Introduction

Burnout is a dynamic, stress-related process caused by a combination of high workload and low coping resources. Dimensions of burnout include emotional exhaustion––a lack of energy and feeling worn out; depersonalization––a negative approach to others and treating them as objects, and decreased sense of personal accomplishment––feelings of incompetence and lack of achievement or productivity at work [1]. Burnout is common in members of the healthcare professions, including nurses, physicians, and medical students, who are involved in caregiving and intensive interaction with people, often with a tendency to put others in the center, sometimes compromising their own well-being [2]. Burnout has severe personal consequences. For example, medical students’ burnout was associated with low sleep quality [3], alcohol abuse/dependence [4], depression [5], and suicidal ideation [6]. Burnout has negative professional implications for medical students, including academic problems [3], decreased altruistic professional values, suboptimal patient care, and medical errors [6].

A recent meta-analysis [7] involving 42 studies and 26,824 undergraduate (pre-intern) medical students reported an overall burnout prevalence rate of 37.23%. Prevalence of emotional exhaustion was 38.08%, depersonalization was 35.07%, and personal accomplishment was 36.85%. When comparing medical students to age- and education-matched population control samples, medical students were more likely to be burned out [6,8,9], with an increased burnout percentage during years of medical school [5,10].

Despite the high incidence of burnout among medical students and its problematic consequences [11], not all medical students experience burnout, and some manage to overcome it [12]. One personal ability that may protect individuals from burnout is resilience [13]. Resilience is the capacity to bounce back and adapt positively when faced with adverse, challenging, and threatening situations [14,15]. Resilient individuals are usually optimistic, with high coping competence and high tolerance, which are related to better physical and mental health [16]. Two substantial components are required for resilience to be expressed: adversity and positive adaptation in the face of that adversity. Adversity is usually a challenging event with a high likelihood of a problematic outcome; however, positive events, such as acceptance to medical school and work promotion, may also pose challenges and require resilience. Positive adaptation is a behavioral manifestation of social competence or of successfully meeting stage-salient developmental tasks [14].

Although the role of resilience in preventing burnout has been extensively studied, and the negative association between resilience and burnout is well-established [17–19], the intuitive connection between resilience and burnout has become an obstacle since a considerable number of researchers measured resilience as a "lack of burnout," notwithstanding the distinction between the two concepts [12,20]. According to Strümpfer [21], underpinning the concept of resilience are some psychological factors that enhance the resistance to burnout. These psychological factors include engagement, meaningfulness, subjective well-being, positive emotions, and proactive coping. Engagement is a fulfilling work-related cognitive-affective state that is characterized by vigor, dedication, and absorption. Meaningfulness describes individuals’ ability to perceive themselves as necessary and valuable. Subjective well-being describes both the sense of value and satisfaction from the person’s daily life and enjoyment of life. Positive emotions describe a mental state that, in the short term, is conducive to increasing the conscious broadening of desirable thoughts and, in the long term, to performing effective and valuable activities [22]. Proactive coping describes people’s ability to identify situations that are likely to cause stress and to behave in a way that will prevent them from worsening and even lead to posttraumatic growth [23]. These psychological factors of resilience can be nurtured by developing various individual and environmental behavior components, such as a sense of control, a sense of meaning in the life routine, and the presence of a mentor attuned to a worldview of competence and confidence [24].

During their taxing years in medical school, and especially during their clinical years, medical students are exposed to high prevalence of stress, distress, and adverse life events, such as high academic demands, economic difficulties, situations of helplessness, and moral and ethical dilemmas [25,26]. Additional distress relates to the tendency among healthcare professionals, including medical students, to focus on the care of others, sometimes at the cost of self-neglect [2] and lack of self-care. In view of this tendency, the present study focused on examining how medical students’ self-care practices during their stressful clinical years of training were related to burnout.

Material and methods

Sample and procedure

A quantitative cross-sectional study was conducted among a class of 95 fourth-year medical students from Tel Aviv University in Israel (M_age = 27.26, SD = 2.81), representing a response rate of 76% (95 of 125 students completed the questionnaires). Data from these students were collected in May 2016, immediately after a 14-week internal medicine clerkship. The clerkship is a critical and very intense stage in students’ training, requiring them to adjust to the medical system. During this period, medical students may experience increased stress and distress [26]. The Tel Aviv University Ethics Committee approved the study (approval #6116), and all participants signed a written informed consent form before completing the self-reported questionnaires. (See Table 1 for participants’ demographic characteristics and S1 File for the study fundamental data).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Demographic characteristics of the study participants (N = 95).

https://doi.org/10.1371/journal.pone.0309994.t001

Results

The present study examined the associations between resilience, self-care, and burnout among medical students (see Table 2 for the variables’ psychometric characteristics and Pearson’s correlations).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Psychometric characteristics and correlations of the study variables.

