns −0.57 ns −1.35 ns −0.45 ns 1.11 ns 0.31 ns
14. Perceived Health (0 = problematic/very problematic; 1 = good/very good)a – −5.63** −3.67** 3.61** 2.17* −3.43** −2.23* 0.40 ns 0.01 ns

Notes: **p ≤ 0.01 (two-tailed); *p ≤ 0.05 (two-tailed). aMeasured at Time 1 only; ns = not significant. §As BMI and perceived health were treated as a dichotomous
variable, t-test was employed; ns = not significant.

902
S. Viotti, et al. Safety Science 118 (2019) 898–906

Table 3
Confirmatory factor analyses (CFA): test of alternative models (good of fit indices).
χ2(df) df χ2/df CFI TLI SRMR RMSEA (CI) AIC BIC

Time 1 (a)
M1. One-factor model 874.745*** 152 5.75 0.58 0.52 0.10 0.12[0.10–0.12] 16626.58 1686.32
M2. Two-factor model 868.919*** 151 5.75 0.58 0.52 0.10 0.11[0.10–0.12] 16552.65 16776.25
M3.Three-factor model 433.577*** 149 2.90 0.83 0.81 0.07 0.07[0.06–0.08] 16095.63 16326.94
M4.Four-factor model 299.836*** 146 2.05 0.91 0.90 0.06 0.05[0.05–0.06] 15959.44 16202.31

Time 2 (b)
M1. One-factor model 790.679*** 152 5.20 0.62 0.58 0.09 10[0.10–0.11] 1.1390 –
M2. Two-factor model 736.790*** 151 4.87 0.65 0.61 0.09 10[0.10–0.11] 1.0939 M1b-M2b
M3. Three-factor model 396.279*** 149 2.65 0.85 0.83 0.07 0.07[0.06–0.08] 1.0915 M2b-M3b
M4. Four-factor model 264.678*** 146 1.81 0.93 0.91 0.05 0.04[0.05–0.06] 1.0596 M3b-M4b

Note: df = degree of freedom. CFI = Comparative Fit Index. TLI = Tucker-Lewis Index. SRMR = Standardized Root Mean Square Residual. RMSEA = Root Mean
Square Error of Approximation. AIC = Akaike Information Criterion. BIC = Bayes Information Criterion. ***p = .0001.

Table 4
Cross-lagged associations (SEM) – Test of alternative models – Goodness-of-fit indices.
χ2 Df χ2/df CFI TLI SRMR RMSEA (CI) Scaling Correction Factor for MLR Model comparisons Δχ2(p)

M1 (stability model) 1046.924*** 630 1.66 0.91 0.90 0.06 0.04[0.04–0.05] 1.0212 –
M2 (causality model) 1037.962*** 627 1.65 0.91 0.90 0.06 0.04[0.04–0.05] 1.0220 M1-M2 7571.16***
M3 (reversed causation model) 1045.428*** 627 1.67 0.90 0.89 0.06 0.04[0.04–0.05] 1.0219 M1-M3 0.90 ns
M4 (reciprocity model) 1037.017*** 624 1.66 0.91 0.90 0.06 0.04[0.04–0.05] 1.0210 M2-M4 1.02 ns
M2a (adjusted for control variables) 1416.397*** 717 1.97 0.86 0.84 0.06 0.05[0.05–0.06] 1.0021 — —

Note: df = degree of freedom. CFI = Comparative Fit Index. TLI = Tucker-Lewis Index. SRMR = Standardized Root Mean Square Residual. RMSEA = Root Mean
Square Error of Approximation. ***p = .0001. ns = not significant.

