RESEARCH ARTICLES
Knowledge/Lack of knowledge of Burnout Syndrome among nursing students
Sabrina Corral-MulatoI; Sonia Maria Villela BuenoII
IPostdoctoral student at the University of São Paulo, Ribeirão Preto School of Nursing, Department of Psychiatric Nursing and Human Sciences. Ribeirão Preto, São Paulo, Brazil. E-mail: sbcorral@yahoo.com.br.ABSTRACT: This study aimed to assess nursing students' knowledge of Burnout Syndrome, and to promote a related educational program. To that end, we performed a qualitative and quantitative research, mediated by the action-research methodology, using participant observation and a questionnaire, conducted in a public university in São Paulo from November 2009 until July 2010. Data analysis was performed by categorization, resulting in themes guiding the educational program. Twenty-nine students from the fourth-year undergraduate course participated, mostly unmarried women between the ages of 20 and 25 years. Of these, 9 (31%) did not know about the syndrome. Nineteen (65%) knew about the syndrome, but 4 (21%) of these women did not remember what it was and 3 (15.8%) were mistaken. Knowing that these women will be future professionals vulnerable to stress, fatigue, and physical discomfort (nursing/teaching), we emphasized the need for an educational program, aiming at the suitable identification and identifying assistance for the prevention, control, and early treatment of this syndrome.
Keywords: Burnout professional; nursing students; health education; health promotion.
INTRODUCTION
Burnout Syndrome is a disease resulting from disharmony between the somatic, emotional, and intellectual spheres, and it can lead to serious consequences in the personal, family, and professional spheresIII. It presents itself in a slowly progressive and insidious form and is difficult to detect at this stage, thus being able to cause an undefined feeling of physical or mental malaise, resulting from the excess of work1.
Although most studies on burnout are related primarily to professionals in the fields of health and education, this syndrome has already been considered a relevant and differentiated question also regarding students in related areas2. Thus, some researchers are applying the concept and conducting important studies with this population in various sectors of the health area2-10.
In the meantime, the objective of this particular study was to investigate the knowledge of nursing students on Burnout Syndrome and to promote an educational program accordingly.
LITERATURE REVIEW
Burnout Syndrome is a cumulative reaction to continuous occupational stress factors characterized as an important risk factor for mental health problems, thus being able to cause a major impact on the family and work life of the individual affected11.
It may be caused by individual genetic and environmental factors when they occur simultaneously. Moreover, the high number of imponderable elements of the work, a relative identification, as well as the emotional ties that often arise between professionals and their clients may contribute to a greater incidence12.
The first signs of mental distress are the loss of energy and continual tiredness, exhaustion, apathy, and disinterest, among others13.
The main symptoms of Burnout Syndrome are1:
Burnout Syndrome affects not only the faculty, but also the students from related fields. Clearly, there is a close relationship between work (field work) and study, thus the student’s performance is affected in both dimensions3.
A previous study with undergraduate nursing students from the first to fourth year observed an elevated average in reduced professional achievement size, stressing the need for intervention with participants aiming to rediscover the initial motivation of their professional choice4.
Yet, when students approached the end of the undergraduate course, they experienced various situations, such as fear about the future and leaving the responsibilities of being a student to become a professional, demands that can be cited as sources of stress14.
Interventions and prevention programs strived to highlight three levels15:
Furthermore, the development of guidance and training methods for preventing emotional disorders and disturbances should be goal-focused on graduation courses14.
Thus, the information becomes crucial, enabling professionals to be aware of the problem and seek help if necessary16. There is need for preparing future health professionals to develop self-care as a condition precedent to caring for others17.
METHODOLOGY
This investigation was appropriated from the qualitative and quantitative research with a humanistic characteristic, mediated by the research-action methodology according to theoretical and methodological frameworks18-20. This allowed the survey of needs/problems and proposed the development of educational activities, together with the study participants, in order to reflect, and proposed the change and transformation of reality on the central theme.
This study was conducted after approval by the Research Ethics Committee (CEP), under Protocol No. 1079/2009, according to Resolution No. 196/96 of the National Health Council, which provides the Guidelines and Standards for Regulating Research Involving Human Beings, fulfilling the ethical precepts.
The participants of this research consisted of 32 students from the Bachelor's Degree Nursing Course at a state college in the state of São Paulo, all of whom were attending the fourth year of the course in the 2009 school year. Of these, 29 students agreed to participate in the research. This class was selected because it was the first of the course in this school and it was about to complete the undergraduate degree, therefore making it a sample of convenience.
The research consisted of three phases for data collection, described below.
The first was the application of the participant-observation technique, to detect data from the academic environment that occurred in their classroom during the course of Teaching Methodology in Nursing I, in November 2009, during three approximately four-hour meetings, making use of the daily field instrument.
