Exploring the Impact of the COVID-19 Pandemic on Academic Burnout Among Nursing College Students in China: A Web-Based Survey

Background

Burnout has been defined as a psychological syndrome characterized by 3 dimensions: emotional exhaustion, cynicism, and reduced personal accomplishment [1]. Early burnout studies were aimed at employees. Schaufeli et al [2] extended the concept to students and proposed that burnout was a combination of emotional exhaustion, academic inefficiency, and cynicism due to persistent failure to manage learning stress effectively. Moreover, Schaufeli et al [2] defined academic burnout as a combination of emotional exhaustion, cynicism, and academic inefficiency caused by the persistent failure to manage learning stress properly. Lian et al [3] proposed academic burnout as a series of negative psychological manifestations in learning caused by a lack of interest or excessive stress in learning that leads to negative attitudes and behaviors, indicating that students are tired of learning. Studies have shown that academic burnout has some adverse effects and can lead to unsatisfactory academic performance and poor mental health[4]. When exposed to chronic occupational stressors, individuals present significant burnout-related difficulties[5]. It is vital to investigate the academic burnout problem among nursing students because the research shows that burnout begins in medical school and persists long after graduation[6]. Given the importance of academic burnout conditions, especially for nursing students, academic burnout conditions have always been a hotspot of research.

Professional identity is the individual’s attitude and dedication to a profession, which reflects their willingness to continue to engage in the profession and their degree of liking the profession [7]. A study has shown that low professional identity is a risk factor for caregiver attrition [8]. Professional identity can also affect a student’s mental health [9]. Resilience generally refers to the ability of an individual’s dynamic system to adapt to disturbances that threaten system function, viability, and development [10]. Because it gives an individual the ability to bounce back and recover in the face of adversity, resilience can effectively promote an individual’s mental health [11]. Moreover, Li Y et al [12] found that the prevalence of depression and anxiety disorders in college students increased significantly during the COVID-19 pandemic, which had an enormous negative impact on the mental health of college students. A study found that nursing students relate their self-care factors with the severity of the strain they experience or their overall performance [13].

Owing to the different instruments used or the socio-cultural background of respondents, the reported prevalence of academic burnout among medical students varies. Many factors affect the levels of medical students’ academic burnout, such as sex [14], major area of study [6], grade [15], overload learning [16], personality characteristics [17], self-efficacy[18], and social support [19]. To summarize, studies have shown that a certain degree of academic burnout is widespread among medical students due to heavy academic pressure and severe competitive pressures. However, most studies have referred to all medical students, and there is less focus on nursing students. Therefore, it is necessary to investigate academic burnout and explore its influencing factors among nursing students.

Studies have shown that burnout is strongly associated with depression, suicide, and substance abuse [20,21]. Medical students with burnout are reported to be less effective at an educational and professional level [22]. They present more academic failure and absenteeism and drop out more frequently [23,24]. In addition, people with higher burnout scores are more likely to consume substances such as alcohol, tobacco, and drugs [25,26].

Due to the COVID-19 pandemic, all schools in mainland China started online learning, which is a massive challenge for nursing students. Online learning can make it difficult for nursing students to adapt. They can feel tired or frustrated and have difficulty adapting to this way of learning. Little is known about how the COVID-19 pandemic has affected nursing students’ learning, stress, and burnout levels. Although nursing student academic burnout is a growing concern, data have been limited in China. Academic burnout negatively affects the learning of nursing students and may reduce the quality of care provided to patients in their future work. Therefore, it was essential to conduct this survey to better understand academic burnout in nursing students.

Material and Methods

STUDY SETTING AND DESIGN:

An online cross-sectional survey of undergraduate nursing students enrolled in a medical college in Anhui Province in eastern China, was conducted using a self-reported, anonymous questionnaire.

This study strictly followed the items in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [27]. The questionnaire data were collected between April 1, 2022, and April 10, 2022. In this study, the inclusion criterion was the participation of freshmen, sophomores, and juniors pursuing a full-time undergraduate degree at Wannan Medical College. The exclusion criteria were students who were unwilling to participate and fourth-year nursing students.

