SIGNS AND SYMPTOMS OF THE BURNOUT SYNDROME AMONG UNDERGRADUATE NURSING STUDENTS

This is a qualitative study aimed to learn the signs and symptoms of the burnout syndrome among undergraduate nursing students, by means of semi-structured interviews with 24 nursing undergraduates from a public university in the south of Brazil. The discursive textual analysis was used and defined three categories, related to the dimensions of the burnout syndrome in students: emotional exhaustion, disbelief and low professional efficacy. The specificities of the situations experienced by students are associated with emotional exhaustion, contributing to the detachment from their studies and compromising their sense of professional efficacy. The worn-out signs, detachment from studies and inefficacy mentioned by the students demand appropriate attention and consideration from higher education institutions, provided with the planning and implementation of actions to minimize the stress caused by the identified situations, which seem to be associated with the development of the burnout dimensions among students. DESCRIPTORS: Students, nursing. Burnout professional. Nursing education. MANIFESTAÇÕES DA SÍNDROME DE BURNOUT ENTRE ESTUDANTES DE GRADUAÇÃO EM ENFERMAGEM RESUMO: Para conhecer as manifestações da síndrome de burnout presentes entre estudantes de graduação em enfermagem, realizou-se pesquisa qualitativa com 24 estudantes de graduação em enfermagem de uma universidade pública do Sul do Brasil, mediante entrevistas semiestruturadas. Utilizou-se a Análise Textual Discursiva, definindo-se, a priori, três categorias referentes às dimensões do burnout em estudantes: exaustão emocional, descrença e baixa eficácia Profissional. As especificidades das situações vivenciadas pelos estudantes estão associadas à exaustão emocional, contribuindo para seu distanciamento dos estudos e o comprometimento do seu sentimento de eficácia profissional. As manifestações de desgaste, distanciamento dos estudos e ineficácia referidas pelos estudantes requerem atenção e valorização por parte das instituições de ensino, com planejamento e implementação de ações para minimizar o estresse ocasionado pelas situações identificadas, as quais parecem estar associadas ao desenvolvimento das dimensões do burnout entre os estudantes. DESCRITORES: Estudantes de enfermagem. Esgotamento profissional. Educação em Enfermagem. MANIFESTACIONES DEL SÍNDROME DE BURNOUT ENTRE ESTUDIANTES DE GRADUACIÓN EN ENFERMERÍA RESUMEN: Para conocer las manifestaciones del síndrome de burnout presentes entre los estudiantes de grado en Enfermería, se realizó una investigación cualitativa con 24 estudiantes de grado en Enfermería de una universidad pública del sur de Brasil, mediante entrevistas semi-estructuradas. Se utilizó el análisis textual discursivo, definiendo a priori tres categorías relacionadas con las dimensiones de burnout en estudiantes: debilidad emocional, incredulidad y baja eficacia profesional. La especificidad de las situaciones vividas por los estudiantes están asociadas con la debilidad emocional, contribuyendo para que se distancien de los estudios y para el deterioro de su sentimiento de eficacia profesional. Las manifestaciones de desgaste, el distanciamiento de los estudios y la ineficiencia mencionadas por los estudiantes requieren atención y valoración por parte de las instituciones educativas, con planificación e implementación de acciones que visen minimizar el estrés causado por situaciones identificadas, las cuales parecen estar asociadas al desarrollo de las dimensiones del burnout entre los estudiantes. DESCRIPTORES: Estudiantes de enfermería. Agotamiento profesional (Burnout). Educación en enfermería. 754