https://doi.org/10.1371/journal.pone.0309994.t002

Table 2 demonstrates that Hypothesis 1, examining associations between resilience and burnout, was partially supported. We found a negative association regarding emotional exhaustion, i.e., students who reported high levels of resilience felt less exhausted. Additionally, Hypothesis 2, examining associations between self-care and burnout, was partially supported. We found negative associations regarding emotional exhaustion, i.e., students who reported high stress management and interpersonal relations felt less exhausted. We also found a positive association regarding personal accomplishment, i.e., students who reported high spiritual growth and interpersonal relations had a greater sense of accomplishment. Finally, Hypothesis 3, examining associations between resilience and self-care, was partially supported. We found positive associations regarding three out of four activities, i.e., students who reported high resilience reported high stress management, spiritual growth, and interpersonal relations.

In addition to examining linear associations between the variables, we tested whether the associations between resilience and burnout are mediated by self-care (see below Fig 1 and Table 3). Fig 1 and Table 3 demonstrate that Hypothesis 4, examining the mediation model, was partially supported. In path a, examining the direct effects between resilience and self-care, we found positive associations regarding stress management, spiritual growth, and interpersonal relations. In path b, examining the direct effects between self-care and burnout, we found negative associations regarding emotional exhaustion (with the role of stress management and interpersonal relations) and a positive association regarding personal accomplishment (with the role of spiritual growth). Additionally, in path c, examining the total effects between resilience and burnout, we found a positive association regarding emotional exhaustion. As expected, it becomes insignificant while controlling this total effect with the other variables (path c’). Finally, in paths ab, examining indirect effects between resilience and burnout, we found mediations of stress management and interpersonal relations between resilience and emotional exhaustion, and mediation of spiritual growth between resilience and personal accomplishment.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. The study model: The association between resilience and burnout mediated by self-care.

https://doi.org/10.1371/journal.pone.0309994.g001

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Regression analyses examining whether the association between resilience and burnout is mediated by self-care.

https://doi.org/10.1371/journal.pone.0309994.t003

Discussion

The present study examined associations between resilience, self-care, and burnout among medical students at the beginning of their clinical training, a period that evokes acute stress and burnout [26]. The study hypotheses were partially supported since associations between resilience, self-care, and burnout were found, but not in all self-care and burnout dimensions. The study findings demonstrated associations between the variables insofar as the self-care variable mediated the association between resilience and burnout for some of the self-care and burnout dimensions.

Like earlier studies, the present study showed that resilience has a direct negative association with one burnout dimension—emotional exhaustion [54–57]. This finding is consistent with the theory of positive psychology [58], which asserts that when individuals succeed in overcoming stressful situations, they undergo an internal change and a process of growth that allows them to moderate the emotional exhaustion and to avoid the sense of emptiness, fatigue, and lack of motivation. Furthermore, in a qualitative study among resilient teachers, most participants reported that their ability to grow and learn from previous experiences with difficult situations helped them avoid a sense of emptiness, fatigue, and stress. This ability also led to a sense of control and responsibility for their actions as significant components of their resilience [59]. Individuals who have this sense of control will often perform well-being-enhancing actions, such as engaging in self-care practices.

Indeed, the present study model broadened this understanding, showing that the association between resilience and emotional exhaustion is mediated by two self-care practices: stress management and interpersonal relations. These findings are in accordance with Strümpfer’s [21] theory that claims that proactive coping, which relates to people’s ability to identify stress-inducing situations and to behave in a way that will prevent their aggravation and will evoke a sense of control and self-efficacy, is one of the resilience components. The findings of the present study suggest that effective stress management is a behavior that may prevent the worsening of stressful situations. In that way, students with high resilience can predict situations that may cause stress (e.g., academic overload before the internal medicine clerkship exam) and therefore implement a suitable coping strategy; namely stress management (e.g., practicing calming techniques at different hours of the day) or seeking social support and interpersonal relations as a buffer and as protection from the negative influences of the cause of stress [60].

Regarding depersonalization, the interpersonal relations dimension that emphasizes personal connection might have been expected to help reduce burnout, since meaningful relationships with others would decrease negative perceptions of patients or the act of relating to people as objects [1]. However, this association was not found to be significant in the present study. One reason for this is that we had no information about whom the study participants had interpersonal relationships with. Their interpersonal relationships may have been primarily with student peers—a population on whom medical students tend to rely for sharing their experiences of traumatic events [45]. If that was the case, these relationships might be part of the professional socialization process, in which the hospital’s organizational culture and norms encourage emotional detachment [61]. Therefore, these relationships, despite their advantage in providing social support and protection from emotional exhaustion, do not contribute to the prevention of depersonalization and cynicism.