SOCIODEMOGRAPHIC CHARACTERISTICS OF THE PARTICIPANTS:

The participants’ mean age was 21.6 years (SD, 1.12), and the age range of participants was 17 to 24 years. Among the respondents, 522 (79.9%) were female and 131 (20.1%) were male, 393 (60.2%) lived in rural areas, 172 (26.3%) lived in suburban areas, 88 (13.5%) lived in urban areas, 248 (38.0%) were freshmen, 240 (36.8%) were sophomores, and 165 (25.3%) were juniors. The demographic profiles of the participants are shown in Table 1.

SOCIAL-DEMOGRAPHIC INFORMATION QUESTIONNAIRE:

Through a literature review, we designed 5 demographic characteristics according to the research purpose, including age, sex, grade, place of residence, and satisfaction with major area of study.

ACADEMIC BURNOUT SCALE:

Academic burnout was measured using the Chinese version of the Academic Burnout Scale (ABS), modified by Lian et al [3]. The ABS consists of 20 items that constitute 3 domains: emotional exhaustion (8 items), improper behavior (6 items), and low professional efficacy (6 items). The ABS includes 12 positive scoring questions and 8 reverse scoring questions, and all items are graded on a 5-point Likert scale, ranging from 1 (never) to 5 (always). The higher the score, the higher the level of academic burnout. This scale has also been confirmed to be reliable and valid for nursing students in China [9]. This study’s ABS exhibited excellent internal consistency (Cronbach’s α=0.884).

CONNOR-DAVIDSON RESILIENCE SCALE: Resilience among nursing students was assessed using the 10-item Connor-Davidson Resilience Scale (CD-RISC) [28]. Each item on the CD-RISC was rated on a 5-point Likert scoring method (0=never to 4=always). The total CD-RISC scores range from 0 to 40, with higher scores indicating high levels of resilience. This subscale had a Cronbach’s α of 0.93 in this study.

IMPACT OF EVENT SCALE-6: The Impact of Event Scale-6 (IES-6) developed by Ma et al [29] was used to measure nursing students’ acute stress associated with COVID-19 within 1 week. Each item is rated on a 5-point Likert scale, from 0 (not at all) to 4 (extremely). A sum score for the IES-6 ranges from 6 to 30, with a higher score indicating a greater level of acute stress associated with COVID-19, including post-traumatic stress disorder (PTSD). Cronbach’s α was 0.91 for this sample.

PATIENT HEALTH QUESTIONNAIRE-2: The Patient Health Questionnaire-2 was used to measure nursing students’ self-reported depression over the past 2 weeks [30]. The PHQ-2 scale is composed of 2 items, and participants are asked to rate the frequency of depression symptoms on a 4-point Likert scale, from 0 (never) to 3 (nearly every day). The total score ranges from 0 to 6, with a higher score indicating a more significant level of depression. The Cronbach’s α was 0.95 in the current study.

PROFESSIONAL IDENTITY SCALE: The Professional Identity Scale developed by Brown R et al [31] was used to measure the professional commitment of nursing students. This self-reported measurement tool consists of 10 items scored on a 5-point Likert scale, from 1 (not at all) to 5 (very often). It has been validated for clinical use. In the present study, a higher score indicated the greater professional identification of the nursing undergraduates.

ETHICAL CONSIDERATIONS:

The study was conducted according to the principles of the Declaration of Helsinki and was approved by the Nursing Department of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College). Before conducting the survey, the purpose, content, and significance of this study were detailed and introduced to the nursing students. Nursing students who agreed to participate in this research study signed an electronic consent form. Students were informed that submission of the questionnaire indicated voluntary participation, and they could withdraw from participation at any time without any negative consequences. The data collected for this study are kept by the first author. All data were used for academic research only, and the selection results of nursing students were confidential and used only for data analysis by research team members.