INTRODUCTION
The burnout syndrome has demonstrated its relevance in the labor setting, as it elucidates a considerable part of the consequences of the impact of occupational activities for the worker and those regarding this individual towards the work institution. 1It is characterized as a process resulting in physical, mental and emotional exhaustion, as a consequence of hard work, without looking after to the individual's needs, emerging mainly among professionals who develop activities aimed at the care of others; and comprising three related dimensions, despite being independent: emotional exhaustion, depersonalization and reduced professional accomplishment. 2In addition, burnout is the result of a prolonged state of stress and its progression, when the individual no longer has enough defense mechanisms to cope with the situations causing stress. 1 Some studies have investigated the burnout syndrome among nursing professionals, [3][4][5] due to their exposure to several sources of stress, making it one of the professions with the highest incidence of burnout.However, burnout may begin still in the academic phase, during the period of professional education. 6n the one hand, the stress among working nurses is not necessarily the same as the stress among nursing undergraduates, since a different set of circumstances prevails.Undergraduates do not have the responsibilities of a working nurse in his/her work environment, as they stay in these places for a reduced amount of time, during the undergraduate program. Moreover, the initial decision of choosing an undergraduate course is often fragile and lacks reflection and knowledge, resulting in false expectations regarding the course and, when these are not met, they favor the development of feelings of disappointment, demotivation, loss of enthusiasm and frustration, which may lead the student to the situation of stress. 9ence, when the student finds difficulties adapting to situations inherent to the profession, or even when he/she is not satisfied with the professional choice, sources of stress and suffering may be identified, [8][9] which may lead to the development of burnout.Consequently, there may be repercussions in the professional future of this individual, towards the context and work relationships, the different subjects to whom he/she interacts and the care delivered.
The burnout syndrome among undergraduates presents three specific dimensions: emotional exhaustion, described as the feeling of being exhausted in response to intense study demands; disbelief, perceived as the development of a skeptic and detached attitude in the scope of their studies; and low professional efficacy, indicated as the perception of being ineffective undergraduates. 12herefore, this study is justified considering that the burnout syndrome constitutes a theme that is still poorly explored in the context of nursing undergraduates, and that its recognition and the identification of its possible occurrence among nursing undergraduates is fundamental so that coping strategies may be adopted, as early as during the undergraduate program.Moreover, it is important to highlight that most of the studies developed regarding the burnout syndrome among undergraduate nursing students used a quantitative approach 7,[13][14][15][16] , which instigates the development of a qualitative study to provide a further knowledge on the signs and symptoms of the syndrome among nursing undergraduates.
In the light of these considerations, the following study question emerged: which signs and symptoms of the burnout syndrome are present among undergraduate nursing students?Therefore, this study was aimed at identifying the signs and symptoms of the burnout syndrome among undergraduate nursing students.

METHODOLOGY
This is a qualitative exploratory-descriptive study, which aimed to obtain a further under-standing of the phenomenon investigated, emphasizing the processes experienced and the meanings attributed by the subjects. 17he study was developed in the settings of an undergraduate nursing course at a public university in the south of Brazil, which had 242 undergraduate students enrolled in the beginning of the second semester of 2011.The course, which was founded in 1976, is developed in nine terms, since its last and third curricular reformulation in 2005, with a total course load of 4,055 hours.The supervised training constitutes the activities of professional exercise developed in the two last terms of the program, in which the undergraduate must also develop the end-of-course monograph.Moreover, the undergraduate must compulsorily attend 200 hours of complementary activities, developing activities of his/her interest throughout the course, such as the participation and presentation of projects in events, optional disciplines, research and/or extension activities, publication of scientific articles, among others.
The inclusion criteria for the sample selection were applied to undergraduates of this course and who, apparently, presented singular signs and symptoms of the burnout syndrome.The study participants were 24 undergraduate nursing students, enrolled between the 1 st and 9 th term of the course, who were selected by means of snowball sampling. 18Initially, an undergraduate who apparently presented singular signs and symptoms of the burnout syndrome was identified empirically and, after the interview, this undergraduate was requested to indicate other students who presented signs and symptoms that could possibly indicate burnout syndrome, and so forth, until the selection of new subjects was interrupted due to data repetition.It is important to highlight that a minimum number of two undergraduates was established per course term, so as to assure the representativeness of the several moments of the course.
Data were collected in the period between September and December of 2011, in the classrooms of the studied undergraduate nursing course, which were reserved for this purpose, by means of semi-structured interviews with a mean duration of 30 minutes.The interviews were recorded and contained closed questions, for the characterization of the subjects, and open questions, focusing on aspects related with the three dimensions of the burnout syndrome: emotional exhaustion, disbelief, and low professional efficacy.
Data were submitted to the discursive textual analysis, which is "comprehended as a self-organized process of construction of comprehension in which new understandings emerge from a recursive sequence of three elements": 17:12 unitarization, the establishment of relationships and communication.
Unitarization was performed based on the text deconstruction, by means of a close and careful reading, analyzing the text in its details, fragmenting it and highlighting the units of meaning.The constitution of the categories occurred a priori, according to the three dimensions of the burnout syndrome: emotional exhaustion, disbelief and low professional efficacy, with the posterior identification of relationships between the units of meaning, comparing them and grouping elements of close meaning.The last stage of analysis, the communication, comprised the description and interpretation of the senses and meanings built from the text. 17he research proposal was approved by the Local Research Ethics Committee (Protocol number 135/2011).The statements of the students are identified by the letter I, followed by a sequential number and the course term, from T1 to T9.

