Academic Burnout, Stress, and the Role of Resilience in a Sample of Saudi Arabian Medical Students

Abstract

Background:

Medical school can be difficult and stressful. Academic burnout is described as exhaustion from curricular activities. Medical students are more likely to experience anxiety.

Objective:

This study investigated the level of academic burnout and stress as well as their level of resilience.

Methods:

Saudi medical students were surveyed in a cross-sectional questionnaire-based study. We used the following scales: Perceived Stress Scale, Maslach Burnout Inventory-Student Survey, and the Connor-Davidson Brief Resilience Scale to assess stress, academic burnout, and resilience respectively.

Results:

The mean score for emotional exhaustion, 20.23 ± 6.8, indicated a high level of burnout among students. The students reported a moderate level of stress. Females, students who were single or lived away from home had higher levels of burnout in certain domains. Students with a higher level of resilience experienced less stress and burnout.

Conclusion:

Academic burnout has a negative impact on mental health. Effective interventions should be designed to assist students to cope better with stress and also identify solutions to avoid burnout. More research is needed to investigate the social and environmental factors contributing to medical student burnout.

1. BACKGROUND

Medical education is a lengthy process that can be difficult and challenging. Medical schools are expected to prepare students to become competent physicians and to equip them with the necessary knowledge and skills to practice safely. As a result, many medical students may feel that their studies are stressful and difficult (1). They may develop mental health issues including academic burnout as a result of the multiple stresses they face during their medical education (2). There is good evidence that medical students are at higher risk for depression and anxiety due to the stressful and overwhelming nature of medical education (3).

The term “burnout” describes a mental, emotional, and physical exhaustion emerging after prolonged exposure to emotionally demanding circumstances (4). Academic burnout is distinct from job burnout in that it encompasses students’ exhaustion from curricular activities, their cynicism toward education, and a lack of satisfaction with their academic accomplishments (5). The first symptom of academic burnout is emotional exhaustion which manifests itself as a decreased emotional response to the surrounding environment such as demands from college and perhaps people. Cynicism, the second symptom, can be described as a lack of interest in school and social activities, and the third symptom, decreased academic performance, manifests itself as a lowered sense of competence and achievement in the academic realm.

Evidence suggests that medical students experience greater levels of stress and mental health issues than their peers majoring in other college disciplines (6) and age-matched populations (7). The prevalence of academic burnout is found to vary among different schools, student populations, and countries. In a recent meta-analysis, Almutairi et al. (2022) reported that 37.23% of medical students experience burnout, with individual prevalence rates of 38.08%, 36.85%, and 35.07% for emotional tiredness, reduced personal accomplishment, and depersonalization, respectively (8).

In general, coping with stressful situations is primarily dependent on the psychological resources of each individual (9). Because resilience has been identified as one of the most important psychological resources, numerous researchers have investigated its positive impact on stress reduction and mental well-being (10). Resilience has been described by Connor and Davidson as a personality trait that allows people to remain persistent in the face of hardship and to recover quickly from disappointments or failures (11). Evidence shows that medical students who are more resilient are more likely to experience lower levels of psychological distress, fewer anxiety symptoms, higher levels of pleasure and life satisfaction, and a greater sense of well-being (12).

Academic burnout among Saudi medical students has received little attention in the literature.

2. OBJECTIVE

The objective of the current cross-sectional study, which was carried out in a single Saudi Arabian university, was to measure the stress and burnout levels among medical students. Secondary objectives included investigating whether resilience, stress, and burnout are influenced by age, gender, marital status, and family support.

3. MATERIAL AND METHODS

This was a cross-sectional study surveying medical students at Imam Abdulrahman Bin Faisal University (IAU), Eastern Province, Saudi Arabia. We collected data using a secure online survey platform (QuestionPro) between February and May 2023. The survey was self-administered in English, and the information was collected anonymously. A convenience sample of participants was recruited through popular social media platforms. We used Raosoft, an online software, to calculate the sample size. The minimum sample size required for this study was 377 to reach a confidence interval of 95% with a 5% margin of error. We collected a total of 530 responses. The survey consisted of four parts: a) General sociodemographic information; b) Perceived Stress Scale; c) Maslach Burnout Inventory-Student Survey, and d) Connor-Davidson Brief Resilience Scale.