DATA COLLECTION:

The survey was conducted between April 1, 2022, and April 10, 2022. We explained this research’s purpose, importance, and the necessity to the counselors and class leaders; counselors and class leaders summoned all nursing students in the included grades to fill out the questionnaire. The electronic version of the questionnaire link created by Questionnaire Star was distributed through Tencent’s WeChat and Q.Q. Groups to the nursing students. Data collection was obtained through a voluntary and anonymous online survey questionnaire. This study’s online questionnaire was distributed using Questionnaire Star, the most widely used online survey platform in China. The data collection process took approximately 5 to 10 min. A total of 653 questionnaires were completed and recovered (because they were filled out online), and it was compulsory for students to answer each item. All questions were required questions, and there were no missing data in the database.

DATA ANALYSIS:

The survey data from the Questionnaire Star questionnaires were imported to Microsoft Office Excel 2020, which was used to summarize and clean the data. Descriptive statistics (numbers and percentages) were used to represent the general demographic characteristics of the surveyed nursing students, whereas means and standard deviations were used to describe the continuous variables. The t test and analysis of variance (ANOVA) were used to analyze group differences in the total scores of academic burnout among nursing students. The correlation between the variables was analyzed using Pearson’s correlation coefficients.

Stepwise multiple linear regression was performed to measure the relationship between sociodemographic characteristics, resilience, and academic burnout. With α=0.05 as the significance level, a 2-tailed P value <0.05 was considered statistically significant.

Results

DIFFERENCES IN ACADEMIC BURNOUT BY PARTICIPANT CHARACTERISTICS:

As shown in Table 1, among all participants in this study, 335 participants (51.30%) had academic burnout. Academic burnout was significantly different by academic year (F=5.906, P<0.01), satisfaction with specialty (F=44.444, P<0.001), adaptation to online learning (F=18.013, P<0.001), and satisfaction with effectiveness of online learning (22.113, P<0.001).

CORRELATIONS AMONG ACADEMIC BURNOUT, IES, PSYCHOLOGICAL RESILIENCE, PROFESSIONAL IDENTITY, AND DEPRESSION:

As shown in Table 2, the IES and depression of medical college students had positive correlations with academic burnout (P<0.01). In contrast, there was a negative correlation between psychological resilience and professional identity (P<0.01).

MULTIPLE LINEAR REGRESSION ANALYSIS OF ACADEMIC BURNOUT:

As can be seen from Table 3, the model could explain 36.8% (adjusted R2 scores: 36.8%) variance of nursing students’ academic burnout. As shown in Table 3, academic year (B=−0.683, P=0.030), satisfaction with specialty (B=−1.834, P=0.000), satisfaction with the effectiveness of online learning (B=−1.174, P=0.002), professional identity (B=−0.174, P=0.000), psychological resilience (B=−0.401, P=0.003), depression (B=1.537, P=0.000), and IES-6 (B=0.248, P=0.001) were significantly associated with the level of academic burnout.

Discussion

LIMITATIONS:

The present study had some limitations and should be interpreted with caution. First, because our study was a cross-sectional survey, it is difficult to determine the causal relationship between academic burnout and associated factors in nursing students. Finally, the data were obtained by convenience sampling and only from the School of Nursing of the Medical College in China. Therefore, the results may not be representative of all Chinese nursing students. Future studies including larger nursing student populations are recommended. This study was conducted in the context of COVID-19, and the research factors all relate to the pandemic. Therefore, other factors will be investigated later. Furthermore, since this survey is cross-sectional, longitudinal studies are also necessary to examine changes and factors in academic burnout over time. Overall, the results of this study should be interpreted with caution. However, despite the mentioned drawbacks, the findings may help suggest potential interventions to improve nursing students’ academic burnout. Importantly, this study provides a practical theoretical and methodological approach to preventing learning burnout in nursing students.

Conclusions

This study demonstrated that Chinese nursing students experienced a certain degree of academic burnout. Academic year, satisfaction with specialty, satisfaction with online learning, professional identity, and psychological resilience were the influencing factors found to cause academic burnout in nursing students.