An-Najah National University Faculty of Graduate Studies Resilience, Self-Efficacy, and Burnout among Nursing Students in Palestine By Zareefa Shaabna Supervisor Dr. Adnan Sarhan This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Community Mental Health Nursing, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2021 ii iii Acknowledgements I would like to extend my sincere and heartfelt gratitude toward all who have helped me with this endeavor. Without their active guidance, support, and encouragement, I would not have been successful with this project. I would like to dedicate this work to my supportive family specially, to my mother, my role model and my supportive husband. I would also like to dedicate this work to my second family (my colleagues) for their supportive role from the beginning of this journey. I am indebted to Dr. Adnan Sarhan, my research adviser, for his conscientious guidance and direction throughout this entire process. Zareefa Shaabna iv االقرار أنا السؾقع أدناه، مقّجم الخسالة التي تحسل العشؾان: Resilience, Self-Efficacy, and Burnout among Nursing Students in Palestine أقخ بأن ما اشتسمت عميو ىحه األطخوحة إنسا ىؾ نتاج جيجي الخاص، باستثشاء مــا تســت االشارة إليو حيثسا ورد. وأن ىحه الخسالة كاممة، أو اي جدء مشيا لؼ يقجم مؽ قبل لشيل اي درجة او لقب عمسي او بحثي لجى أي مؤسدة تعميسية أو بحثية أخخى. Declaration The work provided in this thesis, unless otherwise referenced, is the researcher‟s own work, and has not been submitted elsewhere for any other degree or qualification. Student’s Name: :اسم الظالب Signature: :التهقيع Date: :التاريخ v List of Contents No. Contents Pages Acknowledgements iii Declaration iv List of Tables vii List of Figures viii List of Annexes ix List of Abbreviation x Abstract xi Chapter One: Introduction 1 1.1 Research background 1 1.2 Problem statement 8 1.3 Significance of the study 11 1.4 Aims of the study 12 1.5 Research questions 12 1.6 Research hypothesis 13 1.7 Definition of terms 13 1.7.1 Resilience 13 1.7.2 General Self-Efficacy 14 1.7.3 Burnout 14 Chapter Two: Literature Review 17 2.1 Literature Review Search Strategy 17 2.2 Theoretical Review of Resilience 18 2.3 Theoretical Review of Self-Efficacy 20 2.2.1 Prevalence of Resilience and It‟s Contributing Factors 21 2.2.2 Resilience in Overcoming Stress 23 2.2.3 Resilience in Overcoming Intention to Leave and Burnout 24 2.2.4 Resilience, Self-efficacy, and Burnout in Nursing Students 26 2.2.5 Building Resilience in Nursing Students 33 Chapter Three: Methods 36 3.1 Study design 36 3.2 Study Setting 37 3.3 Sample and Sampling Method 37 3.4 Inclusion and Exclusion Criteria 38 3.5 Instruments 38 3.5.1 Validity and Reliability 39 3.5.1.1 Resilience Scale 39 3.5.1.2 The General Self-Efficacy Scale (GSES) 41 3.5.1.3 The Burnout Scale 42 3.5.1.4 Demographic Data Sheet 43 3.6 Pilot Study 44 3.7 Data Collection 44 vi 3.8 Ethical Consideration 46 3.9 Data Analysis 46 3.10 Management of Subject Attrition 47 3.11 Missing Data 47 3.12 Data Security 47 Chapter Four: Results 49 4.1 Overview 49 4.2 Descriptive Statistics 49 4.3 Resilience, Self-Efficacy, and Burnout Levels 52 4.4 Inferential Statistics 53 4.5 Statistical Significance 55 4.5.1 Gender 55 4.5.2 Smoking 56 4.5.3 Wanted to Study Nursing 57 4.5.4 Viewing Nursing as a Lifelong Career 58 4.5.5 Playing Exercise/ Sports 59 4.5.6 Working 59 4.5.7 Residence 60 4.5.8 Receiving Support from Friends and Family 61 4.5.9 Academic Year 61 4.5.10 GPA 63 4.5.11 Daily Study Hours 65 4.5.12 Preparing for an Exam 66 Chapter Five: Discussion and Conclusion 70 5.1 Overview 70 5.2 Levels of Resilience, Self-efficacy, and Burnout among Undergraduate Nursing Students 71 5.2.1 Resilience 71 5.2.2 General Self-Efficacy 72 5.2.3 Burnout 72 5.3 Correlation Between Resilience, Self-Efficacy, and Burnout 73 5.4 Association Between Socio-Demographic Profile of Participants to the Measures 74 5.5 Implication of the Study 82 5.6 Conclusions 83 5.7 Strength and Limitation of the Study 85 5.8 Recommendations for Future Research 86 References 87 Annex 129 ب الملخص vii List of Tables No. Tittle Pages Table 1 The Participants‟ Demographics 95 Table 2 The Results of the Three Measures 97 Table 3 Correlation Analysis between the Three Measures 98 Table 4 Gender in Relation to the Three Measures 9: Table 5 Smoking in Relation to the Three Measures 9; Table 6 Wanted to Study Nursing in Relation to the Measures 9; Table 7 Viewing Nursing as a Lifelong Career in Relation to the Three Measures 9< Table 8 Playing Exercise/ Sports in Relation to the Three Measures 9= Table 9 Working in Relation to the Three Measures :6 Table 10 Residence in Relation to the Three Measures :6 Table 11 Receiving Support in Relation to the Three Measures :5 Table 12 Academic Year in Relation to the Three Measures :6 Table 12.5 Academic Years in Relation to Burnout :6 Table 13 GPA in Relation to the Three Measures :8 Table 13.5 GPA in Relation to Burnout :8 Table 14 Daily Study Hours in Relation to the Three Measures :9 Table 14.5 Daily Study Hours in Relation to Burnout :: Table 15 Preparing for an Exam in Relation to the Three Measures :; Table 15.5 Preparing for an Exam in Relation to Burnout and Resilience :; viii List of Figures No. Tittle Pages Figure 1 The Study Variables 7: ix List of Annexes No. Tittle Pages Annexes 1 The Approval to use the Connor Davidson Resilience Scale (CD-RISC 10) 56= Annexes 2 The Study Consent Form and Questionnaire 576 Annexes 3 IRB Approval 579 Annexes 4 The