Burnout syndrome in nursing undergraduate students

Burnout syndrome in nursing undergraduate students

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Original ARTICLE

Burnout syndrome in nursing undergraduate students A síndrome de burnout em graduandos de enfermagem Juliana Inhauser Riceti Acioli Barboza1, Ruth Beresin2

ABSTRACT Objectives: To classify nursing students on a socio-demographic basis in order to check whether they are acquainted with the meaning of the term burnout syndrome; to check for the presence of the burnout syndrome and assess its levels in undergraduate nurses. Methods: A cross-section study was carried out of 102 students at the Nursing School of the Hospital Israelita Albert Einstein. A questionnaire was made up by the authors and applied along with the Maslachs Burnout Inventory (MBI). Results: Ninety-five percent of students were female, aged 18 to 50 years, 86% were single and 51% reported having jobs. Most of the surveyed subjects were not acquainted with the term burnout syndrome. Out of the total of 39 students, 56.9% classified the disease as being psychological and caused by professional stress. As for the mean MBI subscales, it was found that a relatively high mean (28.6%) referred a low feeling of professional accomplishment, a low/ moderate mean (23.09%) were emotionally exhausted and (9.176%) felt depersonalized, which intrinsically proves the absence of burnout syndrome in the sample. As for burnout dimensions, the findings showed that 73.5% are at a low/moderate level of emotional exhaustion; 70.53% suffer from a low/moderate level of depersonalization; and 76% reported a high feeling of professional accomplishment. Conclusion: High means were found at the dimensions of reduced professional accomplishment, which calls for the need to intervene in the case of these students so that they may recall their primary initiative concerning their professional choice. Keywords: Burnout, professional/nursing; Stress, psychological/ nursing; Students, nursing/psychology;Occupational diseases/ nursing

RESUMO Objetivos: Caracterizar de forma sociodemográfica os graduandos de enfermagem, verificar se os graduandos conhecem a definição do termo síndrome de burnout, verificar a presença da síndrome de Burnout nos graduandos e avaliar os níveis da síndrome de Burnout em graduandos. Métodos: Estudo transversal realizado em uma amostra

de 102 graduandos matriculados na Faculdade de Enfermagem do Hospital Israelita Albert Einstein, sendo aplicados o “Inventário de Burnout de Maslach” (MBI) e um questionário elaborado pelas autoras. Resultados: 95% dos graduandos eram do sexo feminino, com relação à idade houve uma variação de 18 a 50 anos, 86% eram solteiros e 51% dos graduandos referiram trabalhar. A maioria dos graduandos relatou não conhecer a definição de síndrome de burnout. Entre o total de 39 graduandos que referiram conhecer a definição de síndrome de Burnout, 56,4% definiram-na como sendo uma doença psicológica causada pelo estresse de uma profissão. Verificaram-se quanto às médias das subescalas do MBI uma média elevada (28,6) em reduzida realização profissional, médias baixa/moderada (23,09) em exaustão emocional e em despersonalização (9,176), demonstrando que nesta amostra não há presença da síndrome de burnout. Quanto aos níveis de burnout em dimensões, verificou-se que 73,51% apresentam baixo/moderado nível de exaustão emocional; 70,56% baixo/moderado nível de despersonalização e 76% alto nível de reduzida realização profissional. Conclusão: Observou-se uma elevada média na dimensão “reduzida realização profissional”, o que sinaliza a necessidade de uma intervenção junto a estes graduandos para que possam encontrar a motivação inicial da sua escolha profissional. Descritores: Estafa profissional/enfermagem; Estresse psicológico/ enfermagem; Estudantes de enfermagem/psicologia; Doenças profissionais/enfermagem

INTRODUCTION In the beginning of adult life important changes generally occur in the life of individuals. It is a stage of life full of expectations and decision taking that might play a key role in the future of young adults. During this time, youths are still searching to find themselves, which is typically a transition and adaptation period into the adult phase. Besides that, the exposure to a new educational (university) and work environments leads to inquiries that range from the ability to cope with uncertainty,

Study carried out at Faculdade de Enfermagem do Hospital Israelita Albert Einstein (HIAE), São Paulo (SP), Brazil. 1

Graduate student in Neurology at the Hospital das Clínicas, Medical School, Universidade de São Paulo – USP, São Paulo (SP), Brazil.