The Perceived Stress Scale (PSS) is a 10-item questionnaire which was developed by Cohen et al. (13). The scale is designed to assess the level of perceived stress as a result of stressful life events. PSS responses are scored on a 5-point-Likert-type scale According to the scale manual’s scoring system, results between 0 and 13 are indicative of low stress; moderate stress is a score between 14 and 26, and high stress is a score between 27 and 40.

To measure the level of burnout, we used the Maslach Burnout Inventory-Student Survey (MBI-SS), which has been used widely with university students (14). The questionnaire consists of 15 items which are scored on a 6-point-Likert-type scale. The MBI-SS has three subscales: emotional exhaustion (MBI-EE), cynicism (MBI-CY), and academic efficacy (MBI-CY). Levels 10–14 on the emotional exhaustion scale, 2–6 on the cynicism scale, and 23–27 on the academic efficacy scale all represent moderate burnout. An emotional exhaustion score > 14, cynicism > 6, and academic efficacy < 23 all indicate high burnout.

The Connor-Davidson Brief Resilience Scale (CD-RISC), originally developed by Connor and Davidson in 2003, was composed of 25 items (11). Later, Campbell and Stein adapted a brief version (CD-RISC 10) which had a total of ten items (15). The scale is scored on a 5-point Likert scale where 4 is always, 3 is almost always, 2 is sometimes, 1 is rarely, and 0 is never with a total range of 0–40. A high total on the questionnaire indicated a high level of resilience, and a low total score indicated a low level of resilience.

SPSS version was used to analyze the data with both descriptive and inferential statistics. Frequencies and percentages were used to characterize categorical variables. Means and standard deviations (SD) were calculated to summarize continuous variables. The Pearson correlation test was used to assess correlations between the variables of the psychological scales used in the study. The t-test was used to compare differences between group variables.

4. RESULTS

Sociodemographic information is presented in Table 1. A total of 281 (52.8 %) of the 530 students were female, and 249 (46.8%) were male. The mean age of participants was 21.2 (SD, 1.8) years. Only 36 (6.8%) were married. Two-hundred twenty-two (41.7%) of students reported that studying was “very stressful”, and 145 (27.3%) indicated it was “extremely stressful.”

Table 1. Sociodemographic characteristics of participants.

Character	N (%)
Years of studying
2nd year	133 (25.0)
3rd year	114 (21.4)
4th year	95 (17.9)
5th year	101 (19.0)
6th year	88 (16.6)
Gender
Female	281 (52.8)
Male	249 (46.8)
Living with parents
Yes	466 (87.6)
No	64 (12.0)
Marital status
Single	489 (91.9)
Married	36 (6.8)
Other	6 (1.1)
Do you have children?
Yes	11 (2.1)
No	520 (97.7)
Do you find studying stressful?
Extremely stressful	145 (27.3)
Very stressful	222 (41.7)
Stressful	131 (24.6)
Neutral	29 (5.5)
Not stressful	3 (0.6)

The MBI-SS, PSS, and CD-RISC 10 scores are noted in Table 2. The mean score for emotional exhaustion was 20.23 (SD, 6.8) indicating “high burnout” among students. Compared to males, females exhibited statistically significant higher levels of emotional exhaustion (mean difference, 1.71 points; p < 0.01) and cynicism (mean difference, 1.35 points; p < 0.05). Male students had a higher mean score than females in academic performance (24.4 vs. 22.6; p < 0.01) and CD-RISC 10 (26.3 vs. 23.9; p < 0.001). The mean difference between male and female students in all scales used in this study is noted in Figure 1.

Table 2. Mean and standard deviation calculated for each psychological scale.

Scale	Min Score	Max Score	Total Mean score	SD	Classification (high, moderate, low)
MBI-EE	0	30	20.23	6.80	High
MBI-CY	0	24	11.10	7.10	Moderate
MBI-AE	0	36	23.48	7.63	Moderate
PSS	0	40	22.25	6.42	Moderate
CD-RISC 10	0	40	25.11	6.94	moderate
MBI=Maslach Burnout Inventory; EE=emotional exhaustion; CY=cynicism; AE=academic efficacy; PSS=Perceived Stress Scale-10; CD-RISC 10=Conner Davidson Resilience Scale-10.