RESULTS
According to the characteristics of the 24 undergraduates, it was verified that: age varied between 18 and 31 years; 23 were women; 22 were single; they did not have children; 16 lived with their parents, five with roommates and three lived alone; only two managed to work and study; 13 did not choose nursing as their first course option; and 18 had already reported the intention to quit the course.Regarding the distribution of students per term; three undergraduates were interviewed from the 1 st , 2 nd , 3 rd , 4 th , 5 th and 8 th terms, whereas only two undergraduates from the other terms participated.It is worth highlighting that 20 interviewed undergraduates performed extracurricular activities, such as outreach programs, research or teaching activities.
As per the data analysis, three categories regarding the dimensions of the burnout syndrome in undergraduates were defined, a priori, for the open questions: emotional exhaustion, disbelief and low professional efficacy.The students did not necessarily manifest specific characteristics of all dimensions of the syndrome, as some presented more emphasis on one or other dimension, as described in the continuation.

Emotional exhaustion
The manifestations of emotional exhaustion reported by the undergraduates resulted from the weariness experienced in daily situations of the undergraduate nursing course.Among the manifestations of exhaustion perceived by the students, in response to the intense demands of their studies, it was possible to observe: weariness, physical and mental tiredness, discouragement, stress, irritability, headaches, muscular pains and sleep alterations.I have a lot of headaches, which I did not have before; there are days I sleep too much, because I am really tired, and then my body hurts (I16T6).
The undergraduates evidenced the high workload of the disciplines as well as the extraclass activities required as primordial elements for the development of emotional exhaustion.Apparently, these situations have taken the undergraduates to physical and mental weariness, as they claim they have no time left to satisfy their personal needs.
Another situation reported by the undergraduates as a source of exhaustion refers to the perception of being permanently evaluated by the professors in face of their requests, leading to nervousness, stress, irritability and sleep alterations.
There In addition, the external demands and those of the undergraduates themselves to strengthen their curriculum with extracurricular activities were also evidenced as a source of overload, since they spend a great part of the time involved with teaching, research and outreach activities.As a result, they often dedicate a short amount of time to study for tests, projects and oral evaluations from the professors, resulting in tiredness, weariness and stress due to the quantity of content accumulated and the permanent imminence of evaluation.
When I started the course I used to study day and night, and I was also an intern in a research project.It was too much for me and, after that, I became depressed.It was really hard, I couldn't handle the pressure, I got really exhausted, discouraged (I11T4).