4. Discussion
The aim of the present study was to examine the relationship be-
tween work ability and burnout in a sample of early childhood edu-
cators. As the literature reports a shortcoming regarding the direction of
this relationship, we tested a series of models, underlying three possible
scenarios: whether work ability predicts burnout sub-dimensions (i.e.,
normal causality); whether burnout sub-dimensions predicts work
ability (i.e., reverse causality); and whether work ability and burnout
reciprocally affect each other over time (i.e., reciprocal causality).
Our study showed that the normal causality model had a better fit to
the data over the other two competing models. In particular, whereas
no cross-lagged associations were found between work ability and
cynicism, higher levels of work ability led to increased enthusiasm and
reduced exhaustion measured at a distance of one year. Conversely,
exhaustion and enthusiasm were found not to significantly predict work
ability.
By employing a cross-lagged design, the present study advances the
current literature on two main points. First, it clarifies that on a short
term (i.e., one year) work ability predicts burnout. Previous studies
have provided evidence for the reverse causation. However, these
previous studies showed important shortcomings from a methodolo-
gical point of view; even though studies employed a longitudinal design
in examining the relationship between work ability and some burnout
subdimensions (e.g., Airila et al., 2012), none of them controlled this
relationship for the opposite paths (i.e., cross-lagged design). The

Time 1 Time 2

Work ability Work ability

H1: -.16*

H1r: ns

Exhaustion Exhaustion

H2: .17**
H2r: ns

Enthusiasm Enthusiasm
H3: ns
H3r: ns

Cynicism Cynicism

Fig. 1. The reciprocal model. Note. Solid arrows represent significant paths. Dashed arrows represent non-significant paths. For the sake of clarity, only significant
paths referring to study hypotheses were reported.

