Running head: BURNOUT & NURSING STUDENTS

Burnout in Nursing Students: A Literature Review

Samantha J. Hasenzahl
Bon Secours Memorial College of Nursing
Honor Pledge

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Abstract

The purpose of this integrative review is to examine literature related to burnout in nursing
students. Given the high levels of stress found in nursing education programs, burnout is a likely
experience for many students. However there has not been much research regarding this subject.
An explanation of the burnout phenomenon is provided along with possible interventions that
could be utilized to minimize the experience of burnout. An integrative review was conducted.
Literature was found using various search engines such as PubMed and the EBSCO database.
The initial searches produced over 2,000 studies, but only five met inclusion criteria and were
included in this review. The results of this study show that burnout is a problem for nursing
students and that intervention can help decrease the presence of this phenomenon. Limitations to
the study include, but are not limited to, the shortage of recent articles examining burnout in
nursing students and lack of research experience of the author. Future research should focus on
developing a specific program to address burnout in nursing students as well as testing the
programs effectiveness.

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Burnout in Nursing Students: A Literature Review

This literature review discusses recent research on burnout in nursing students. There are
copious amounts of research on the presence of burnout in healthcare professionals; however,
research on burnout among nursing students is scarce. High stress is a risk factor for the
development of burnout and nursing school is known for its rigor and arduous programming
(Galbraith & Brown, 2011; van der Reit, Rossiter, Kirby, Dluzewska, & Harmon, 2015).
Research has demonstrated that various interventions can help decrease burnout levels among
healthcare professionals. The author is curious if these interventions would have the same impact
on nursing students. The aim of this review is to better understand burnout and to identify
possible strategies aimed at the prevention and treatment of this phenomenon. The literature
presented in this paper is used to answer the following PICO question: what is burnout and what
is the effect of different interventions on burnout among nursing students? The author is
interested in this topic because she is a nursing student and has observed the negative impact that
stress has had on fellow students.
Research, Search Methods, & Search Outcomes
An integrative review of recent literature pertaining to burnout among nursing students
was conducted. Articles published between January 2011 and March 2016 were identified using
PubMed and EBSCO databases. Key search terms included nursing students, burnout,
burnout prevention, and interventions. The search yielded over 2,000 results. Inclusion criteria
for this paper are as follows: publication in the past five years in English, focus on burnout in
nursing students, and examination of possible interventions for stress/burnout. Articles were
excluded from the review if no English translations were available, the sample did not include
nursing students, if burnout was not addressed, or the article did not relate to the researchers

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PICO question. Five articles were used in this review, including four quantitative articles and one
qualitative study.
Findings & Results
This literature review demonstrated that burnout is present among nursing students and
that various interventions such as mindfulness, coping skills, and psychosocial trainings can help
students better manage stress levels thereby reducing burnout. Table 1 provides a closer look at
each individual study. The author will explain the research in two different categories: burnout
and effects of interventions.
Burnout
Burnout is the depletion of an individuals internal resources (Rudman & Gustavsson,
2012). Tomaschewski-Barlem, Lunardi, Lunardi, Barlem, Silva da Silveira, & Vidal (2014)
defined burnout as a progressive process of emotional exhaustion and loss of professional
interest, due to a prolonged period of exposure to high levels of stress arising from work
situations (p. 935). Emotional Exhaustion (EE) and Disengagement are the defining
characteristics of burnout. When an individual has high levels of emotional exhaustion and high
levels of disengagement, they are said to be burned out (Rudman and Gustavsson, 2012;
Tomaschewski et al., 2014). Two of the five studies primarily focused on the presence of burnout
in nursing students. These studies were interested in examining the prevalence, risk for, and
consequences of burnout.
Tomaschewski et al. (2014) examined the presence of burnout among nursing students at
a public university in Southern Brazil. Students were said to have burnout if they reported high
levels of EE and Disengagement and low Professional Effectiveness (PE); this definition is based
off of Maslach Burnout Inventory. The sample consisted of 168 students. Burnout was not

