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

Abstract

Background

The COVID-19 pandemic has brought changes and challenges to nursing students. However, little is known about the prevalence of academic burnout among nursing students in this challenging circumstance. This study aimed to assess nursing student academic burnout and its influencing factors.

Material/Methods

We conducted a sample survey of a 4-year undergraduate nursing university in Wuhu, Anhui Province, China. The social-demographic information questionnaire, Academic Burnout Scale, Connor-Davidson Resilience Scale, Impact of Event Scale-6, Patient Health Questionnaire-2, and Professional Identity Scale were used. Stepwise multiple linear regression was used to clarify the relationship among sociodemographic characteristics, resilience, and academic burnout.

Results

Of all the study participants, 51.30% had a certain degree of academic burnout. Academic year, satisfaction with specialty, satisfaction with online learning, professional identity, and psychological resilience were negatively correlated with academic burnout among nursing students. Depression was positively correlated with academic burnout.

Conclusions

Nursing students had a high degree of academic burnout. Academic year, satisfaction with specialty, satisfaction with online learning, professional identity, and psychological resilience were protective factors that reduced nursing students’ academic burnout.

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.

Table 1.

Participants’ sociodemographic characteristics and Academic Burnout Scale (ABS) mean scores (n=653).

Characteristics		n (%)	ABS mean scores	Test value	P value
Sex				t=−1.692	P=0.091
	Male	131 (20.1%)	56.82±8.560
	Female	522 (79.9%)	58.10±7.573
Age (years)				F=0.434	P=0.729
	≤018	115 (17.6%)	57.91±8.143
	19–20	324 (49.6%)	58.10±8.000
	21–22	197 (30.2%)	57.34±7.448
	≥23	17 (2.6%)	58.47±4.989
Location of home				F=0.753	P=0.471
	Rural	393 (60.2%)	58.12±7.674
	suburban	172 (26.3%)	57.25±7.485
	Urban	88 (13.5%)	57.77±8.857
Academic year				F=5.906	P=0.003
	First	248 (38.0%)	58.10±7.016
	Second	240 (36.8%)	58.77±8.638
	Third	165 (25.3%)	56.13±7.359
Class leader				t=1.403	P=0.162
	No	445 (68.1%)	58.17±6.845
	Yes	208 (31.9%)	57.14±9.486
Specialty satisfaction				F=44.444	P=0.000
	Not satisfied	45 (6.9%)	64.78±7.061
	Moderately satisfied	347 (53.1%)	59.07±6.665
	Satisfied	261 (40.0%)	55.02±8.146
Adaptation to the online learning				F=18.013	P=0.000
	Not adapted	87 (13.3%)	60.72±6.203
	Moderately adapted	303 (46.4%)	58.79±6.812
	Adapted	263 (40.3%)	55.81±8.776
Satisfaction with online education				F=22.113	P=0.000
	Unsatisfied	112 (17.2%)	60.32±6.684
	Moderately satisfied	361 (55.3%)	58.58±6.296
	Satisfied	180 (27.6%)	54.83±9.980

Instruments

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).

Table 2.

Correlations of the investigated variables.

Variable	Academic burnout	Symptoms of PTSD	Psychological resilience	Professional identity	Depression
Academic burnout	1
Symptoms of PTSD	0.160*	1
Psychological resilience	−0.407*	0.165*	1
Professional identity	−0.418*	−.084*	0.398*	1
Depression	0.413*	0.329*	−0.108*	−0.312*	1

^* P<0.01 (2-tail).

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.

Table 3.

Multiple linear regression analysis of academic burnout (n=653).

Variables	B	SE	β	t	P
(Constant)	74.783	2.046		36.554	0.000
Academic year	−0.683	0.314	−0.069	−2.171	0.030
Specialty satisfaction	−1.834	0.463	−0.141	−3.965	0.000
Satisfaction with online learning	−1.174	0.383	−0.1	−3.068	0.002
Professional identity	−0.174	0.049	−0.136	−3.539	0.000
Psychological resilience	−0.401	0.049	−0.289	−8.209	0.000
Depression	1.537	0.215	0.252	7.167	0.000
IES-6	0.248	0.078	0.108	3.199	0.001

F=55.302, R=0.612, R2=0.375, Adjusted R2=0.368, P<0.001.

Discussion

To the best of our knowledge, there were few surveys about academic burnout conducted among nursing students during the COVID-19 pandemic, especially in China. Thus, exploring and intervening in factors related to nursing students’ academic burnout is vital. This study aimed to examine academic burnout and its influencing factors among nursing students in China during the COVID-19 pandemic.

In this study, 51.30% of all nursing students had a certain degree of academic burnout, higher than that found in previous research [32]. This might be because during the time we conducted this survey, the Wuhu government declared a health emergency for COVID-19, and the nursing students that we surveyed were quarantined at the dormitory, which increased their pressure and academic burden.