Acceptance of the Universities to Participate in the Study 57: x List of Abbreviations ICN International Council of Nursing PNIPH Palestinian National Institute of Public Health CD-RISC 10 Connor-Davidson Resilience Scale 10-Item RS Resilience Scale GSES The General Self-Efficacy Scale ProQOL Professional Quality of Life Scale SOWN State of the World's Nursing GPA Grade Point Average ERIC Education Resources Information Center TRC Trait Resilience Scale NURS Model Nursing Universal Retention and Success Model. xi Resilience, Self-Efficacy, and Burnout among Nursing Students in Palestine By Zareefa Shaabna Supervisor Dr. Adnan Sarhan Abstract Introduction: Given the global shortage of nurses and the desire to provide safe and high-quality care, maintaining a healthy nursing workforce is crucial. Nurse burnout is one of the widely discussed topics in the world of psychology and organizational behavior. In today's complex healthcare system, resilience and self-efficacy are critical nursing characteristics to survive adversity. Recently, efforts have been made to understand the roles of resilience and self-efficacy in determining the psychological adjustment of employed nurses. As nursing students are the future of the nursing workforce, it is important to advance our understanding of their impact on this population. Aim: The study aimed to assess the levels of resilience, self-efficacy and burnout, and to examine the relationship between these three measures, and to identify the factors that contribute to these three variables. Methods: A cross-sectional descriptive correlational study was conducted using an online survey on 409 undergraduate nursing students from three large nursing institutions in West Bank-Palestine. The study used The Connor-Davidson Resilience Scale (CD-RISC 10) to assess resilience, The General Self-Efficacy Scale (GSE) to assess self-efficacy, and The Burnout xii Sub-scale from the Professional Quality of Life Scale (ProQOL) to assess burnout. Results: Moderate levels of resilience, self-efficacy, and burnout was found in the participants. The analysis revealed a positive correlation between resilience and self-efficacy (r= .68), whereas a negative correlation was found in burnout with resilience (r=-.35), and self- efficacy(r=-.21). In addition, the study findings showed that half of the students 47% were not satisfied/convinced when joined the nursing program, and half of the students 50.9% do not view themselves working in nursing as a lifelong career. In this study, higher resilience and self-efficacy were associated with (male gender, wanted to study nursing, playing exercise/sports, working, living on campus, receiving support from friends and family, viewing nursing as a lifelong career, and studying for a week or more of the exam). Whereas, not receiving support from family & friends, not exercising, smoking, not viewing nursing as a lifelong career, higher academic level, lower GPAs, studying an hour or less daily, and study in a day or less of the exam were all associated with higher burnout. Conclusion: It's widely acknowledged that a growing nursing shortage is on the horizon. The alarming rate of burnout among nurses around the world is contributing to this shortage. Resilience and self-efficacy in baccalaureate nursing students might play an important role in decreasing nursing shortage by enhancing academic and future success, decreasing future burnout and intention to leave. Therefore, gaining a better xiii understanding of the role of resilience on nursing student cumulative success might be helpful in developing curricula and teaching/learning practices that promote retention in both nursing programs and future career. Keywords: Resilience, Self-efficacy, Burnout, Nursing Students. 1 Chapter One Introduction This descriptive-correlational research study examined the relationship between Resilience, Self-efficacy, and Burnout Among Undergraduate Nursing Students in Palestine. This chapter includes the background of the study, the problem statement, the significance of the study, study implications, study purpose, the research questions, hypotheses, and the definition of terms. 1.1 Background Globally, the study of nursing is reported by students to be stressful (Edwards et al., 2010; Oner Altiok and Ustun 2013; Walker and Mann, 2016; Tung et al., 2018). Nursing students are frequently exposed to a variety of stressors that might negatively impact their academic performance and overall health (Santos et al.,2010). These stressors include challenging course subjects, extended study periods, the anxiety of clinical training, and the need for critical thinking. In addition, Nursing students have been found to face similar stress-related occupational health risks to staff nurses for example; stress related to academic and clinical staff's expectations (Khater et al., 2014), exposures to death, communicable diseases, and social problems of patients (Hodges et al., 2005; Thomas & Revell, 2016; Yasmin et al., 2018), handling emergencies (Lopez et al., 2018), a lack of professional knowledge and skills (Kaldal et al., 2018), providing care for acutely ill patients in situations with limited staff and 2 resource (Zhao et al., 2014) and the overriding fear of committing medical errors (Pulido-Martos et al., 2011). On a personal level, nursing students are dealing with greater financial pressure as well as the difficulties of combining their personal and professional