2

Master’s degree, Lecturer in charge of the subjects Psychology Applied to Health and Sociology and Philosophical Anthropology at the Nursing School, Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.

Corresponding author: Juliana Inhauser Riceti Acioli Barboza – Rua Sílvio de Souza, 280 – ap. 34 – Jardim Santa Clara – CEP 03273-500 – São Paulo (SP), Brasil – Tel.: 11 6104-7790 – e-mail: juinhauser@ yahoo.com.br Received on Mar 17, 2007 – Accepted on Jun 15, 2007

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Barboza JIRA, Beresin R

contradiction and imperfection to issues related to commitment and responsibility(1). In face of this, decisions must be taken regarding, for instance, the hard task of choosing a profession, academic education and work(). Work, one of the most relevant aspects in the shaping of the individual identity, where they will actually take a stand in life and be faced with a more complex development of social interactions, may become a stress factor. Thus, many studies point out stress among health professionals in general, including nurses(2). Taking this into account, some nursing graduates show a difficulty in organizing themselves as to new functions established by the profession, which requires care, flexibility and complexity for the care taking of another human being. Furthermore, it is the time when some of these individuals will conciliate the dynamics of their lives and develop the senses of discipline, responsibility and the ability to solve conflicts both internally and externally. A situation is hence created, in which emotional instability and misadapted conducts may lead these undergraduates to develop the Burnout Syndrome(2). In English, the term “burnout” means to burn or destroy by means of fire. It is a labor site syndrome that features a chronic occupational stress-response process, when confronting methods fail or come short, entailing negative consequences at the individual, professional, family and social levels(3). According to psychoanalyst Freudenberger, who first approached the term in the field of Psychology, the burnout syndrome is also defined as a result of intense work that is disregardful of the needs of the individual, which leads not only to physical but also emotional wearout(4). Thus, “burnout” is here defined as a “failure, inside out burn, becoming worn out by the over-expenditure of energy, force or resources”. The term was further spread by Cristina Maslach and Susan Jackson in more recent studies over the last years(4). According to Maslach and Jackson, the burnout syndrome affects professionals in direct relation with people who are exposed to chronic stress, in which they stay for a generally extended period of time(5). In this way, health-assisting professionals are the most affected ones because they are in constant contact with people in problem situations and overwhelmed with heavy emotional loads (6). The development of the disease may occur in a random fashion, thus not following an order or steps, for it is considered a syndrome (2). The main characteristics of burnout syndrome are emotional exhaustion, depersonalization and reduced professional feeling of professional accomplishment, or simply lower personal and professional satisfaction(2,4). einstein. 2007; 5(3):225-230

The symptoms found may be grouped into four areas: psychosomatic, behavioral, emotional and defensive. The psychosomatic symptoms are onset of headache; muscle tensions; gastrointestinal alterations; weight loss; insomnia; asthma; and arterial hypertension(7). The behavioral symptoms are absence of work; increased violent behavior; inability to relate to other people; drug abuse; and family problems. Emotional symptoms are pinpointed by affective distance, impatience, irritability, difficulty in concentrating and memorizing. Finally, defensive symptoms are emotional denial, social detachment and selective attention – all that can avoid a negative experience(7). Nevertheless, the development of the burnout syndrome in undergraduate nurses sets in even before graduation, being assigned to the expectations generated upon them when entering university. However, when these expectations are not met over and at the end of the course, gradual and chronic stress arises (8). Still, Schwab et al reported that the burnout syndrome go much beyond these expectations regarding workers and working conditions(9). In a longitudinal study that aimed to prospectively investigate undergraduate nurses as for determinants and the inter-relation among the following factors: stress, burnout and university course dropouts, Deary et al. found that these aspects may not be directly related to each other. Yet, personality features at the beginning of the course contribute significantly to predicting the likelihood of developing burnout syndrome by the time of completion, unlike relations among the factors which proved not to be so marked(10). Hence, the lack of practice-based training, the little time for experience and professional skill development at university schools and clinical centers, become a problem for these youths who set out their professional tasks in the field of nursing. In this way, it is important to identify the level of impact caused by the burnout syndrome among nurse school graduates, since it is best to try to balance chores so that both life quality and professional background are kept high.