903
S. Viotti, et al.
results obtained in the present study may appear to be in contrast with
COR theory (Hobfoll, 1989), which suggests that psychological and
health-related resources reciprocally affect each other. Our results also
seem to contradict those of the study by Airila et al. (2014), which, even
if it did not employ a full cross-lagged study, suggested the reciprocal
relationship between work ability and work engagement over ten years.
However, our findings do not necessarily contradict the evidence re-
corded in Airila et al. (2014) and the COR theory (Hobfoll, 1989). The
lack of the significance of the paths from the burnout dimensions to
work ability in our study may suggest that one year, which is a short-
term distance, is not a sufficient time lag to observe the development of
this mechanism. In particular, this evidence suggests that the loss spiral
initiated by a reduction in health-related resources may be more rapid
in momentum when compared with a loss spiral initiated by a reduction
of psychological energy. Reduced levels of work ability may very
quickly lead to the “break point” because, in order to try to rebalance
the disequilibrium between personal resources and the demands posed
by the job, a worker may need to expend extra compensatory efforts by
employing extra amounts of energy (Gorgievsky and Hobfoll, 2008).
Chronic use of this strategy may lead the worker to develop burnout
symptoms. However, chronic levels of burnout may require longer time
(e.g., ten year) to erode health-related resources, such as work ability.
This is because this process involves the deep modification of bio-
chemical body conditions, thereby gradually leading to an alteration in
the worker’s health status and/or functional capacity (Gorgievsky and
Hobfoll, 2008). In order to ascertain the accuracy of this interpretation,
future studies should employ multi-wave cross-lagged designs, in-
cluding different timeframes (e.g., one year, five years, and ten years).
This would ascertain whether, and in which timeframe, burnout and
work ability reciprocally affect each other.
The second important contribution of the present study is its iden-
tification of the specific burnout components affecting work ability. No
previous study has simultaneously assessed the relationship between
work ability and all the burnout sub-dimensions. Most studies have
focused on examining the relationship between work ability and work
engagement, which represents the motivational component of burnout
(e.g., Airila et al., 2012). Fewer studies have considered exhaustion, the
energetic component of burnout (e.g., Glise et al., 2010). The present
study demonstrated the influence of work ability on all the dimensions.
Interestingly, work ability was found to be more strongly related to
enthusiasm toward the job than exhaustion. This is in accordance with
previous findings employing the COR theoretical framework (Hobfoll,
1989), which found that personal resources are more strongly related to
motivational (i.e., enthusiasm) than energetic (exhaustion) burnout
component (Bakker et al., 2014).
Surprisingly, the relationship between work ability and cynicism
was found not to be significant. A possible explanation can again be
found in the time frame employed: cynicism may represent a longer-
term effect of work ability, and a time frame of one year may be too
short to observe this relationship to be significant. This is also in ac-
cordance with previous studies (Gil-Monte, 2012; Guidetti et al., 2018)
demonstrating that while reduced enthusiasm toward the job and ex-
haustion represent early burnout symptoms, cynicism arises in the later
phases of this syndrome. Future study might employ three-wave panel
design to examine whether enthusiasm and exhaustion represent
mediators in the relationship between work ability and cynicism.
The findings from the present study have relevant practical im-
plications, indicating that a decrease in work ability is an early pre-
cursor of burnout among early childhood educators, and possibly in
general among caregiving occupations. Previous literature has in-
dicated that the most appropriate types of intervention to prevent
burnout among caregiving professionals are those primarily addressed
at boosting the psychological (e.g. self-efficacy), social, and job re-
sources that directly help workers in better managing the relationship