Figure 1. Mean difference between males and female students in all the scales.

An independent-samples t-test was performed to compare the MBI-SS subscales, PSS, and CD-RISC 10 between the male and female groups with the results noted in Table 3. There were significant differences on the PSS (t = 4.12, p < 0.001) scores with the mean score for females (23.3 ± 5.5) higher than that for males (21.0 ± 7.1). The magnitude of the differences in the means (mean difference, 1.83; 95% CI, 1.20–3.40) was statistically significant ( p < 0.001).

Table 3. Differences in means using t-test analysis.

				95% CI
Variables		Mean difference	SD error difference	Lower	Upper	t	p-value
Gender	MBI-EE	1.71	0.59	0.55	2.87	2.90	0.004**
	MBI-CY	1.35	0.61	0.14	2.56	2.19	0.029*
	MBI-AE	-1.90	0.66	-3.13	-0.52	-2.75	0.006**
	PSS	-1.83	0.55	1.20	3.40	4.12	0.000***
	CD-RISC 10	-2.30	0.59	-3.52	-1.17	-3.92	0.000***
Marital status	MBI-EE	2.32	1.16	0.04	4.61	2.000	0.046*
Living with parents	MBI-EE	0.05	0.90	-1.73	1.83	0.05	0.956
	MBI-AE	-2.26	1.01	-4.26	-0.27	-2.23	0.026*
	CD-RISC 10	-2.08	0.92	-3.89	-0.27	-2.25	0.024*
*** p<0.001; ** p<0.01; * p<0.05

Burnout, perceived stress, and resilience of students who were married was compared to those who were not. The only statistically significant difference was in the MBI-EE subscale (t = 2.00; p < 0.05). The mean was higher among single as opposed to married individuals (2.32; 95% CI, 0.04–4.61). No statistically significant differences between married and single students were noted on the MBI-CY, MBI-AE, PSS, and CD-RISC 10 scales. Furthermore, students who were living with their parents had higher scores on MBI-AE (t = 2.26; p < 0.05) and CD-RISC 10 (t = 2.25; p < 0.05) than those who were not living with their parents. There were no significant differences in scores between those living with parents and those living away from parents on the MBI-EE, MBI-CY, PSS, and CD-RISC 10 scales.

There was no correlation between age and any psychological variable (MBI-EE, MBI-CY, MBI-AE, PSS, and CD-RISC 10) on Pearson correlation coefficient (Table 4). The bivariate Pearson correlation coefficient was computed to assess the relationship between MBI-EE and PSS. There was a significant, strong positive correlation between the two variables (r = 0.576; n = 527; p < 0.001). There was also a strong negative correlation between MBI-EE and CD-RISC 10 (r = −0.364; n = 524; p < 0.001) (Table 5).

Table 4. Pearson correlations between MBI scores and other scales scores.

		Test variables
Test variables		PSS 10 Total Score	CD RISC 10 Total Score
MBI - Emotional Exhaustion	Pearson Correlation	.576**	-.364**
	Sig. (2-tailed)	<0.001	<0.001
MBI - Cynicism	Pearson Correlation	.510**	-.456**
	Sig. (2-tailed)	<0.001	<0.001
MBI - Academic Efficacy	Pearson Correlation	-.495**	.631**
	Sig. (2-tailed)	<0.001	<0.001
**. Correlation is significant at the 0.01 level (2-tailed).

5. DISCUSSION

There have been few studies of academic burnout among medical students in Saudi Arabia. To the best of our knowledge, this is the first study investigating the role of resilience on academic burnout and stress in this cohort. The present study found that academic burnout is common among Saudi medical students. These students displayed high levels of emotional exhaustion and cynicism. The mean MBI-EE score was 20.2 out of 30, while the mean score for MBI-CY was 11.1 out of 24. This indicates that medical students have a high level of emotional tension and mental exhaustion. Students in general demonstrated moderate levels of academic efficacy and resilience.