This technique is performed by the researcher's direct contact with the phenomenon observed aiming to obtain information regarding the situation of the participants within their context, and is important when apprehending situations that are not obtained through questions21.
After the survey of sociodemographic data and questions of a central theme were carried out, a self-administered questionnaire developed and validated by the authors was used as an instrument. This collection was developed in the classroom, after academic activities, in November 2009, lasting approximately thirty minutes. Thirty-two sealed envelopes were distributed containing a questionnaire and two copies of the Statement of Informed Consent Form (ICF) signed by the researcher, and twenty-nine completed questionnaires were received.
Therefore, this questionnaire consisted of two parts: the first with sociodemographic data; the second with questions related to the study topic: Have you ever heard of Burnout Syndrome? What have you heard?
The letter P, for participants, was attributed for the identification of subjects in addition to a number that was given according to the sequence of the returned envelopes.
After applying the questionnaires, a survey of the problems was conducted for the analysis of the responses obtained through the thematic universe survey (for the identification of the categories), using the theoretical-methodological framework19,20.
This framework is based on the pedagogy of awareness within the critical-social approach, which means learning to read the world and understand its context. This procedure aims at the description and interpretation of the subjects’ situation, characterizing their needs, prior knowledge, and skills. The organization of this analysis suggests the following phases20: survey of the generative themes; organization of the data collection material; selection and coding of recorded/issued words and phrases; synthesis of selected words and phrases; and order of the generative themes.
Educational actions/interventions were developed later when the researchers themselves prepared an educational booklet, in which all aspects of Burnout Syndrome were addressed with illustrations and language appropriate to the target audience. In addition, participants were asked to make an assessment of the material distributed.
The action-research option was used due to it allowing us to diagnose the needs and propose educational actions/interventions, fostering a better understanding and interpretation of the findings. This then allowed us to get to the analysis of the thematic bases, aiming at the preparation, completion, and implementation of a program beyond the planning and realization of an educational booklet, considering the importance of partnership, complicity, and awareness of the subject to change and transform20.
RESULTS AND DISCUSSION
Personal and professional data
With regard to personal data, students who participated in this study were characterized as: 24 (82.8%) female; 19 (65.5%) aged 20 to 25 years; 19 (65.5%) Catholics; 24 (82.8%) single; 25 (86.2%) with no children. All entered the university in 2006, the first year of the BSc. Degree in Nursing at this school, and studied between five and seven subjects in the eighth period. Of the participants, 23 (79.3%) only studied, none possessed any other higher-education course, and 7 (24.1%) possessed professional experience in healthcare. Regarding the city of origin, 11 (37.9%) were from the city where the researched university was located and 10 (34.5%) were from cities in the same region; 14 (48.3%) reported living with parents and 6 (20.7%) with husband/children.
Category: students' knowledge of Burnout Syndrome
When asked about their knowledge of Burnout Syndrome, 9 (31%) said they did not know about it, 19 (65%) said they knew about it or had heard of it, and 1 (3.4%) did not answer this question.
In a previous study conducted with nursing students from the first to fourth year, 62% did not know about the syndrome4, quite different from this study in which only 31% reported knowing about it. However, only one-third of those surveyed responded with an adequate definition of the condition.
Although 19 (65%) students confirmed knowing about or at least knowing what Burnout Syndrome was about, only 10 (52.6%) of them gave appropriate and conscious responses on the subject. Of those who said they knew about it, 4 (21%) reported not remembering what it was about, 3 (15.8%) gave incorrect answers about the syndrome, and 2 (10.5%) answered vaguely about it. This suggests that most of them did not really know what the problem in question was all about.
In a previous study, among the 38% who reported knowing about Burnout Syndrome, 56.4% defined it as a psychological illness caused by the stress in a profession, 38.5% defined it as exhaustion, fatigue, and physical limitations due to work overload, and 5.1% defined it as a person becoming cold towards human beings and their work4.
Adequate responses
Of the 29 students, only 10 (34.5%) responded adequately on Burnout Syndrome, for example:
[...] it is caused by stress at work, it is more common among healthcare and education professionals [...] (P5)
[...] this syndrome includes professionals who have more to do with the public (teachers, nurses, public relations), it is the everyday stress of the professional [...] (P9)
[...] an occupational disease due to the high degree of stress, physical, and mental fatigue [...] (P12)
A study on the identification of stress factors identified that this can provide a process of reflection for students in their school activities, therefore improving academic achievement and preparing them to face the future labor market22.
Do not remember what it is about
Of the participants, 4 (21%) admitted not remembering what it is about, for example:
I do not remember at the moment [...] (P21)
Incorrect answers
Another 3 (15.8%) participants answered incorrectly, for example:
[...] it is the known limit of a person to withstand something [...] (Q1)
Vague answers
Moreover, 2 (6.9%) participants gave vague answers, for example:
[...] Just out of curiosity, nothing profound [...] (Q6)
Based on these findings, we inferred the need for an educational program to inform them, educate them, and to reflect about the subject more deeply and comprehensively.