with their recipients. Conversely, the current results have highlighted
the centrality of supporting work ability in preventing burnout for
904
Safety Science 118 (2019) 898–906
caregiving professionals. Based on our results, it is possible to identify
two main categories of intervention. The first category includes inter-
ventions focused on the workplace and work characteristics. In parti-
cular, interventions at the task level, such as job redesign or ergonomic
modifications of the work environment, may be crucial for promoting a
healthy and satisfactory working life (Van der Meer et al., 2016; Zarei
et al., 2016). The second category is health promotion programs aimed
at enabling workers to increase control over their health, and at en-
couraging workers to adopt a healthier lifestyle (e.g. diet modification
or the introduction of low-intensity physical activities) (Pohjonen and
Ranta, 2001; De Boer et al., 2007).
Finally, due to the ageing workforce, workers with poor work ability
due to health problems and chronic diseases are becoming more nu-
merous, with the number expected to increase in the coming years
(Milczarek et al., 2007). Given this fact, job design and ergonomic in-
terventions specifically for workers with chronic diseases, with the aim
of improving their fitness in terms of their health needs and the job,
may enhance their perception of work ability, thus preventing burnout
development and preserving the quality of service they can offer.
4.1. Limitations
The present study has limitations. In particular, two main concerns
should be made explicit, one of which is that all the measures employed
were self-reported. Single-source data may introduce the issue of
common method variance (Podsakoff et al., 2003). Future studies may
benefit from employing research designs that include a combination of
objective and subjective measures or from using data from multiple
sources (i.e., diagnosis, medical assessment, etc.).
Moreover, the use of a non-randomized sample represents a limiting
factor. The study participants comprised a specific professional group,
i.e., pre-school teachers from a single municipality. Therefore, caution
should be exercised when generalizing the results to the wider Italian
pre-kindergarten sector as well as to teachers of other grades.
4.2. Conclusion
The aim of the present study was to explore the directionality of the
relationship between wok ability and burnout in a sample of early
childhood educators. In order to ascertain the causal predominance
between the two constructs, a cross-lagged design was employed. The
main contribution of this study was to have shed light on the role of
reduced work ability in causing, on a short term (one year later), ex-
haustion and reduced enthusiasm toward the job. The present study has
relevant practical implications, indicating that interventions aimed at
fostering work ability are crucial to prevent burnout and thus to im-
prove the quality of services.
Appendix A. Supplementary material
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ssci.2019.06.027.
References
Ahola, K., Toppinen-Tanner, S., Huuhtanen, P., Koskinen, A., Väänänen, A., 2009.
Occupational burnout and chronic work disability: An eight-year cohort study on
pensioning among Finnish forest industry workers. J. Affect. Disord. 115 (1),
150–159. https://doi.org/10.1016/j.jad.2008.09.021.
Airila, A., Hakanen, J.J., Schaufeli, W.B., Luukkonen, R., Punakallio, A., Lusa, S., 2014.
Are job and personal resources associated with work ability 10 years later? The
mediating role of work engagement. Work Stress 28 (1), 87–105. https://doi.org/10.
1080/02678373.2013.872208.
Airila, A., Hakanen, J., Punakallio, A., Lusa, S., Luukkonen, R., 2012. Is work engagement
related to work ability beyond working conditions and lifestyle factors? Int. Arch.
Occup. Environ. Health 85 (8), 915–925. https://doi.org/10.1007/s00420-012-
0732-1.
Argentin, G., 2013. Come cambia la forza lavoro nel sistema scolastico. Le tendenze de-
mografiche degli insegnanti italiani, 1990–2010. Sociologia del Lavoro 131, 74–88.
S. Viotti, et al.
https://doi.org/10.3280/SL2013-131005.
Awa, W.L., Plaumann, M., Walter, U., 2010. Burnout prevention: a review of intervention
programs. Patient Educ. Couns. 78 (2), 184–190. https://doi.org/10.1016/j.pec.
2009.04.008.
Bakker, A.B., Demerouti, E., 2008. Towards a model of work engagement. Career Dev. Int.
13 (3), 209–223. https://doi.org/10.1108/13620430810870476.
