The Relationship between Resilience and Academic Burnout among Nursing and Midwifery Students in Kermanshah, Iran

Background . Nursing and midwifery students have relatively high levels of academic burnout. One of the mechanisms to combat this issue is resilience. The results related to the association between academic burnout and resilience indicate a negative association, but various studies have reported diﬀerent correlation coeﬃcients. Therefore, the current study was aimed to investigate the association between resilience and academic burnout among nursing and midwifery students. Methods . A total of 240 nursing and midwifery students were recruited in this cross-sectional study using stratiﬁed random sampling. Data were collected by a demographic information questionnaire, the Connor–Davidson Resilience Scale (CD-RISC), and the Maslach Burnout Inventory-Student Survey (MBI-SS). Data were analyzed by SPSS-16 using t-test, ANOVA, Spearman’s correlation coeﬃcient, and linear regression analysis. Results . The mean scores of academic burnout for nursing and midwifery students were 41.4 ± 14.8 and 41.2 ± 12.3, respectively, but the diﬀerence was not statistically signiﬁcant ( p � 0.368). The mean scores of resilience for nursing and midwifery students were 58.1 ± 13.3 and 52.9 ± 13.9, respectively, which showed a statistically signiﬁcant diﬀerence ( p � 0.004). Resilience was signiﬁcantly inversely correlated with academic burnout in nursing and midwifery students ( r �− 0.04, p < 0.001; r �− 0.39, p < 0.001). Increased resilience in students decreased academic burnout ( p < 0.001). Conclusion . Academic burnout was moderate in nursing and midwifery students, but resilience was relatively high. Given the negative correlation between resilience and academic burnout, it is necessary to strengthen resilience skills and reduce factors that cause


Introduction
Individuals working in any profession can be exposed to stress at the workplace. However, the nature of some occupations, including nursing and midwifery, requires that their employees be more exposed to job stress [1][2][3][4][5][6]. e teaching/ learning process, especially in the fields of nursing and midwifery, is a stressful experience. In addition to academic stress, students in these fields face various stressors such as observing patient death, fear of making mistakes at the patient's bedside, dealing with various infectious diseases, and the need to learn various skills for different roles [7,8].
Prolonged exposure to emotional and interpersonal stressors may cause emotional exhaustion, skepticism, and procrastination, all of which are referred to as educational burnout syndrome [9][10][11][12][13][14][15]. Evidence suggests that nursing and midwifery students have relatively high levels of burnout [5][6][7]16]. In this regard, Aghajani et al., Behrozi et al., and Marzooghi et al. reported that nursing students in Iran experience moderate to high levels of academic burnout [7,16,17]. Further, Eaves and Payne reported a high rate of academic burnout in midwifery students [8].
Various studies have investigated the association between academic burnout and resilience. Some other studies have shown a moderate to high rate of academic burnout [28,29]. In terms of resilience, some studies have indicated high levels of resilience [10,24,30,31], and some have reported low levels [32]. e results related to the association between academic burnout and resilience in nursing and midwifery students indicate a negative and significant association, but various studies have reported different correlation coefficients [10,29,[33][34][35][36][37][38][39][40][41][42].
Given the severe consequences of academic burnout and nursing and midwifery students' lack of knowledge about academic burnout and resilience, the current study was aimed to investigate the association between resilience and academic burnout and compare nursing with midwifery students. is study sought to answer the following questions: (1) what is the rate of resilience and academic burnout in nursing and midwifery students? and (2) what is the relationship between resilience and academic burnout in nursing and midwifery students?

Study Design.
is cross-sectional study was conducted at Kermanshah University of Medical Sciences (KUMS) from September to December 2018.

Sample and Sampling Method.
e study population included all nursing and midwifery students of KUMS in 2019. According to the results of the study conducted by Kamalpour et al. [34] and using the correlational sample size formula, with 95% confidence interval and 80% study power, the sample size was calculated to be 120 subjects. Since both nursing and midwifery students were recruited, a total of 240 participants were selected. e inclusion criteria were willingness to participate in the study, being a nursing or midwifery student, having at least one academic year, no history of psychiatric illness (according to participants' self-report), not being in the examination period, not using psychiatric drugs (according to participants' self-report), and not having thyroid (according to participants' self-report). In this study, there were no missing data, and the response rate was 100%.