Disbelief
As observed, the feeling of disbelief experienced by the students was demonstrated in the form of specific defensive behaviors, such as not attending classes, detachment from studies and extra-class activities, and the desire to quit the course, besides the decreased involvement with classmates, professors and even with patients.
I am completely discouraged.I don't feel like getting out of bed to come here, I started skipping classes frequently, and I am often late, too.I failed a discipline for the second time now, this time because of attendance, and I don't have any encouragement to continue (I4T3).
The weariness and exhaustion experienced by the undergraduates contributed so that they would feel discouraged to study and to develop extracurricular activities, which resulted in a defensive behavior with non-attendance to classes and detachment from the studies.Therefore, failures in evaluations or even in disciplines became more frequent, intensifying their discouragement and the lack of interest in the course activities.
My performance in the course is just reasonable, due to the lack of time to study and the physical and mental weariness.There comes a point you can't take it anymore (I9T3).
The perception of not being able to meet the demands of professors and not being understood in their individuality also constituted a situation that apparently led the students to the feeling of disbelief regarding their studies.They reported that the professors did not understand their limitations, which was reflected in their evaluations, resulting in demotivation and in the desire to quit the course.
When it comes to practice you are not well evaluated, because the professor who is there evaluating you does not take into consideration the fact that you are touching a patient for the first time, it is the first time you are operating on something real, and you often end up unmotivated; I have already felt like quitting because of this (I22T8).
Moreover, the dichotomy between theory and practice evidenced by the undergraduates seems to strengthen feelings of frustration and dissatisfaction with the course, also contributing to distance them from the studies and to intensify their desire to abandon the future profession.The frustration and dissatisfaction with the course were even more intense when the undergraduates had initially intended to take another course in the health area or when they perceived a lack of identification with the nursing activities, especially when they were inserted in practical and training activities.
I started really motivated towards the course, I had enthusiasm, but as I took the disciplines, I got unmotivated, because in the theoretical classes they have this beautiful and wonderful speech but in the practice it is not the same; we learn something in theory and something else, completely different, in the practice, and for me it was horrible, I did not feel like coming to class (I22T8).

I didn't feel like doing anything, especially coming to class, also because I didn't even want to be studying nursing in the first place. I got distant for a long time, failed both because I didn't study and because I didn't come to class, because I didn't feel like getting out of my house, I didn't want to do anything or see anyone (I11T4).
Another source of discouragement for the undergraduates was the lack of embracement during the practical activities and training programs on the part of the different health teams acting in these environments, leading the student away from the dynamics of the health care units and the professionals, which could have damaged his/her learning and academic performance.

The relationship with the team was very traumatic. The team from a certain unit I went through was closed, I didn't have a chance. I felt bad in the field and I couldn't say anything, I had a more reserved attitude, I didn't even want to do things, and my grades were consequently harmed (I23T9).
The frequent contact with situations of suffering seemed to intensify the undergraduates' doubts and questions as for their professional choice, leading to a reduction in their interest in the course activities and to the manifestation of the intention to quit it.In addition, when patients and their families did not acknowledge and appreciate the nursing actions, the students felt more discouraged and started avoiding contact with them, assuming a defensive attitude.

It creates a barrier when the patient does not
acknowledge what you are doing, we start avoiding the patient (I20T9).

Low professional efficacy
The manifestations of low professional efficacy, indicated as the perception of being ineffective as students, evidenced feelings of insufficiency, powerlessness, insecurity, low self-esteem and inferiority, which contributed to intensify the dissatisfaction with the course.In the undergraduates from the initial terms, these manifestations seemed to be associated with the difficulty to perceive the practical application of the contents developed in the disciplines of Health and Biological Sciences and Social and Human Sciences, and to delimit the actions of competence of the nurse in the professional practice.
The course is not what I expected; there are basic disciplines that seem to be useless.Although the professors say it is important, I don't find it very useful, we don't use it much, at least according to the idea that the nurse transmits.I feel lost (I5T2).
Among the undergraduates from the final terms, however, it was evidenced that, as the end of the course approached, they presented greater insecurity in the development of their activities and as for their professional future, manifesting feelings of insufficiency.
I feel insecure in the practices and I end up feeling stupid.I am afraid of graduating and being an unskilled professional.This generates a lot of distress (I17T7).
The perception of not being able to meet the demands of the professors and the lack of autonomy, especially during the development of procedures in the practical activities and training programs, apparently triggered the nervousness of the students, who felt insecure and unable to perform their tasks.
The professors think we don't know how to do the procedures and this is not good.I feel powerless.Even though we don't have the same skills they do, we know how to do it and we are here to learn; so they should give us more autonomy (I13T4).
The recognition of the devaluation of the profession also favors the emergence of feelings of inferiority, low self-esteem, loss of enthusiasm and incapability.Moreover, the apparent lack of autonomy of the nurse, the subordination and the identification of attitudes of carelessness of the working nursing towards patients strengthened the feelings of powerlessness and inefficacy experienced by the undergraduates, since they perceived themselves as a reflection of the professionals in contact with them in the practical activities.