Bakker, A.B., Demerouti, E., Sanz-Vergel, A.I., 2014. Burnout and work engagement: the
JD–R approach. Annu. Rev. Org. Psychol. Org. Behav. 1 (1), 389–411. https://doi.
org/10.1146/annurev-orgpsych-031413-091235.
Bentler, P.M., 1995. EQS Structural Equations Program Manual. Multivariate Software,
Encino, CA.
Bliese, P.D., 2000. Within-group agreement, non-independence, and reliability:
Implications for data aggregation and analysis. In: Klein, K.J., Kozlowski, S.W.J.
(Eds.), Multilevel Theory, Research, and Methods in Organizations: Foundations,
Extensions, and New Directions. Jossey-Bass, San Francisco, pp. 349–381.
Blöchliger, O.R., Bauer, G.F., 2018. Correlates of burnout symptoms among child care
teachers. A multilevel modeling approach. Eur. Early Childhood Educ. Res. J. 26 (1),
7–25. https://doi.org/10.1080/1350293X.2018.1412012.
Bresó, E., Schaufeli, W.B., Salanova, M., 2011. Can a self-efficacy-based intervention
decrease burnout, increase engagement, and enhance performance? A quasi-experi-
mental study. Higher Educ. 61 (4), 339–355. https://doi.org/10.1007/s10734-010-
9334-6.
Byrne, B.M., 1998. Structural Equation Modeling with LISREL, PRELIS and SIMPLIS: Basic
Concepts, Applications and Programming. Erlbaum, Mahwah, NJ.
Converso, D., Viotti, S., Sottimano, I., Cascio, V., Guidetti, G., 2015. Work ability, psycho-
physical health, burnout, and age among nursery school and kindergarten teachers: a
cross-sectional study. La Medicina del lavoro 106 (2), 91–108.
de Boer, A.G., Burdorf, A., van Duivenbooden, C., Frings-Dresen, M.H., 2007. The effect of
individual counselling and education on work ability and disability pension: a pro-
spective intervention study in the construction industry. Occup. Environ. Med. 64
(12), 792–797. https://doi.org/10.1136/oem.2006.029678.
De Simone, S., Planta, A., Cicotto, G., 2018. The role of job satisfaction, work engage-
ment, self-efficacy and agentic capacities on nurses' turnover intention and patient
satisfaction. Appl. Nurs. Res. 39, 130–140. https://doi.org/10.1016/j.apnr.2017.11.
004.
Gil-Monte, P.R., 2012. The influence of guilt on the relationship between burnout and
depression. Eur. Psychol. 17, 231–236. https://doi.org/10.1027/1016-9040/
a000096.
Gil-Monte, P.R., Figueiredo-Ferraz, H., 2013. Psychometric properties of the ‘Spanish
Burnout Inventory among employees working with people with intellectual dis-
ability. J. Intellect. Disabil. Res. 57 (10), 959–968. https://doi.org/10.1111/j.1365-
2788.2012.01591.x.
Glise, K., Hadzibajramovic, E., Jonsdottir, I.H., Ahlborg, G., 2010. Self-reported exhaus-
tion: a possible indicator of reduced work ability and increased risk of sickness ab-
sence among human service workers. Int. Arch. Occup. Environ. Health 83 (5),
511–520. https://doi.org/10.1007/s00420-009-0490-x.
Gorgievski, M.J., Hobfoll, S.E., 2008. Work can burn us out or fire us up: Conservation of
resources in burnout and engagement. In: Halbesleben, J.R.B. (Ed.), Handbook of
Stress and Burnout in Health Care. Nova Science Publishers, Hauppauge, NY, pp.
7–22.
Grabara, M., Nawrocka, A., Powerska-Didkowska, A., 2018. The relationship between
physical activity and work ability–a cross-sectional study of teachers. Int. J. Occup.
Med. Environ. Health 31 (1), 1–9. https://doi.org/10.13075/ijomeh.1896.01043.
Green, D.E., Walkey, F.H., Taylor, A.J., 1991. The three-factor structure of the Maslach
Burnout Inventory: a multicultural, multinational confirmatory study. J. Soc. Behav.
Personal. 6 (3), 453–472.
Guidetti, G., Viotti, S., Gil-Monte, P.R., Converso, D., 2018. Feeling guilty or not guilty.
Identifying burnout profiles among Italian Teachers. Curr. Psychol. 37 (4), 769–780.
https://doi.org/10.1007/s12144-016-9556-6.
Hakanen, J.J., Bakker, A.B., Schaufeli, W.B., 2006. Burnout and work engagement among
teachers. J. Sch. Psychol. 43, 495–513. https://doi.org/10.1016/j.jsp.2005.11.001.
Hall-Kenyon, K.M., Bullough, R.V., MacKay, K.L., Marshall, E.E., 2014. Preschool teacher
well-being: a review of the literature. Early Childhood Educ. J. 42 (3), 153–162.
https://doi.org/10.1007/s10643-013-0595-4.
Hobfoll, S.E., 1989. Conservation of resources. A new attempt at conceptualizing stress.
Am. Psychol. 44, 513–524. https://doi.org/10.1037/0003-066X.44.3.513.
Hobfoll, S.E., Shirom, A., 2001. Conservation of resources theory: applications to stress
and management in the workplace. In: Golembiewski, R.T. (Ed.), Handbook of