Study Instruments.
Data were collected using a demographic information form, the Connor-Davidson Resilience Scale (CD-RISC), and the Maslach Burnout Inventory-Student Survey (MBI-SS). e demographic information form included five questions about the field of study, age, gender, semester, and residence. e CD-RISC was used to measure resilience [43]. Various studies have investigated the validity and reliability of these tools. Ramirez-Granizo et al. reported Cronbach's alpha of 0.86 for this tool [24].
e Persian version of CD-RISC has been psychometrically evaluated in Iran, with Cronbach's alpha levels of 0.87 and 0.89 [25,26]. Mohammadi et al. reported Cronbach's alpha level of 0.89 [22]. In the present study, the internal consistency of CD-RISC was evaluated and confirmed with Cronbach's alpha of 0.85. e CD-RISC contains 25 questions and 4 subscales: achievement motivation (items 13, 14, 15, 19, and 25), self-confidence (items 3, 5, 10, 12, 16, 17, 20, 22, and 23), tenacity (items 4, 6, 18, and 21), and adaptability (items 1, 2, 7, 8, 9, 11, and 24). A 5-point Likert scale is used to answer the questions: "not true at all" (0), "rarely true" (1), "sometimes true" (2), "often true" (3), and "almost always true" (4). e level of resilience is equal to the sum of the scores of all items. e total score ranges from 0 to 100. A score range of 0 to 50 is equivalent to "low resilience" and a score range of 51 to 100 is equivalent to "high resilience." e MBI-SS, developed by Maslach and Jackson, was used to measure academic burnout [18]. e validity and reliability of this tool have been confirmed in previous studies. Yavuz et al. examined the internal consistency of the instrument using Cronbach's alpha, and the alpha coefficients for the exhaustion, cynicism, and reduced efficacy subscales were 0.838, 0.844, and 0.875, respectively [15,20].
e Persian version of MBI-SS has also been psychometrically evaluated in Iran, with alpha coefficients of 0.89, 0.84, and 0.67 for exhaustion, cynicism, and reduced efficacy A total of 240 nursing and midwifery students were selected using the systematic sampling technique Data were entered into SPSS software and analyzed Questionnaires were collected by the researchers after completion The objectives of the study were explained to the students, and if they agreed, the questionnaires were given to them subscales, respectively [19]. In the current study, the internal consistency of MBI-SS was evaluated and confirmed by Cronbach's alpha. e alpha coefficients for the exhaustion, cynicism, and reduced efficacy subscales were 0.85, 0.80, and 0.70, respectively. e MBI-SS contains 15 questions, including questions 1-5, 6-9, and 10-15, which are related to exhaustion, cynicism, and reduced efficacy subscales, respectively. Questions 10-15 score in reverse. A 7-point Likert scale is used to answer the questions: "never" (0), "very rarely" (1), "rarely" (2), "sometimes" (3), "often" (4), "more often" (5), and "always" (6). To determine the level of academic burnout, the scores of all items were added. e total score ranges of 0-30, 31-60, and 61-90 indicate mild, moderate, and severe burnout, respectively.

Data Collection Method.
After obtaining the approval of the ethics committee, the list of nursing and midwifery students was obtained from the school of nursing and midwifery. A total of 240 students were selected using the systematic sampling technique. en, based on the students' class schedule, the researcher referred to their classes to explain the study objectives to them, and if they agreed, the questionnaires were given to them to complete. To increase the accuracy of the study, the students were provided with sufficient time to fill out the questionnaires (Figure 1).

Statistical
Analysis. SPSS-16 software was used to analyze and describe the data. Initially, the Kolmogorov-Smirnov test was used to check the normality of quantitative variables (i.e., age, resilience, burnout, and their components). e results showed a normal distribution for age, components of resilience, and burnout. e independent t-test was used to compare normal quantitative variables (i.e., resilience, burnout, and emotional exhaustion components) in nursing and midwifery students. e chisquare test was used to compare nominal qualitative variables (gender and occupation) in the two groups. e independent t-test was used to compare resilience and academic burnout between men and women as well as between students who were living in the dormitory and those who were not living in the dormitory. ANOVA test was used to compare resilience and academic burnout in students with various age ranges and academic semesters. Spearman's correlation coefficient was used to assess the association between resilience and academic burnout. Linear regression was used to investigate the factors affecting academic burnout. e significance level was set at p < 0.05.

Ethical Considerations.
e ethics committee of Kermanshah University of Medical Sciences confirmed the study. Written informed consent was obtained from all participants, and confidentiality of information was assured.