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detected in this specific sample per se because although most students reported high levels of EE,
they displayed low levels of Disengagement and high levels of PE. ANOVA analyses were used
to examine potential differences among burnout factors related to demographic and academic
variables. Findings from this analysis showed that younger students who participated in leisure
activities had higher levels of PE than students who did not engage in extracurricular activities.
Students who had to work while attending school had lower levels of PE in regards to their
academic studies. Due to the specific sample used in this study the results are not generalizable
to nursing students as a whole. However, the authors noted that according to Maslachs theory of
the development of burnout, emotional exhaustion is the first dimension to manifest which
suggests that burnout may be developing in these students investigated (Tomaschewski et al.,
2014, p. 938). Recognizing that emotional exhaustion is the first symptom of burnout allows for
earlier detection and possible prevention.
A 2012 longitudinal study conducted by Rudman and Gustavsson investigated burnout
among nursing students throughout their educational years and one year post graduation. Over
1,700 Swedish nursing students participated in the study from fall 2002 to spring 2006. The
researchers used the Oldenburg Burnout Inventory to measure burnout and used Latent Growth
Curve Modeling to analyze changes in burnout levels over time. This study found that levels of
emotional exhaustion and disengagement increased over time as students progressed in their
education; thereby significantly increasing burnout. According to Rudman and Gustavssons
(2012) findings, the development of burnout during schooling predicted lower levels of in-class
engagement and occupational preparedness in the final year of school. In addition, earlier
burnout development was associated with lower use of evidence-based practices, lower skill
mastery, and higher turnover intentions in the first year post-graduation (Rudman & Gustavsson,

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2012). The longitudinal design allows the readers to see how burnout can develop overtime and
demonstrates some potential long-term effects of burnout on the students career and wellbeing.
Effects of Interventions
Both of the previously mentioned studies have found high levels of emotional exhaustion
in nursing students; EE is a risk factor for burnout. Given this information, what can be done to
better manage or prevent the development of this phenomenon? Three of the five studies in this
review demonstrated positive outcomes for psychosocial interventions (Galbraith & Brown,
2011; Skodova et al., 2015; van der Reit et al., 2015). Each study explored different
interventions.
van der Reit et al. (2015) piloted a seven week stress management and mindfulness
program for first year undergraduate and midwifery students. The program consisted of seven,
hour long sessions held every Friday during the lunch hour. The sessions were comprised of a
didactic and experiential component which allowed for students to learn about an intervention
like mindfulness as well as time to practice the skill. Ten students volunteered and participated in
the study, but only one of the ten attended all sessions. Two weeks following the conclusion of
the program, an hour long focus group was conducted. A descriptive qualitative design was
employed to analyze the impact of the program. The interviewer was not the same person that
taught the classes. The interview was recorded, transcribed, and analyzed using a thematic
analysis.
After reviewing and discussing the transcripts, three major themes were identified:
attending to self, attending to others, and attending to the program (van der Reit et al., 2015). In
regards to attending to self, students shared that these new skills helped them better manage their
time, improved the quality of their sleep, and allowed them to be present in the moment/relax.

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When referring to attending to others, the participants discussed how these new skills would
impact their nursing practice and patient care. Lastly, attending to the program, subjects
discussed practicing the program at home, but also the challenges they face in doing so. Even
though attendance was irregular, students reported positive results in multiple areas. The van der
Reit et al. (2015) study demonstrates that intervention is beneficial in the beginning, but it
provides no insight about long-term benefits. A follow up study would be needed to determine
any long term benefits. In addition, it is unclear what was taught at each session so this study
could not be replicated.
Skodova and Lajciakova (2015) also investigated the impact of psychosocial training on
burnout. However, this studys sample included nursing, midwifery, and psychology students. A
quasi-experimental approach was taken. The psychosocial training was presented as part of the
curriculum of a regular course. Data was collected from students who voluntarily filled out
questionnaires. The experimental group consisted of 50 psychology students who took this class.
The control group was comprised of 47 nursing and midwifery students who did not take the
class, but filled out the same questionnaires. The training included relaxation techniques, stress
management, self-perception, communication skills (active listening), assertiveness, conflict
management, and other various interventions/skills.
Prior to the start of the training, several questionnaires (The School Burnout Inventory, a
short version of the Utrecht Work Engagement Scale, Antonovskys Sense of Coherence
questionnaire, and the Baruth Protective Factor Inventory) were filled out (Skodova &
Lajciakova, 2015). Spearman correlation analysis, t-tests, one way ANOVA tests, and LSD post
hoc tests were done. The initial responses found no differences between the experimental and
control groups in regards to burnout, engagement, sense of coherence, and resilience. However,