Organizational Behavior, second ed. Marcel Dekker, New York, NY, pp. 57–80.
Hobfoll, S.E., Johnson, R.J., Ennis, N., Jackson, A.P., 2003. Resource loss, resource gain,
and emotional outcomes among inner city women. J. Pers. Soc. Psychol. 84 (3),
632–643. https://doi.org/10.1037/0022-3514.84.3.632.
Hu, L., Bentler, P.M., 1999. Cutoff criteria for fit indexes in covariance structure analysis:
conventional criteria versus new alternatives. Struct. Equ. Model. 6, 1–55. https://
doi.org/10.1080/10705519909540118.
Huang, J., Wang, Y., You, X., 2016. The job demands-resources model and job burnout:
the mediating role of personal resources. Curr. Psychol. 35 (4), 562–569. https://doi.
org/10.1007/s12144-015-9321-2.
Ilmarinen, J., Tuomi, K., Klockars, M., 1997. Changes in the work ability of active em-
ployees over an 11-year period. Scand. J. Work Environ. Health 23 (1), 49–57.
Ilmarinen, J., Tuomi, K., Seitsamo, J., 2005. New dimensions of work ability. Int. Congr.
Ser. 1280, 3–7. https://doi.org/10.1016/j.ics.2005.02.060.
Innstrand, S.T., Espnes, G.A., Mykletun, R., 2004. Job stress, burnout and job satisfaction:
an intervention study for staff working with people with intellectual disabilities. J.
Appl. Res. Intellect. Disabil. 17 (2), 119–126. https://doi.org/10.1111/j.1360-2322.
2004.00189.x.
905
Safety Science 118 (2019) 898–906
Janssen, P.P., Schaufeli, W.B., Houkes, I., 1999. Work-related and individual determi-
nants of the three burnout dimensions. Work Stress 13 (1), 74–86. https://doi.org/
10.1080/026783799296200.
Khan, F., Ng, L., Turner-Stokes, L., 2009. Effectiveness of vocational rehabilitation in-
tervention on the return to work and employment of persons with multiple sclerosis.
Cochrane Database Syst. Rev. 1, CD007256. https://doi.org/10.1002/14651858.
CD007256.pub2.
Kristensen, T.S., Hannerz, H., Høgh, A., Borg, V., 2005. The Copenhagen Psychosocial
Questionnaire-a tool for the assessment and improvement of the psychosocial work
environment. Scand. J. Work Environ. Health 438–449.
Kline, R.B., 2005. Principles and Practices of Structural Equation Modeling, second ed.
Guilford Press, New York, NY.
Lewis-Beck, M.S., Bryman, A., Liao, T.F., 2004. Encyclopedia of Social Science Research
Methods. Sage Publications, London.
Mache, S., Danzer, G., Klapp, B.F., Groneberg, D.A., 2013. Surgeons’ work ability and
performance in surgical care: relations between organisational predictors, work en-
gagement and work ability. Langenbeck's Arch. Surg. 398 (2), 317–325. https://doi.
org/10.1007/s00423-012-1044-3.
Maslach, C., 2003. Job burnout: new directions in research and intervention. Curr. Direct.
Psychol. Sci. 12 (5), 189–192. https://doi.org/10.1111/1467-8721.01258.
Maslach, C., Schaufeli, W.B., Leiter, M.P., 2001. Job burnout. Annu. Rev. Psychol. 52,
397–422. https://doi.org/10.1146/annurev.psych.52.1.397.
McGonagle, A.K., Barnes-Farrell, J.L., Di Milia, L., Fischer, F.M., Hobbs, B.B., Iskra-Golec,
I., Smith, L., 2014. Demands, resources, and work ability: a cross-national ex-
amination of health care workers. Eur. J. Work Org. Psychol. 23, 830–846. https://
doi.org/10.1080/1359432X.2013.819158.
McGonagle, A.K., Fisher, G.G., Barnes-Farrell, J.L., Grosch, J.W., 2015. Individual and
work factors related to perceived work ability and labor force outcomes. J. Appl.
Psychol. 100, 376–398. https://doi.org/10.1037/a0037974.
Meade, A.W., Johnson, E.C., Braddy, P.W., 2008. Power and sensitivity of alternative fit
indices in tests of measurement invariance. J. Appl. Psychol. 93, 568–592. https://
doi.org/10.1037/0021-9010.93.3.568.
Mészáros, V., Ádám, S., Szabó, M., Szigeti, R., Urbán, R., 2014. The bifactor model of the
Maslach Burnout Inventory-Human Services Survey (MBI-HSS)—An alternative
measurement model of burnout. Stress Health 30 (1), 82–88. https://doi.org/10.
1002/smi.2481.
Milczarek, M., Brun, E., Houtman, I., Goudswaard, A., Evers, M., Bovenkamp, M.,
Morvan, E., 2007. Expert Forecast on Emerging Psychosocial Risks Related to
Occupational Safety and Health. European Agency for Safety and Health at Work.
Office for Official Publications of the European Communities, Luxembourg.
Okorodudu, D.O., Jumean, M.F., Montori, V.M., Romero-Corral, A., Somers, V.K., Erwin,
P.J., Lopez-Jimenez, F., 2010. Diagnostic performance of body mass index to identify
obesity as defined by body adiposity: a systematic review and meta-analysis. Int. J.
Obesity 34 (5), 791–799. https://doi.org/10.1038/ijo.2010.5.