To that end, after the categorization of responses, an educational booklet containing information and explanations about Burnout Syndrome was created and this was delivered to all students in the participating class (whether survey respondents or not) before the end of the undergraduate course.
A recent study found, in nursing residents with a similar profile to the present study and mean age of 25.8 years, that 17.2% had high levels of emotional exhaustion and depersonalization and 18.8% showed incompetence/lack of professional fulfillment. It also identified a resident with changes in the three sub-scales of a specific inventory for burnout, being characterized as a person suffering from Burnout Syndrome23.
Study with nursing professionals found that mental and behavioral disorders account for 23% of cases of absence from work. Accordingly, it is necessary to pursue courses of prevention and intervention to reduce absenteeism, focusing on the quality of life24.
Thus, the graduation period may contribute to the prevention and confrontation of Burnout Syndrome5. Therefore, there is a need to strengthen the information, through lectures, workshops, pamphlets, and group discussions, enabling the detection or even the early intervention of Burnout Syndrome, before the malaise overlaps personal and professional development. From this perspective and sense, prevention is directed towards awareness and knowledge of the syndrome as an important ally in this process25.
However, there is also a need for younger students who attend the initial semesters to be acted upon while still in the training phase, which may be a more effective way of primary prevention of this syndrome in professionals in the health area2.
In prevention/intervention programs suggested for and focused on both the individual15 and the occupational context, the first step in achieving success is knowledge of the problem with: theoretical exposition, background knowledge, and the syndrome and its consequences, among others. The resources used can be from the exposition of the theory, reading documents, and even case studies. Other helpful aspects include building the situation, delving deeper into triggering causes of the problem, defining characteristic symptoms and possible consequences of the process, and reflecting on the elements involved, because when you know the problem, you can learn to identify it better.
However, a study of nursing students' knowledge about stress showed that even though students may have an incipient knowledge on the subject in their training, they feel prepared to work the issue with others, often using common sense and running the risk of transmitting the wrong information26. This becomes very concerning, considering that they are trend-setting professionals in the health area.
Furthermore, a study of nursing students identified the importance of early detection of altered levels of stress and care in order to minimize them, demonstrating the need for nursing care for oneself in the first place and then taking care of others27.
After delivery of the textbooks, students proved to be particularly excited because they had received a positive response directed at them from a researcher. During data collection, they often criticized the lack of action that could benefit them by the previously held research which, when actions were planned, was intended only for upcoming classes, considering that they were first BSc. Degree class in Nursing at the school. This was a major concern, because there was a need to provide an adequate return to them which not only benefited the students for the following year, but also showed them how much they were and continued to be important in this process.
After reading the material, participants rated the booklet as objective, didactic, succinct, and enlightening about the disease and its risks, so it clearly raised awareness about prevention of the illness. The booklet fulfilled its objectives by informing and promoting health education, being relevant in its job to inform about preventing and identifying signs and symptoms of Burnout Syndrome. The participants also recognized the predisposition of nursing students to the disease, with their knowledge and recognition being extremely important.
A previous study underscores the importance of this action, in the sense that to answer the questions, participants needed to think about their knowledge on the topic, organize their ideas and put them on paper, as well as be encouraged them to seek more knowledge on the subject discussed25. In this process there was a critical unveiling in which action-reflection-action occurred, with action in reading the question, reflection in answering it, and action to put into words their ideas and organize their knowledge28.
CONCLUSION
We can perceive in this study that a significant portion of undergraduate students in a nursing degree course still do not know how to properly identify Burnout Syndrome, and others believe they can do it but have mistaken or generalized ideas.
Given the importance of the prevention of Burnout Syndrome for the health area, especially in the professions of nursing and education, and that the degree course covers the two professions, we highlight the great need for educational initiatives towards information and reflection, therefore promoting health and quality of life besides the preventing thereof within the same universities.
We therefore propose that topics like this be widely discussed and reflected upon among teachers and students, so that the knowledge of this reality and the identification of signs and symptoms of this problem can be grasped by them and applied to identify the possible onset of symptoms in themselves, in family, with co-workers, and with clients.
Furthermore, we stress the importance of proposing educational activities for participants of research like this, in order that there is positive feedback, so they do not feel as mere providers of data which will be used for the benefit of others and not just those participants themselves, and that they are aware of the great importance they pose for researchers and the advancement of science.
Among the limitations of the study include the difficulty in reconciling the students' timetable for carrying out educational activities such as lectures, workshops, and feedback on the evaluation of the material available. Also, the small sample and unique scenario hamper generalization of the findings.
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