Determinants of burnout syndrome among nursing students in Cameroon: cross-sectional study
Njim et al. BMC Res Notes
Determinants of burnout syndrome among nursing students in Cameroon: cross-sectional study
Tsi Njim 0
Clarence Mbanga 2
Dave Mouemba 1
Haman Makebe 6
Louis Toukam 5
Belmond Kika 4
Isabelle Mulango 3
0 Health and Human Development (2HD) Research Group , Douala, Littoral region , Cameroon
1 Regional Hospital Annex Kousseri , Garoua, Far north region , Cameroon
2 Mankon Sub-divisional Hospital , Bamenda, North west region , Cameroon
3 District Hospital Kumba , Kumba, South west region , Cameroon
4 District Hospital Ekondo-Titi , Ekondo-Titi, South west region , Cameroon
5 Faculty of Health Sciences, University of Bamenda , Bamenda, North west region , Cameroon
6 Faculty of Health Sciences, University of Buea , Buea, South west region , Cameroon
Objectives: Burnout syndrome defined as a state of emotional exhaustion and disengagement; which could reduce optimal healthcare delivery, is relatively common amongst healthcare trainees. We sought to assess the determinants of burnout syndrome amongst nursing students in Cameroon. A cross-sectional study which included 447 nursing students recruited after written informed consent by convenience sampling, was carried out from January to April 2018. A printed self-administered questionnaire assessing burnout using the OLdenburg Burnout Inventory was used. Multivariable linear regression was used to identify independent determinants of burnout syndrome. Results: Most (81.17%) of the students were female with the average for disengagement items being 17.10 ± 3.09 (minimum = 8, maximum = 26) and 20.94 ± 3.04 (minimum = 13, maximum = 31) for exhaustion items. After multivariable linear regression analysis, satisfaction with results (RC: − 1.42, 95% CI − 2.52, − 0.32, p value: 0.012) and regret of choice of nursing studies (RC: 2.13, 95% CI 0.58, 3.68, p value = 0.007) were found to be independent predictors of burnout in these students. Early identification of these determinants is required to prevent progression to burnout.
Burnout syndrome; Nursing students; Cameroon; OLdenburg Burnout Inventory
Burnout syndrome is a psychological state
characterised by emotional exhaustion and distancing one’s self
from their job (cynicism) [
]. It usually results from job
stressors and is highly prevalent amongst medical
]. It is widely accepted that due to the
strenuous academic life of medical students characterised by
competitive entrance exams, difficult transitions across
the various phases of clinical work and the exposure to
critically ill patients; these students are quite likely to
experience burnout syndrome [
]. In Cameroon,
students who wish to obtain a nursing degree have similar
exposures as enumerated above. There are only two
stateowned nursing schools in the English-speaking regions
in Cameroon, which provide nursing degrees with highly
competitive entrance exams. It is also widely accepted
that burnout syndrome starts at the early stages of
training and worsens during practice with work environment
stressors; and increased workload being a huge
contributing factor [
Researchers have found a relatively high prevalence
of burnout amongst nursing students. In Brazil, a study
showed that 64.04% of nursing students in the sample had
emotional exhaustion, 35.79% had a high level of
cynicism, and 87.72% had a low level of professional efficacy
]. There is an acute shortage of nurses in Cameroon
with a nurses’ density of 0.67 per 1000 [
]. With such a
workload awaiting nursing students with burnout, it is
necessary for early detection of the syndrome as
burnout in known to reduce optimal healthcare delivery. If the
determinants of burnout can be identified amongst these
students and early detection made a priority, the
morbidity associated with this condition could be reduced.
This research aims to raise awareness on mental health
issues amongst these group of students in a field where
there is usually a dearth of data. This could help inform
public health policy to help with the investigation and
institution of adequate preventive measures.