OECD, Organization for Economic Cooperation and Development, 2014. Education
Indicators in Focus. http://www. oecd.org/education/skills-beyond-school/
EDIF2014No.20(eng).pdf.
Pak, K., Kooij, D.T., De Lange, A.H., Van Veldhoven, M.J., 2018. Human Resource
Management and the ability, motivation and opportunity to continue working: a
review of quantitative studies. Hum. Resour. Manage. Rev. https://doi.org/10.1016/
j.hrmr.2018.07.002. (on-line first).
Podsakoff, P.M., MacKenzie, S.B., Lee, J.Y., Podsakoff, N.P., 2003. Common method
biases in behavioral research: a critical review of the literature and recommended
remedies. J. Appl. Psychol. 88 (5), 879–903. https://doi.org/10.1037/0021-9010.88.
5.879.
Pohjonen, T., Ranta, R., 2001. Effects of worksite physical exercise intervention on
physical fitness, perceived health status, and work ability among home care workers:
five-year follow-up. Prev. Med. 32 (6), 465–475. https://doi.org/10.1006/pmed.
2001.0837.
Rentzou, K., 2012. Examination of work environment factors relating to burnout syn-
drome of early childhood educators in Greece. Child Care Pract. 18 (2), 165–181.
https://doi.org/10.1080/13575279.2012.657609.
Rongen, A., Robroek, S.J., Schaufeli, W., Burdorf, A., 2014. The contribution of work
engagement to self-perceived health, work ability, and sickness absence beyond
health behaviors and work-related factors. J. Occup. Environ. Med. 56 (8), 892–897.
https://doi.org/10.1097/JOM.0000000000000196.
Siu, O.L., Cooper, C.L., Phillips, D.R., 2014. Intervention studies on enhancing work well-
being, reducing burnout, and improving recovery experiences among Hong Kong
health care workers and teachers. Int. J. Stress Manage. 21 (1), 69–84. https://doi.
org/10.1037/a0033291.
Sottimano, I., Viotti, S., Guidetti, G., Converso, D., 2017. Protective factors for work
ability in preschool teachers. Occup. Med. 67 (4), 301–304. https://doi.org/10.1093/
occmed/kqx031.
Tamminga, S.J., De Boer, A.G.E.M., Verbeek, J.H.A.M., Frings-Dresen, M.H.W., 2010.
Return-to-work interventions integrated into cancer care: a systematic review. Occup.
Environ. Med. 67 (9), 639–648. https://doi.org/10.1136/oem.2009.050070.
Taris, T.W., Le Blanc, P.M., Schaufeli, W.B., Schreurs, P.J., 2005. Are there causal re-
lationships between the dimensions of the Maslach Burnout Inventory? A review and
two longitudinal tests. Work Stress 19 (3), 238–255. https://doi.org/10.1080/
02678370500270453.
Tuomi, K., Ilmarinen, J., Jahkola, A., Katajarinne, L., Tulkki, A., 1998. Work Ability
Index, second rev. ed. Finnish Institute of Occupational Health, Helsinki, Finland.
Van den Berg, T.I., Elders, L.A., de Zwart, B.C., Burdorf, A., 2009. The effects of work-
related and individual factors on the Work Ability Index: a systematic review. Occup.
Environ. Med. 66, 211–220. https://doi.org/10.1136/oem.2008.039883.
Van der Meer, L., Leijten, F.R., Heuvel, S.G., Ybema, J.F., de Wind, A., Burdorf, A.,
S. Viotti, et al.
Geuskens, G.A., 2016. Company policies on working hours and night work in relation
to older workers’ work ability and work engagement: results from a Dutch long-
itudinal study with 2-year follow-up. J. Occup. Rehabil. 26 (2), 173–181. https://doi.
org/10.1007/s10926-015-9599-9.
Viotti, S., Guidetti, G., Loera, B., Martini, M., Sottimano, I., Converso, D., 2017. Stress,
work ability, and an aging workforce: a study among women aged 50 and over. Int. J.
Stress Manage. 24 (S1), 98–121. https://doi.org/10.1037/str0000031.
Whitaker, R.C., Dearth-Wesley, T., Gooze, R.A., 2015. Workplace stress and the quality of
teacher–children relationships in Head Start. Early Childhood Res. Quart. 30, 57–69.
https://doi.org/10.1016/j.ecresq.2014.08.008.
906
Safety Science 118 (2019) 898–906
Xanthopoulou, D., Bakker, A.B., Demerouti, E., Schaufeli, W.B., 2007. The role of per-
sonal resources in the job demands–resources model. Int. J. Stress Manage. 14,
121–141. https://doi.org/10.1037/1072-5245.14.2.121.
Zapf, D., Dormann, C., Frese, M., 1996. Longitudinal studies in organizational stress re-
search: a review of the literature with reference to methodological issues. J. Occup.
Health Psychol. 1 (2), 145–169. https://doi.org/10.1037/1076-8998.1.2.145.
Zarei, E., Khakzad, N., Reniers, G., Akbari, R., 2016. On the relationship between safety
climate and occupational burnout in healthcare organizations. Saf. Sci. 89, 1–10.
https://doi.org/10.1016/j.ssci.2016.05.011.