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responses to the same questionnaires following the completion of the course found statistically
significant differences between groups. The experimental group had significantly lower levels of
burnout than the control group. Although this study did not specifically examine the effects of
training on nursing students, it did show that it was beneficial to students who were exposed to
the material and warrants further investigation on the effects this course might have on nursing
students.
In 2011, Galbraith and Brown conducted a quantitative systematic literature review that
assessed the effectiveness of different interventions in decreasing stress in nursing students. In
order to be included in the review the studies had to be published in English between January
1980 and March 2009, empirically evaluated a stress intervention for nursing students, and
include a description of the intervention as well as the outcome measures utilized in the study
(Galbraith & Brown, 2011). Their initial search yielded 186 studies. A quality appraisal of these
studies narrowed the total to 16.
In order to better analyze the data, Galbraith and Brown (2011) grouped studies based on
the target of each intervention. The three targets included: reducing the number or intensity of
stressors, cognitive reappraisal of stressors, and effective coping with stress. All but one of the
studies included in the review provided interventions that focused on effective coping with
stress. These interventions included relaxation techniques, imagery, exercise, deep breathing, etc.
Six of the sixteen studies interventions target effective coping with stress. Only two of these
studies showed significant improvement in physiological responses to stress.
Six different studies interventions targeted cognitive reappraisal in addition to effective
coping skills. Cognitive reappraisal methods included Schaters model of emotion, Lazarus and
Folkmans transactional model, and Kabat-Zinns mindfulness. The studies demonstrated more

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improvements in levels of anxiety, stress, and depression than other studies that focused on
dealing with stress a sole intervention. The last six studies presented interventions which
addressed all three targets (dealing with stress, cognitive reappraisal, and reduction in the
number/intensity of stressors). Methods used in these studies included skills previously
mentioned, but also included interventions like time management skills. These studies also led to
improvements in anxiety, self-esteem, depression, and measures of stress.
Based on their systematic review, Galbraith and Brown (2011) determined that in order to
effectively reduce stress, interventions must include methods of cognitive reappraisal and coping
skill development. An interesting finding from this study suggests that the amount of stressors a
person is facing does not impact the experience of stress. In other words, simply reducing the
number of stressful stimuli will not decrease stress. Appropriate perception and management of
stress are the more critical components of decreasing the stress experience. The take home
message here is that teaching skills that allow students to look at stressors differently in addition
to dealing with the stress will have the biggest impact.
Discussion & Implications
Discussion
The findings of this review demonstrate that burnout is evident in nursing students and
that interventions can be employed to help decrease this phenomenon. A commonality among all
five articles is the identification of the high levels of stress of nursing students. Tomaschewski et
al. (2014) and Rudman and Gustavsson (2012) found that emotional exhaustion is a key player in
the development of burnout. Skodova and Lajciakova (2015) and van der Reit et al. (2015)
demonstrated that psychosocial training can have positive impact on burnout reduction. Galbraith