The results of studies on academic burnout among nursing students in China vary widely, depending on the choice of school and the timing of the survey. In this study, nursing students’ academic burnout scores were higher than the scores reported from studies conducted prior to the COVID-19 pandemic. This may have been caused by the changes in learning styles and increased stress associated with the COVID-19 pandemic. For many students, school curriculum learning has been severely impacted by the COVID-19 outbreak, and nursing students were forced to adapt to online learning, which brought on new pressure. It is reported that medical students had more stress than did non-medical students after the COVID-19 outbreak [33].

Also, satisfaction with online learning is an essential aspect of evaluating the effectiveness of education. The present study confirmed that online learning satisfaction was negatively correlated with nursing students’ academic burnout. Low expectations for online learning lead to low satisfaction, affecting student interaction with online courses’ teaching content due to the minimal interaction of online learning. Feelings of isolation and alienation often accompany low emotional engagement [34].

High satisfaction with online learning can stimulate students’ sense of achievement in the learning process and help them to improve their confidence in successfully completing online learning tasks, thus effectively alleviating their academic burnout. This means that improving nursing students’ online learning satisfaction is beneficial for reducing academic burnout. Therefore, teachers can take flexible measures to enhance nursing students’ emotional interaction [35], including stimulating their interest and enthusiasm for online learning, creating an atmosphere of positive communication, paying attention to dynamic patterns in the whole online learning process, and providing them with timely and effective feedback.

The results of the present study indicated that first- and second-year undergraduate students also reported higher levels of academic burnout than did third-year undergraduate students, consistent with previous studies. One explanation may be that third-year undergraduate students have adapted to online learning, owing to the association between academic burnout and online learning adaptability and readiness. Furthermore, third-year nursing students generally have more knowledge about the nursing profession and make clear learning objectives and plans, which may increase their motivation to learn.

Experts believe that interest in and satisfaction with a student’s major area of study are among the most important factors influencing the academic achievement of college students [36]. A study also found that dissatisfaction with nursing courses was considered an essential factor in student burnout [37]. Moreover, nursing students who considered dropping out of nursing studies were more likely to have academic burnout [38]. The academic profession of nurses will evolve into their future profession. Moreover, students with low satisfaction with their specialty may take a leave of absence from the university, withdraw, or abandon their academic specialty after graduation. Given the stereotype of nursing as low status, nursing students reported more significant perceived prejudice, lower satisfaction with their major, and lower willingness to be nurses [39]. In our study, low satisfaction with specialty was associated with academic burnout in nursing students. This finding indicates that schools and educators need to find effective measures to improve nursing students’ satisfaction with specialty to reduce academic burnout.

Professional identity was shown to be a protective factor against academic burnout in a previous study [40]. In the present study, students with a positive professional identity had lower academic burnout scores. This result is consistent with results of a previous study that found that when nursing students’ professional identification is high, they are more satisfied with the profession and have lower occupational pressure [41].

Students with positive professional identities tend to evaluate professional nursing studies positively, which can help the students effectively cope with academic pressure, thereby reducing academic burnout. Therefore, professional identity should be considered essential in reducing academic burnout among nursing students. Nursing students are aware of their nursing profession’s purpose, meaning, and value and, with adequate professional identity, they can focus on online learning and are less likely to be disrupted by the uncertainty and isolation of the COVID-19 pandemic, thus avoiding academic burnout. Therefore, making efforts to strengthen the professional identity of nursing students is necessary [41].

In this study, a significant negative relationship was found between resilience and academic burnout, which is consistent with the research of Abram et al [42]. VanMeter et al found that high resilience reduced destructive emotions, such as stress and depression [43]. Specifically, individuals with high resilience mobilized additional resources to cope with learning stress. Therefore, enhancing nursing students’ resilience is considered a strategic approach to reducing academic burnout. Nursing students who have improved their resilience are better able to cope with the learning disabilities and uncertainty brought on by the COVID-19 pandemic, have increased their ability to adapt, and are likely to have less academic burnout.

In this study, we also found the higher the PTSD of nursing students, the higher the academic burnout. This study adds new knowledge that the IES-6 is positively associated with academic burnout. For many students, their school curriculum learning was severely impacted by the COVID-19 outbreak. Therefore, it is not a surprise that many nursing students experienced PTSD. In our study, there was a significant relationship between depression and academic burnout. Therefore, depression might be a risk factor for the development and eventual accumulation of academic burnout in nursing students. Studies have found that Chinese college students developed symptoms of PTSD, stress, anxiety, and depression [44,45] and may have experienced more stress than non-medical students during the COVID-19 pandemic [33]. Government and schools should pay more attention to the mental health of nursing students during the pandemic and provide more mental health counseling and support for nursing students to promote their mental health.

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.