Population and design
Population, sampling and sample size This manuscript
was written from data obtained from a wider study
assessing burnout and depression in nursing students in
Cameroon (the Me-HeLTC project). The sampling frame
included all the nursing students from the two state-owned
nursing schools (University of Bamenda and University of
Buea) and other private nursing schools (Saint Veronica
higher institute of biomedical and nursing sciences Buea
and Saint Louis higher institute of health Bamenda); in
the two English-speaking regions of the country. These
students were recruited by a convenience sampling until
the minimum sample size required was attained which
was calculated by the formula below [
Z2 P (1 − P)
where n = sample size, Z = Z statistic for a level of
confidence, P = expected prevalence or proportion (in
proportion of one: 27.4, P = 0.274) [
], and d = precision (in
proportion of one; if 5%, d = 0.05). Z statistic (Z): For the
level of confidence of 95%, which is conventional, Z value
is 1.96. For a 95% confidence intervals (CI).
A minimum of 306 nursing students were required for
the study and 447 questionnaires were handed out and
Design This was a cross-sectional study that was carried
out over 4 months (January to April 2018).
Instrument The following information was collected:
Socio-demographic characteristics: age; sex;
marital status; number of children; level of nursing studies;
number of hours spent studying; presence of problems
in personal relationships (defined as a close connection
between two people formed by emotional and sexual
interactions); monthly income and the perception of
sustainability on their monthly income; average academic
results attained; alcohol use; (assessed using units of
alcohol consumed a week); smoking and history of any
chronic disease (which included asthma, chronic pelvic
pain, hypertension, diabetes mellitus, gastroesophageal
reflux disease, chronic peptic ulcer disease, migraines,
cancers, HIV/AIDS, cerebral lesions, chronic liver and
kidney disease. An open-ended question was also
provided for the students to state their chronic illness which
was used by the investigators to assess the suitability of
the response for this scenario).
The OLdenburg Burnout Inventory (OLBI) which is a
self-administered questionnaire consisting of 16
positively and negatively framed questions to assess two core
parameters of burnout with eight questions for each
parameter: exhaustion (intense physical, affective and
cognitive strain) and disengagement (characterized as
cynicism referring to distancing from one’s work in
general) was used to assess burnout syndrome [
]. The OLBI
version used in this study was adapted from that used by
Reis et al. [
] in an academic milieu. The OLBI ranges
on a scale of one to four from strongly agree to strongly
Data management and statistical analysis
Data entry was done using EPI Info version 7 (CDC,
Atlanta). Accuracy of data entry was assessed by
crosschecking a random sample of 10% of the data.
Results were presented as proportions and means
with standard deviations (SD). The reliability and
validity of the OLBI was assessed by means of Cronbach alpha
Emotional exhaustion and disengagement as defined
by the OLBI were used to define burnout. Negatively
phrased questions were reversed (1 = 4, 2 = 3, 3 = 2,
4 = 1) such that higher scores indicated higher
exhaustion and disengagement and the values entered by each
participant for both dimensions were summed up to
obtain a total score for burnout syndrome.
Univariable linear regression analysis was used to
compare the outcome (burnout syndrome) with potential
determinants such as: marital status; sex; age; level of
studies; presence of a chronic illness; perceived poor
academic performance; alcohol consumption and smoking.
Significant predictors were inputted in a multivariable
linear regression model to identify independent
determinants of burnout syndrome. Significance was set at p
values < 0.05.
A total of 447 questionnaires were distributed and
returned filled from the nursing students. There were 99
(22.45%) students from the University of Bamenda, 91
(20.63%) from the University of Buea and 251 (56.92%)
from the private nursing schools (Saint Veronica higher
institute of biomedical and nursing sciences Buea and
Saint Louis higher institute of health Bamenda). Most
(81.17%) of the students were female with a majority
(39.73%) being in their second year of studies (Table 1).
a Personal relationship was defined as close connections between two people
formed by emotional and sexual interactions
b Life changing crises defined as loss of a loved one, physical or sexual trauma
and conditions of emotional or social instability
c Chronic illnesses included: Asthma, chronic pelvic pain, diabetes mellitus,
gastroesophageal reflux disease, chronic peptic ulcer disease, migraines,
cerebral lesions and paralysis
d Recreational drugs included: marijuana and tramadol
The ages of the students ranged from 17 to 50 years with
a mean age of 22.28 ± 3.61 (Table 2).