Results
e mean age of nursing students was 22.3 ± 2.6 years; 49.2% (n � 5 9) of them were female; and 42.5% (n � 51) lived in the dormitory.
e mean age of midwifery students was 21.6 ± 1.7 years, and 56.67% (n � 68) of them were living in the dormitory (Table 1). e mean scores of academic burnout for nursing and midwifery students were 41.4 ± 14.8 and 41.2 ± 12.3 (out of 90), respectively, which were not significantly different. For the academic burnout subscales (exhaustion, cynicism, and reduced efficacy), the mean scores for nursing students were 13.2 ± 7.2, 10.0 ± 6.5, and 18.2 ± 6.9, respectively. For midwifery students, the mean scores of exhaustion, cynicism, and reduced efficacy were 13.3 ± 5.7, 10.5 ± 5.6, and 17.4 ± 5.9, respectively. In terms of the academic burnout subscales, there was no significant association between nursing and midwifery students (p < 0.05).
According to the multiple regression model, after adjusting the other variables (Table 5), the resilience, residence, and semester variables were significantly associated with burnout. Dormitory residents and students in the fifth and sixth semesters had significant burnout. Academic burnout decreased with an increase in resilience. However, no statistically significant relationship was found between the age and sex variables and academic burnout (Table 5).

Discussion
e current study was aimed to investigate the association between resilience and academic burnout in nursing and midwifery students. e results showed that nursing and Education Research International midwifery students had an average level of academic burnout. Some studies have reported an average level of academic burnout in students, which is in line with the results of the present study [9,11,21,34]. Problems such as the high volume of lessons, multiple assignments, concerns about the future career, and financial problems are common during college education, which may consequently cause depression [5,17,44]. e results showed that the level of resilience in nursing and midwifery students was moderate to high, and nursing students had a higher rate of resilience than midwifery students. Resilience is individual differences in coping with and responding to difficult situations [25]; therefore, the higher resilience of nursing students than midwifery students can be related to their individual differences.
Bahadir-Yilmaz showed low resilience in Turkish nursing and midwifery students [3]. However, there is some evidence that students have a high degree of resilience [21,34,44], confirming the results of the current study. High levels of resilience, as a protective factor, can help students cope with academic problems and tensions and thus reduce their academic burnout [4,5].
Decreased academic burnout, in turn, can have several positive educational outcomes, including academic achievement [6]. e results showed a statistically significant and inverse association between resilience and academic burnout in nursing and midwifery students so that individuals with higher resilience had lower levels of burnout and academic failure. Several studies also suggest a significant and inverse association between resilience and    academic burnout [5,23,34,39]. Students with resilience skills can manage difficult life situations and adapt themselves to stressful situations, which increases their performance and reduces their academic burnout [2,6,34]. e results showed a statistically significant relationship between semester and academic burnout so that academic burnout was significantly higher in students of fifth and sixth semesters than students of third and fourth semesters. is finding is consistent with the results of Fernández-Castillo and Fernández-Prados [42] but in contrast with the results of Shin et al. and Kamalpour et al. [34,41]. As students progress to higher semesters, their experiences in dealing with stressful events are expected to increase, which can lead to a reduction in burnout.
In the present study, academic burnout was significantly higher in students living in dormitories than those living with their families. is finding is consistent with the results of Wang et al. and Cheng et al. [11,45] but in contrast with the results of Lee [35]. It seems that living with family can reduce many of the stresses of student life and increase their resilience.
e results showed no statistically significant relationship between academic burnout and age. is finding is in contrast with the results of Oyoo [37]. In this study, academic burnout was higher in the older students than the younger ones. As students get older, their personal experiences as well as their self-confidence are expected to increase, which plays an important role in increasing their resilience and thus reducing their academic burnout.
e results also showed no statistically significant relationship between academic burnout and gender. is finding is in line with the results of Oyoo [37]. In this study, academic burnout was higher in the male students than the female ones. Due to the nature of nursing and midwifery disciplines, male and female students are expected to have a high level of resilience to be able to react appropriately to different types of stressors and not suffer from academic burnout.

Limitations.
is study had some limitations. First, due to the cross-sectional nature of the study, it was not possible to investigate the causal association between variables. Data were collected through self-report, which may have affected the accuracy of the data. Interventions such as workshops are recommended to prevent academic burnout and increase resilience among students.

Conclusions
Nursing and midwifery students had moderate levels of academic burnout. In terms of resilience, nursing and midwifery students had moderate to high levels of resilience, and nursing students were more resilient than midwifery students. A significant and inverse association was found between resilience and academic burnout in nursing and midwifery students. Regarding the negative correlation between resilience skills and academic burnout, face-to-face or virtual workshops are recommended to be held to enhance students' resilience skills. Further cross-sectional and longitudinal studies are also suggested to investigate the impacts of such workshops on resilience and academic burnout.
Data Availability e identified data sets analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest
e authors declare that there are no conflicts of interest.