OBJECTIVES General objective To check for the presence of the burnout syndrome in undergraduate nursing students at the Hospital Israelita Albert Einstein Nursing School. Specific objectives • To classify undergraduate nursing students as to a sociodemographic characteristics.


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• To check whether the undergraduate nursing students

Thus, when high EE and DE scores are obtained, associated with low PA values, there is evidence for the burnout syndrome(4). The MBI was adapted into the Portuguese Language by Robayo-Tamayo(4). A questionnaire, made up by the authors, was also applied.

METHODS It’s a quantitative, descriptive and exploratory study, carried out with undergraduates enrolled in the first to the fourth grades of the Hospital Israelita Albert Einstein Nursing School, São Paulo – Brazil.

Procedures Data collection The procedures for data collection followed authorization granted by the institution to the study and a Researcher Commitment Term was signed. Next, nursing undergraduates were instructed and invited to sign the Informed Consent Form, moving onto to the next stage which consisted of answering to the Maslach Burnout Inventory. Last, they filled out the sociodemographic data form.

are acquainted with the term burnout syndrome. • To check for the presence of the burnout sydrome in undergraduate nursing students. • To assess the levels of the burnout syndrome in undergraduate nursing students.

Study design A cross-section study was carried out from January to October 2006, in a sample of 102 undergraduates enrolled in the first to the fourth grades at the nursing school. A questionnaire was made up and applied along with the Maslach Burnout Syndrome Inventory (MBI). Sample The sample of the study comprised 102 undergraduates from the Hospital Israelita Albert Einstein Nursing School, São Paulo – Brazil. The inclusion criteria were: • to be attending the 1st, 2nd, 3rd or 4th grades of the undergraduate nursing course; • to be available and to consent to participate in the study. Instrument The Maslach Burnout Syndrome Inventory (MBI), prepared by Cristina Maslach, was used as the assessing instrument of the present study. The MBI is questionnaire to be answered through a five-score frequency scale, ranging from one (never) to five (always). It features three subscale: Emotional Exhaustion (EE), Depersonalization (DE) and reduced Professional Accomplishment (rPA). EE consists of nine items and refers to both physical and mental exhaustion, to the feeling of having come to the limit of possibilities, whereas, DE contains five items consisting of behavior alterations by the individual upon the contact with the users of their services, when they take up a cold and impersonal attitude towards suffering, and, finally, rPA with eight items that measure the perception of the influence caused by others, the feeling comfortable at work as well as their relation with their own problems, which provides evidence for the feeling of dissatisfaction(4).

Data analysis The results were analyzed through a statistical descriptive analysis of the data (mean, standard deviation, median and percentages) and by a statistical program, MINITAB, for the consttion of accumulated frequency tables. The levels were estimated by adding up the scores within the factors (continuous variable), hence followed by distribution percentiles that established intervals for the identification of low/moderate and high scores (interval variable).

RESULTS A total 120 questionnaires were distributed to students at the Nursing School of the Hospital Israelita Albert Einstein, who attended the 1st through 4th grades of the undergraduate course. A total of 102 questionnaires were answered and handed back. Sociodemographic characteristics In the 102 undergraduate group surveyed, 95% were female. The age ranged from 18 to 50 years (mean age of 23 years; standard deviation of 6 years; median of 22 years). As to marital status, 86% were single, and 11% reported having children. Among these, 54% hade one child, 27% had two children and 18% had three or four children. Regarding religion, more than half sample (57%) reported religious practice, being 68% catholic. Furthermore, most of them (91%) lived in São Paulo, 83% lived with their families and 76.5% reported having their own home. Concerning remuneration, 51% reported having jobs (Table 1). einstein. 2007; 5(3):225-230

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Table 1. Distribution of sociodemographic characteristics of nursing undergraduates Variable Age

Category 18-25 years 26-50 years

N 80 22

% 78.3 21.7

Female Male

97 5

95 5

Single Married Divorced Widow/er

88 7 6 1

86 7 6 1

Children

No Yes

91 11

89 11

Religion

Catholic Evangelic Other No answer

70 13 16 3

68 13 16 3

Religion practicing

Yes No No answer

58 41 3

57 40 3

Place of birth

São Paulo Other

68 34

67 33

Brazil Other countries

101 1

99 1

Yes No

93 9

91 9

Lives with

Family Alone Student’s hall

85 9 8

83 9 8

Household

Own house Rent

78 24

76.5 23.5

Yes No

52 50 102

51 49 100

Sex Marital status

In 102 undergraduates surveyed, it was found that the highest mean (28.6%) corresponded to the reduced professional accomplishment subscale (Table 3). Table 3. MBI subscale means MBI Subscales