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and Brown (2011) determined that the best interventions include methods of cognitive
reappraisal paired with various coping skills.
Research clearly demonstrates that burnout is a significant problem among nursing
students. However, research has yet to provide a specific outlined program to address the
problem; no single program has been developed, utilized, and replicated. There is research
showing the benefits of various interventions, but no research on how to disseminate this
information for students to utilize and practice. Another issue observed by the author pertains to
the lack of common outcome measures between studies. This lack of consistency in outcome
measures makes comparing different study results difficult. Examining burnout (and its
associated interventions) through a similar theoretical perspective and measuring outcomes with
the same tools will increase validity and reliability of the different research studies.
Implications
As this literature review has demonstrated, various interventions can be used to help
students better manage their stress and thus prevent/decrease the experience of burnout. To better
facilitate the study of burnout, a consensus among researchers about the most appropriated
theoretical perspective should be established. Similarly, it would be helpful to utilize congruent
outcome measures in order to establish the effectiveness of interventions used. In order to
discover which specific interventions are helpful in burnout prevention and/or management,
future research should focus on developing a specific program that can be tested and retested.
After developing a program, research should be done to determine the best way to disseminate
this information.
Limitations

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There are numerous limitations for the current study. Articles were limited to the last 5
years and only 5 articles were allowed to be used. There were several articles where only the
abstract was translated into English, but based on those abstracts, each would have greatly
contributed to the analysis of this subject. Lastly, the author has limited experience conducting
research, analyzing data, and writing articles.
Conclusion
This literature review has demonstrated that burnout is a problem for nursing students. It
has shown that interventions can be helpful. However, burnout is still a major problem due to the
lack of consistency in regards to programming, testing, and measuring outcomes. Emotional
exhaustion and disengagement are the defining characteristics of burnout (Rudman and
Gustvasson, 2012; Tomaschewski et al., 2014). The theoretical model of burnout suggests that
the first stage of burnout is the development of emotional exhaustion (Tomaschewski et al.,
2014). All of the articles in this review have discussed the rigors found in nursing programs.
Every study mentions the stress experienced by nursing students. Although nursing students
might not display signs of full-fledged burnout while still in school, they could be on their way to
developing burnout before even entering the field. Given the high levels of emotional
exhaustion found in this population and their potential for developing burnout, it is important to
teach nursing students coping skills that will help them offset the potential negative
consequences of this phenomenon (academic interferences, psychological distress, etc.).
Early intervention is key to better outcomes is all aspects of medicine. The nursing
shortage and aging population are going to place higher amounts of stress on future nurses.
Higher stress leads to burnout. Nursing school is known for being very stressful and demanding.
Nursing education programs have the unique opportunity to provide students with a skill set that

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can help them better manage stress before they begin working in the field. Teaching students
about various coping skills such as meditation and mindfulness will provide them with tools that
can help protect them from developing burnout.

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References

Galbraith, N.D., & Brown, K.E. (2011). Assessing intervention effectiveness for reducing stress
in student nurses: Quantitative systematic review. Journal of Advance Nursing, 67(4),
709-721. doi: 10.1111/j.1365-2648.2010.05549.x
Rudman, A., & Gustavsson, J.P. (2012). Burnout during nursing education predicts lower
occupational preparedness and future clinical performance: A longitudinal study.
International Journal of Nursing Studies, 49, 988-1001. doi:
10.1016/j.ijnurstu.2012.03.010
Skodova, Z., & Lajciakova, P. (2015). Impact of psychosocial training on burnout, engagement
and resilience among students. Central European Journal of Nursing and Midwifery,
6(3), 313-319. doi: 10.15452/CEJNM.2015.06.0021
Tomaschewski-Barlem, J.G., Lunardi, V.L., Lunardi, G.L., Barlem, E.L.D., Silva da Silveira, R.,
& Vidal, D.A.S. (2014). Revista Latino-Americana de Enfermagem, 22(6), 934-941.
doi: 10.1590/0104-1169.3254.2498
van der Riet, P., Rossiter, R., Kirby, D., Dluzewska, T., & Harmon, C. (2015). Piloting a stress
management and mindfulness program for undergraduate nursing students: Student
feedback and lessons learned. Nurse Education Today, 35, 44-49. doi:
10.1016/j.nedt.2014.05.003