Assessment of burnout syndrome
The average for disengagement items was 17.10± 3.09
(minimum = 8, maximum = 26) while the average for
exhaustion items was 20.94 ± 3.04 (minimum = 13,
maximum = 31). All the items showed average covariances
and the alpha Cronbach coefficient was 0.6 showing that
the OLBI measured the same underlying construct of
burnout amongst the participants (Additional file 1).
Determinants of burnout syndrome
On univariable linear regression analysis, burnout
syndrome was associated with: marital status [regression
coefficient (RC): 6.19; 95% confidence intervals (CI) 2.82,
9.56, p value: < 0.001]; relationship difficulties (RC: 2.55,
95% CI 1.05, 4.05; p value: 0.001); number of children
(RC: − 0.89; 95% CI − 1.55, − 0.23; p value: 0.008); level of
studies (RC: 2.05, 95% CI 0.91, 3.20; p value: < 0.001);
satisfaction with results (RC: − 1.17; 95% CI − 2.21, − 0.13;
USD United states dollars, GPA cumulative grade point average, OLBI Oldenburg
p value: 0.028); and regret of choice of nursing studies
(RC: 2.30; 95% CI 0.91, 3.69; p value: 0.001) (Table 3).
After multivariable linear regression analysis, the
following variables were identified to be independent
determinants of burnout: satisfaction with results (RC:
− 1.42, 95% CI − 2.52, − 0.32, p value: 0.012) and regret
of choice of nursing studies (RC: 2.13, 95% CI 0.58, 3.68,
p value = 0.007) (Additional file 2).
In this study, we showed that independent determinants
of burnout syndrome amongst nursing students in the
two English-speaking regions of Cameroon were
dissatisfaction with results and regret of choice of nursing
Students who regretted choosing nursing as a future
career scored on average two points higher on the OLBI
scale after adjusting for confounders. Burnout syndrome
has been associated with the intention of giving up
nursing studies among nursing students in the South of Brazil
] and amongst students in other fields like medicine
5, 14, 15
]. Nursing studies in Cameroon are
particularly stressful. The entrance examinations into
the two state universities are very competitive and the
private sector which offers a few more opportunities are
quite expensive to pay for. The studies are also time
consuming, with students having to sit through several hours
of classes per week; which happens to be exhausting
both mentally and physically. As such, they end up
having little or no time to engage in social and pleasurable
activities which they enjoy; and which have been shown
to have not only mental but equally physical benefits [
]. This could lead to regrets and ultimately burnout as
pointed out by our analysis.
Furthermore, students who get into these nursing
programmes are faced with the harsh realities of
autonomous university life, the difficulties of transitioning in the
basic nursing sciences and the daily dilemmas of dealing
with critically-ill patients during their routine clinical
clerkships. They also begin to spend less time at home
with family as they begin to run shifts during their
internships; are faced with big emotional tests as they start to
lose patients under their care; and equally get to realize
the workload associated with nursing in Cameroon due
to the acute shortage of nurses in the country (nurses’
density: 0.67 per 1000) [
]. With all the above mentioned
difficulties linked to nursing studies in Cameroon, it is
understandable that some of these students may start to
feel uncomfortable with their choice of studies especially
if they have the feeling of not coping in this environment
and lack the hardiness to survive the coursework. Such
feelings could easily perpetuate further an already toxic
academic milieu [
] which could easily lead to them
becoming burnt out. Both environmental and personal
factors can lead to stress among students, previous
studies have shown an association between certain
personality traits such as resilience and burnout syndrome in
nursing students [
A vast range of career opportunities usually awaits high
school leavers but the nursing field is a popular choice
in Cameroon due to its high employability and apparent
financial safety. The realities of the nursing studies and a
career in nursing are hardly made available to
prospective students. Students who are ill-equipped to deal with
such pressure may end up making a poor career choice.