Mean

Standard deviation

Reduced professional accomplishment Emotional exhaustion Depersonalization

28.647 23.09 9.176

3.741 4.955 2.566

MBI = Maslach Burnout Syndrome Inventory

Nationality Lives in São Paulo

Remuneration Total

Presence of the burnout syndrome regarding MBI levels Among 102 undergraduates assessed, 76% presented a high level of reduced professional accomplishment, in contrast with 23% who showed a low/moderate level (Table 4). Table 4. Distribution by MBI levels Burnout syndrome levels High Moderate/Low

DE 29.40% 70.56%

rPA 76.45% 23.52%

Key: EE = Emotional exhaustion; DE = Depersonalization; rPA = Reduced professional accomplishment

Knowledge of the definition of burnout syndrome Among 102 undergraduates, most (62%) referred not being familiar with the definition of burnout syndrome. Out of 39 undergraduates who reported being acquainted with the definition of burnout syndrome, the majority (56.4%) defined it as being a psychological disease caused by professional stress (Table 2). Table 2. Distribution of nursing undergraduates according per definition of the term burnout syndrome Definitions of burnout syndrome

N

%

Psychological disease caused by professional stress

22

56.4

Exhaustion, tiredness and physical limitation due to work overload

15

38.5

Person becomes “cold” towards human beings and his/her work Total

2 39

5.1 100

Burnout syndrome in undergraduate nursing students Presence of burnout syndrome regarding MBI means einstein. 2007; 5(3):225-230

EE 26.46% 73.51%

Assessment of burnout syndrome levels in undergraduate nursing students according to dimensions Score distribution of undergraduate students related to emotional exhaustion In the group surveyed, 75% of the undergraduate nursing students present a score up to 25. Considering that score the cut-off point, it was found that 26.46% of students show a high level of emotional exhaustion and 73.51% showed a low/moderate score in this dimension (Table 5). Table 5. Scores of nursing undergraduates in emotional exhaustion Scores 12 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 37 38 Total

N 1 3 1 9 3 3 2 4 8 10 13 8 10 4 7 2 5 2 3 1 1 1 1 102

% 0.98 2.94 0.98 8.82 2.94 2.94 1.96 3.92 7.84 9.80 12.75 7.84 9.80 3.92 6.86 1.96 4.90 1.96 2.94 0.98 0.98 0.98 0.98 100.0

Accumulated % 0.98 3.92 4.90 13.73 16.67 19.61 21.57 25.49 33.33 43.14 55.88 63.73 73.53 77.45 84.31 91.18 93.14 96.08 96.08 97.06 98.04 99.02 100 100.0


Score distribution of undergraduate nursing students according to depersonalization In the group surveyed, 75% of the undergraduate nursing students presented a score up to 10. Considering 10 as the cut-off point, it was found that 29.40% of subjects showed a high level of emotional exhaustion and 70.56% presented a low/moderate score in this dimension (Table 6). Table 6. Scores of nursing undergraduates in depersonalization Scores

N

%

Accumulated %

5

6

5.85

5.88

6 7

11 14

10.78 13.73

16.67 30.39

8 9 10 11 12 13 14 17 Total

12 15 14 9 8 9 3 1 102

11.76 14.71 13.73 8.82 7.84 8.82 2.94 0.98 100.0

42.16 56.86 70.59 79.41 87.25 96.08 99.02 100 100.0

Score distribution of undergraduate nursing students according to reduced professional achievement In the group surveyed, 25% of the undergraduate nursing students presented a score up to 26. Considering 26 as the cut-off point, it was found that 76.45% of subjects showed a high level of emotional exhaustion and 23.52% showed a low/moderate score in this dimension (Table 7). Table 7. Scores of nursing undergraduates in reduced professional accomplishment Scores 17 20 22 23 24 25 26 27 28 29 30 31 32 33 34 36 37 Total