My family wanted me to take another course; I keep feeling inferior. This contributes to lower my self-esteem, and I know that's the way it is: the nurse is underappreciated because she is submissive to the physician; the nurse does a bit of every thing, she doesn't do anything specific, and on top of that she is not well paid (I18T6).
I see that the nurse doesn't impose herself in the practice, she doesn't have autonomy, and then I feel powerless, as if I didn't do anything either (I12T5).
I have already experienced situations in which a nurse disdained a patient's pain, and I felt powerless just watching it (I15T5).

DISCUSSION
The emergence of the manifestations evidenced does not necessarily mean that the undergraduate nursing students of the studied course are developing the burnout syndrome.However, this possibility cannot be rejected, since several situations existing in the educational environment of these students were identified as a source of emotional exhaustion, disbelief and low professional efficacy.
Hence, in the light of the specificities of the situations experienced by the nursing undergraduates, a longitudinal study regarding the interrelationship among psychological variables, personality, stress, coping and burnout considered that the undergraduate nursing course may lead to an increase in the levels of burnout and stress. 15ituations associated with exhaustion and weariness were identified among the undergraduates, throughout the course, regardless the term in which they were enrolled, as previously verified in a study regarding situations that generate stress experienced by nursing students. 19Resulting from the overload of activities, emotional exhaustion is characterized as the absence or lack of energy and enthusiasm and the feeling of depletion of resources to cope with a stressful situation, 2 which agree with the manifestations evidenced in the studied undergraduates.
Similar to the findings of this study, another study aimed to discuss the possible factors associated with stress in the quality of life of students evidenced signs of exhaustion, tiredness, anxiety, difficulties in relationships, palpitation, tachycardia and pain in the nursing undergraduates, identifying the possible extracurricular activities, evaluations and overload of tasks as sources of stress. 20Therefore, the beginning of the develop-ment of the burnout syndrome seems to result from emotional exhaustion, in face of the interpersonal demands and increased loads of activity. 21egarding the dimension of disbelief, it is worth highlighting that when the undergraduates experience situations that generate exhaustion and do not have the resources necessary to cope with them, feelings of retraction may occur, translated into demotivation to develop activities of the undergraduate program, leading to the detachment from their studies, which is reflected in the academic performance. 19Hence, the reduction of contact with the studies may evidence an attempt to relieve the tensions and emotional exhaustion, leading to manifestations of skepticism, anxiety, irritability, loss of motivation, hopelessness and lack of commitment to the academic activities. 2 In this sense, the absence in classes may become more frequent as the burnout manifestations also increase, since this strategy seems to constitute a resource to cope with an admittedly unbearable condition. 1oreover, the dichotomy between theory and practice was evidenced by the students as a source of demotivation, favoring the development of skeptic attitudes towards the studies.The undergraduates have expectations regarding the practical application of their studies, including appropriate work conditions, dialogue and embracement on the part of health professionals and patients.However, these undergraduates often face contradictions between theory and practice, stressful environments, and difficulties relating with the patients, team and professors. 22n addition, in many situations, the students feel unmotivated due to the lack of embracement and the devaluation of the activities they perform during the course, on the part of the working professionals. 23n the dimension of disbelief, the frequent contact of the undergraduates with suffering seemed to motivate questions regarding their professional choice, detachment from the studies and intention to quit the course.In this sense, the direct contact with other human beings, in situation of frailty, seems to make them confront their own condition of existence, health or disease, conflicts and dilemmas, favoring the development of defensive attitudes. 10Hence, the burnout syndrome cannot be understood only as a response to chronic emotional tension, resulting also from the excessive contact with individuals who are in difficult situations. 2 Regarding the lack of identity with the activities of the profession, which constitutes a source of disbelief, it is verified that the poor knowledge of the undergraduates regarding the course they chose, or even the lack of interest in the profession chosen, may contribute to distance them from studies and manifest the desire to quit the course. 8,9It is important to highlight that the act of quitting the course has been understood as a consequence of the burnout process. 13However, most of the interviewed undergraduates claim they did not choose nursing as their first option of course, which may strengthen the desire to quit and the burnout process.