The hospital norms can also explain why other study variables were not found to be directly or indirectly associated with depersonalization as a dimension of burnout. Depersonalization variables exist in the organizational culture, and their origins are deeper and more socially based [61]. One example is the norm that doctors do not cry. Therefore, they do not encourage the spontaneous expression of emotions [61] and often, do not behave empathetically [62]. Thus, this aspect is less dependent on the individual’s development (e.g., increased resilience or self-care), and other buffering/protecting factors require enhancement, such as encouragement and teaching of empathy [63].

Regarding personal accomplishment, no direct association was found between resilience and this burnout dimension, but an indirect association was found between them, mediated by spiritual growth. According to existentialist theory, people need a sense of meaning in life and the belief that the actions they perform have a generally positive and even heroic effect [21]. In the absence of a sense of a mission and influence in the workplace, people experience burnout due to the lack of personal accomplishment. According to positive psychology, resilient individuals will find meaning and a sense of a mission in stressful situations and in their ability to overcome them [58]. Finding meaning and a sense of mission contribute to spiritual growth: development of internal resources by transcending (being tuned to the inner self), connecting (a sense of harmony and wholeness), and developing (including a search for meaning and striving toward a goal; [39–40]. Transcending, connecting, and developing help build a positive self-perception and thus increase self-accomplishment [41].

Health responsibility, relating to the active preservation of the individual’s physical and mental health [36], was examined in the present study since it is documented in the literature as problematic among health professionals [64]. As far as we know, the present study is the first to examine the associations between resilience, health responsibility, and burnout. Our findings, which indicate an absence of association between the variables, are interesting and can be explained by the fact that health responsibility, as expressed in the questionnaire, relates to physical rather than mental health and, therefore, might not be associated with burnout dimensions. Another explanation may relate to the fact that physical health responsibility was less relevant to our students because of their relatively young age. Most of the students (93%) were below the age of 30. Even students who neglect their health and do not consult specialist physicians are not yet suffering from the harmful impact of that neglect on their daily functioning.

Alongside the specific findings explained above, self-care was a mediator between resilience and burnout. That is to say that resilience leads to a coping strategy that creates protection from burnout. The explanation for this process may be grounded in seeing resilience as a developmental issue: an acquired capability influenced by individual or group traits and experiences that affect different outcomes in people’s behavior, feelings, and well-being [65]. This raises the question of which experiences are required to develop resilience. According to the behavioral immunization theory [58], to become immune, the body must encounter pathogens (e.g., bacteria or a virus) and create antibodies to destroy them. After the initial illness, the immune system’s memory retains the antibodies and prevents reinfection. Similarly, to develop resilience, the person needs to "encounter" a stressful situation (e.g., the death of a patient) and to recognize ways to cope with it (e.g., debriefing this experience with a mentor or close friend). Effective coping will be retained in the individual’s "memory" and will be a platform for increasing the sense of control in similar stress situations in the future.

In this manner, the findings of the present study suggest that self-care is, in fact, a coping strategy. In stressful situations, people learn to identify activities that reduce stress. Individuals with high resilience have coping strategies, such as stress management, spiritual growth, and interpersonal relations. When they experience a stressful situation, they identify the need to use the strategy and are, therefore, less prone to burnout. However, individuals with low resilience may have difficulty identifying helpful coping strategies and have a lower tendency toward self-care activities. Therefore, they are more at risk of burnout and its negative implications.

Nonetheless, self-care behaviors that are disconnected from the stress and coping context will not necessarily lead to resilience. This was tested in an alternative model of the present study, in which resilience did not mediate the association between self-care and burnout. This finding can be explained in the context of the organizational culture of medicine. The norm in hospitals is a dichotomic separation between caregivers and patients: a clear distinction between providers and receivers of help. Therefore, when entering clinical rounds, many students feel that requesting help or choosing to perform self-care activities goes against the "tough" norm [18,48]. In this way, and in accordance with the behavioral immunization theory [58], students with low resilience will either have difficulty developing resilience under these norms or will develop coping strategies that are appropriate to the existing norms, including neglect of personal life [18], cynicism toward the environment, and other methods that lead to burnout. In contrast, students with high resilience will react to stressful situations according to their "immune memory" and, during stressful situations, will adopt familiar, helpful self-care behaviors, based on the understanding that they will enable them to function better in their work.

Conclusions

Burnout among medical students is a global problem with far-reaching implications for students’ physical and mental health and the health of their future patients. The present study suggests that medical students’ high levels of resilience are associated with taking more self-care actions (stress management, spiritual growth, and interpersonal relations). Additionally, taking more self-care actions is associated with lower levels of burnout (emotional exhaustion and personal accomplishment). The findings of the present study recommend transferring the emphasis in medical schools to developing resilience resources among medical students while exposing them to self-care activities in this context. Furthermore, we recommend exploring other interventions in the attempt to prevent the critical burnout dimension of depersonalization that goes beyond resilience and self-care.

Supporting information