Proper orientation is therefore necessary for these
students to make career choices that match their skill set
The above situation may become more relevant if the
performance of the student becomes affected by this
environment. Studies have shown that dissatisfaction
with results is significantly associated with stress [
] among students in the health training
system. This has a negative impact on students as stress
or burnout may result in a decrease in performance of
daily educational tasks and poor results could ensue. This
leads to dissatisfaction with performance and results, and
more stress about their abilities to succeed in the
chosen field. This vicious cycle continues throughout their
studies which could eventually lead to burnout. Indeed,
in this study, students who were dissatisfied with their
results significantly scored at least one point more on the
OLBI scale than students who were satisfied with their
results. As earlier mentioned, nursing studies in
Cameroon are not only stressful but also time consuming. As
a result, students have little or no opportunity to
accomplish leisure time activities. The inability to accomplish
such activities because of the time consuming nature of
their studies could therefore weigh on their mental health
We did not find a significant association between
burnout syndrome and alcohol consumption, recreational
drug use and tobacco use respectively. These findings are
similar to a study among nurses in Brazil, although high
levels of burnout and risk turnover may lead to alcohol
or recreational drug use as a means of coping with stress
]. However, this study was carried out in a
conservative society where recreational drug use is highly frowned
upon. Students may not have indicated previous drug use
to appear more socially desirable. Also, over half of the
students had experienced a significant life changing
crises in the past 6 months. Though this was not associated
with burnout syndrome in these students, it highlights
the additional strain nursing students undergo alongside
Though mental health is usually neglected in most low
and middle-income countries with health professionals
being ill-equipped to deal with mental health conditions
especially in Cameroon [
], burnout is gaining global
recognition as a psychological state that affects a higher
proportion of medical personnel and trainees compared
to the general public [
]. There is great need for
provision of counselling and support services in nursing
programs and the utilization of effective interventions and
coping strategies to prevent or reduce burnout syndrome
and augment academic motivation. With the dearth of
data on this issue in Cameroon this study provides
determinants of this condition amongst a special population
that may help raise awareness on the need for early
identification of this determinants and management to
prevent progression to burnout syndrome. This could help
decrease the associated morbidity and inform
policymakers on the need for the investigation and institution of
appropriate preventive measures.
This is the first study to the best of our knowledge which
assesses the determinants of burnout syndrome amongst
nursing students in Cameroon and in Central Africa.
However, due to the cross-sectional design of the study
and the use of self-reported questionnaires the study was
subjected to recall bias.
Additional file 1. Covariances of various items on the OLBI and the
associated alpha Cronbach coefficient of 0.6 showing that the items measure
the same underlying construct—burnout.
Additional file 2. Multivariable linear regression analysis of potential
determinants of burnout syndrome amongst 413 medical students
who were assessed for burnout syndrome from January–March 2018 in
OLBI: OLdenburg Burnout Inventory; GPA: grade point average; SE: standard
error; SD: standard deviation; CI: confidence interval.
Conception of study: TN; Study design and implementation: TN, BK; Literature
review: TN, CM, DM, IM; Data collection: CM, DM, HM, LT, BK; Data
management: CM, DM, HM, LT; Data analysis: TN; Write-up of initial manuscript: TN,
CM, IM; manuscript revisions: TN, CM, DM, HM, LT, BK, IM. All authors read and
approved of the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets during and/or analysed during the current study are available
from the corresponding author on reasonable request.
Consent for publication
Ethics approval and consent to participate
Ethical approval was sought from the Cameroon Baptist Health Board
Institutional Review Board and Administrative authorization was obtained from
the regional delegation of Public Health of the South west region. All ethical
principles were respected during the conduct of this research and
confidentiality was assured by collection of anonymous data. All nursing students who
accepted to partake signed a written informed consent document.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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