In the light of the manifestation of dissatisfaction with the course, the students do not seem to perceive the meaning and the reward of their effort in the development of the academic activities, which implicates greater weariness in the development of tasks, attitudes of skepticism and distancing from the studies. 13he perception of not being able to meet the demands of the professors and not being understood in their individuality contributed both so that the undergraduates would feel unmotivated, distancing them from the studies, and so that they would feel insecure and powerless in the development of their activities, favoring the development of disbelief and low professional efficacy.Similar results were verified in a study regarding training experiences in the hospital routine, which evidenced that the nursing undergraduates wish to be acknowledged by the professors as for their strengths and limitations, and feel unmotivated and insecure in the development of their activities, as they perceive the professor as a threat. 24anifestations of low professional efficacy, which were reported by the undergraduates and resulted from the dissatisfaction in developing their own activities, seem to compromise their abilities and competences, favoring the development of feelings of incompetence, powerlessness, inferiority, low self-esteem and decreased personal expectations. 2In the initial terms, the students did not seem to visualize the application and the use of their studies, which leads to feelings of inefficacy, whereas in the final terms, the proximity to the end of the course favored the manifestations of feelings of insecurity.
In addition, it is possible to consider that, in the initial terms of the course, the disciplines of nursing sciences present a more reduced workload, which apparently does not contribute suf-ficiently to the acknowledgement of the nurse's work, in the different health institutions, 9 and may lead the undergraduates not to perceive the importance and the practical application of their studies, possibly compromising their feelings of professional efficacy.
In the final terms of the nursing course, the undergraduates may become apprehensive as for their professional future and their insertion in the work market, and insecure as for their education, and these situations may constitute sources of stress, leading to feelings of insufficiency. 25Moreover, as the nursing undergraduates perceive they will have to deliver care to patients as a health professional, they may demonstrate feelings of fear and insecurity. 26ther situations that seem to lead the students to feelings of low professional efficacy are the recognition of the devaluation and subordination of the profession and the apparent lack of autonomy of the nurse, which favored feelings of inferiority and dissatisfaction with the ongoing course.The recognition of the devaluation of the profession was also evidenced by the students as a source of disbelief, favoring the development of skeptic attitudes towards the studies and the intention to quit the course.Similar results were verified in a study regarding the dropout of nursing undergraduates, which evidenced that these feelings may lead the students to quit the course. 9he reduced autonomy in the development of practical and training activities also constituted a source of dissatisfaction and powerlessness among the students, confirming that the lack of autonomy and involvement in the development of activities of their competence may favor the development of low professional efficacy. 1,27n addition, manifestations of low professional efficacy seem to be associated with the visualization of careless attitudes on the part of he working nursing towards patients.In this sense, a study verified that, despite the poor involvement of the nursing undergraduates with the nursing and health team during the development of practical classes and training programs, they are attentive and observe the actions of these teams, identifying inappropriate attitudes and, often, disdain with patients, which reinforces their feelings of powerlessness. 24Therefore, efficacy decreases in the development of their activities as they perceive themselves as a reflection of the professionals they observe in their practices.

FINAL CONSIDERATIONS
The studied undergraduates reported various manifestations regarding the three dimensions of the burnout syndrome, which were associated to the high workload of the disciplines, extraclass and extracurricular activities, perception of being permanently evaluated by the professors, dichotomy between theory and practice, lack of embracement during practical activities and training programs on the part of the different health teams, frequent contact with situations of suffering, lack of acknowledgement and appreciation of nursing, and lack of identification with the activities of the profession.
The specificities of the situations experienced by the students seem to trigger the emotional exhaustion evidenced, leading them away from their studies and compromising their feeling of professional efficacy.The manifestations claimed by the undergraduates require attention and consideration on the part of the teaching institutions, which must plan and implement actions aimed to minimize the stress caused by the situations identified, and which seem to be associated with the development of the dimensions of burnout among the students.
In addition, assisting the undergraduates in the coping processes with situations that seem to lead them to burnout constitutes a possibility to contribute to strengthen the exercise of self-care, before they professionally assume the attributions of taking care of another being.