This study also found that the level of perceived stress was moderately high with a mean score of 22.2 out of 40. Furthermore, there was a statistically significant positive correlation between emotional exhaustion and perceived stress (r = 0.576; n = 527; p < 0.001). This indicates that students experiencing high stress also exhibited a higher degree of academic burnout. However, a positive correlation does not explain causality, so we cannot be certain that stress caused burnout or vice versa. The literature suggests that stress is a major predictor of burnout (16). Medical school administrators should explore introducing effective intervention tools into the educational program to enable students to cope better with stress. Furthermore, successfully coping with stressors has been shown to reduce stress (17). Teaching medical students stress management techniques in a classroom context was found to be a viable option (18).

This study found that female students experienced a higher level of perceived stress than male students (p < 0.001). Females also reported higher degrees of emotional fatigue (p < 0.01) and cynicism (p < 0 .05) as well as lower levels of academic performance (p < 0.01) and resilience (p < 0.001). This finding is in line with previously published studies noting that female students often exhibited higher stress and burnout than males (19). Further investigation to explore causes of gender differences in the levels of perceived stress and academic burnout is warranted. Differences in psychological profiles may explain higher anxiety in female students. Some studies concluded that females scored higher than males on psychological scales measuring neuroticism, general anxiety, and exam-anxiety (20). Female students who had stressful life situations assessed their situation more negatively than their male counterparts (20). One study noted that female medical students had a higher level of perfectionism and sense of incompetence than male students (21), and there is evidence that perfectionism and a high level of anxiety are related (22).

Marriage and family support were noted to be protective factors against certain domains of academic burnout in this study. Students who lived with their parents had higher MBI-AE scores than those who did not (t = 2.26; p < 0.05). Additionally, those who were married had lower scores on the MBI-EE than unmarried students (t = 2.00; p < 0.05). The literature suggests that close family ties are frequently correlated with a lower level of burnout among medical students (23). A large systematic review found stress levels to be lower for married students compared to their single peers (3). Additionally, studies have found that loneliness and/or social isolation may precipitate burnout syndrome, while a strong and healthy relationship with family is a huge motivator to boost student’s performance (23).

In general, our students had a moderate level of resilience with a mean score of 25.1 ± 6.9 out of 40. This study demonstrated higher resilience in males than females and in those living with their parents compared to those living away from home. Students with higher resilience had lower levels of perceived stress and academic burnout. This finding supports previous studies that found a negative correlation between perceived stress and resilience among college students (24). Extensive research demonstrates that overcoming adversity is an important part of the process of developing resilience (25). Numerous studies have demonstrated the positive role that resilience plays in the mental health of medical students (26). We believe that interventions should aim not only at acquiring coping skills and adaptive, emotional regulation, but also at teaching students how to increase one’s resilience (27) which will result in higher levels of life satisfaction.

Limitation of the study

This study has several limitations. Although the study sample was adequate, the study was conducted at a single university, so the findings cannot be generalized to the entire Saudi medical student population. Because this was a convenience sample, the recruitment strategy may have resulted in selection bias. For example, it is possible that stressed and burned-out students were more interested in study participation than nonstressed students resulting in a higher level of burnout among our sample. In addition, we were unable to identify causal relationships among the variables. Because the prevalence of anxiety and depression is high among medical students worldwide, and because we did not assess anxiety or depression, we could not determine if preexisting mental illness was present and contributed to the high level of burnout.

6. CONCLUSION

Academic burnout, particularly emotional exhaustion, is common among Saudi medical students. Their stress level was moderate. Students who scored higher on resilience scored lower on perceived stress and all domains of academic burnout. Females reported higher levels of burnout and stress than males. Additional research is needed to investigate the social and environmental factors that contribute to medical student burnout.

Institutional Review Board Statement:

The study was approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University (IRB-UGS-2023-01-053).

Informed Consent Statement:

Informed consent was obtained from all subjects involved in the study.

Author Contributions:

Feras Al-Awad: conceptualization, methodology, data collection, software, data analysis, writing – original draft, Writing – review & editing, submission.

Conflicts of Interest:

The author(s) declare no conflict of interest.

Financial support and sponsorship:

Nil.