N 1 3 1 7 3 2 7 8 12 17 12 8 6 4 8 2 1 102

% 0.98 2.94 0.98 6.86 2.94 1.96 6.86 7.84 11.76 16.67 11.76 7.84 5.88 3.92 7.84 1.96 0.98 100.00

Accumulated % 0.98 3.92 4.90 11.76 14.71 16.67 23.53 31.37 43.14 59.80 71.57 79.41 85.29 89.22 97.06 99.02 100 100.00

DISCUSSION The sociodemographic characteristics of the present study confirms what other surveys reported about nursing student

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profile, that is, the predominance of the female gender (95%) in nursing undergraduates(11-12). It also reveals that the mean age among undergraduates is 23, thus confirming this as young professional category(11-12). Regarding knowledge of the subjects about the term burnout syndrome, the majority (62%) did not know its definition. According to a preliminary study about burnout syndrome in physiotherapists and physical therapy undergraduates, knowledge about the syndrome would ontribute to recognizing some triggering factors. As a consequence, it would help undergraduates to prevent and control the levels of burnout, thus properly favoring a high-quality working environment in their task of assisting patients(4,13). However, among the subjects of this study, who did know the definition to burnout syndrome, data corroborated with the definitions provided by Freudenberger as “failures, wear-out, becoming exhausted in face of excessive demands of energy, force or resource expenditure” and as a result of intense work regardless of meeting the needs of the individual, which leads not only to physical but also emotional wear-out(4). In the group of 102 nursing undergraduates surveyed, a high mean (28.647) was found in reduced professional accomplishment, contrasting with a low/moderate score in emotional exhaustion (23.09) and depersonalization (9.176), regarding the mean scores of the MBI subscales. Besides that, concerning the levels of burnout in dimensions, 73.51% of subjects were found to have a low/moderate level of emotional exhaustion; 70.56% a low/moderate level of depersonalization; and 76% a high level of reduced professional accomplishment. Thus, the findings demonstrate that in this sample there is no presence of the burnout syndrome, since it indicates high means of emotional exhaustion (EE) and depersonalization (DE) and a low mean in reduced professional accomplishment (rRA)(4,14-16). Therefore, the results show similarity to those of the burnout syndrome in university students in the field of healthcare, in which the results present a medium/low level of emotional exhaustion, low level in depersonalization, and high level in reduced professional accomplishment, thus neither being indicative of burnout syndrome(14). In the emotional exhaustion dimension it was observed that 26% of the nursing undergraduate students showed a high level of emotional exhaustion, differently from the other study, in which 70% of physiotherapy students showed high emotional exhaustion levels; hence, meaning both a physical and mental wear-out as well as a feeling of having reached the limits of possibilities(4,8,13). Nevertheless, it is worth stressing that this study evaluated exclusively undergraduate students einstein. 2007; 5(3):225-230

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of the fourth grade, differently from the present study which includes first to fourth graders, the pressures of the last term should be taken into account, since the lecturers require much hard work in their probation programs, they find themselves near the closing of the course, up against the competition of the market, on the search for good jobs and filled with expectations regarding their own career plan. It is relevant to note that in the depersonalization dimension, nursing undergraduates presented 70.56% of low/moderate level of depersonalization. This result was similar to another study in which subjects showed 83.5% of low/moderate level of depersonalization(4,13). Therefore, nursing undergraduates prove to suffer from little attitude changes when getting in touch with the users of their services and do not take up a cold and impersonal contact to their suffering. Thus, these results may corroborate with the hypothesis on the reliability of this subscale(2,4,8,13). As for the dimension of reduced professional accomplishment, it is relevant to note that 76.45% of nursing undergraduates refer a low feeling of professional accomplishment similarly to the other study in which 84% of subject-students reported a low professional accomplishment rate. Hence, it is found that the perception of the influence suffered by others, the feeling comfortable with the job as well as the relation of students with their own problems provides evidence for a feeling of dissatisfaction(4,13,16) .

CONCLUSION A high mean of “reduced professional accomplishment” dimension was found to signal the need for intervening in the case of undergraduate nursing students so that they may retrieve the initial motivation to their professional choice. ACKNOWLEDGEMENTS The authors wish to thank for the dedication and collaboration of Professor Ana Villares Musetti for the statistic analysis and librarian Denise de Moura

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Campos Claro for contributing to all stages of this research work process.

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