life (MacDonald et al., 2016; Turner and McCarthy, 2017). Thus, nurses‟ turnover rate is considered among the highest rates for professional groups and the rates across the world are considered high, ranging from 15 to 44% (Alotaibi, 2008; Duffield et al., 2014; Hart, 2005; Roche et al., 2015). The global nursing shortage is a well-recognized issue. In 2020, the first State of the World‟s Nursing (SOWN) report, published by the World Health Organization (WHO), disclosed that the global nursing workforce was at 27.9 million and estimated a global shortage of 5.9 million nurses. Studies showed that 89% of these nurse shortages were concentrated in low- and lower middle countries. With the aging of the nursing workforce, 17% of nurses internationally are projected to retire within the next ten years, and 4.7 million additional nurses will need to be educated and employed just to maintain current workforce numbers, and in total 10.6 million additional nurses will be needed by 2030 (World Health Organization, 2020). With this considerable estimated nursing shortage, nurses need to be effectively and competently prepared for entry into practice. To meet the increasing demands for qualified nurses, Nursing institutions are increasing their student enrollments. However, the turnover rate in the nursing 3 profession and the attrition in nursing students is high. The attrition rate in baccalaureate nursing is around 50% (Beauvais et al., 2014; Merkley, 2015). A survey by The International Council of Nurses (ICN) in December 2020 found that close to 90% of the responding National Nursing Associations (NNAs) revealed they are somewhat or extremely concerned that heavy workloads and insufficient resourcing, burnout and stress are the drivers for nurses leaving. Moreover, 20% of NNAs surveyed reported an increase in the number of nurses leaving the profession as a result of the Covid-19 pandemic (The International Council of Nurses, 2021). Factors affecting academic & clinical performance, attrition, and retention have been an issue of increasing concern for undergraduate nursing schools across the world due to the high incidence of nursing student attrition. Attrition in nursing students is a complicated phenomenon influenced by a variety of factors, including psychological factors such as motivation and stress, demographic factors such as age and gender, and poor academic performance (Beauvais et al., 2014; Jeffreys, 2015). Although we can't completely eradicate attrition, we can do more to understand it and the factors that drive it. In Nursing, approximately 15% to 20% of nursing students drop out during their first and second years of school owing to poor academic performance (Khalaila, 2015). In an effort to reduce nursing student attrition in the future, whether in school or at work, research regarding the factors influencing academic performance or professional success is warranted. Academic achievement and future retention are 4 complex and multifaceted phenomena determined by the interplay of both cognitive and non-cognitive factors (Jeffreys, 2015). Grade point average (GPA) and prerequisite test scores are examples of cognitive factors that have been found to be important in predicting future academic performance (Pitt et al., 2012). Despite vast understanding of the link between cognitive factors such GPA and academic achievement, nursing school dropout remains high. Hence, research recognizing the influence of non-cognitive factors linked with academic success and future retention has increased in recent years. Non-cognitive factors for instance resilience, emotional intelligence, self-efficacy, and mindfulness have the ability to influence academic underachievement, attrition, and future retention (Beauvais et al., 2014; Taylor & Reyes, 2012). However, the influence of resilience and self-efficacy in determining the psychological adjustment (burnout) in nursing students has received limited attention and needs further clarification. Individuals' resilience is defined as their capacity to bounce back or cope well with stress when faced with adversity, especially when recovering from extremes of trauma, deprivation, danger, and severe disturbance (Atkinson et al., 2009; Jackson et al., 2007; Schetter & Dolbier, 2011). Cyrulnik adds that resilience is an individual‟s, „ability to succeed, to live and to develop in a positive way despite the stress or adversity that would normally involve the real possibility of a negative outcome‟ (Cyrulnik, 2009, p. 2). Resilience improves coping, adaptive capacities, and well- being, resulting in cumulative success and greater self-compassion (Chow 5 et al., 2018; Ríos-Risquez et al., 2016; Stephens, 2013; Neff & McGehee, 2010). According to research, resilience can counteract the negative effects of stress and enhance adaptation to adversity. McAllister and Lowe (2011) demonstrated that resilience was critical for nurses to find meaning in their experiences and to effectively control their reactions to stressors faced in the work environment. Therefore, resilience is critical for practicing nurses who operate in a chaotic workplace (Hodges et al., 2005). For nurses to be efficient in their profession, resilience has to become a crucial attribute (Taylor & Reyes, 2012). To fulfill the demands of the profession, nurses must be able to adapt, learn new skills, and adjust easily in an ever- changing work environment. The nurse's understanding of and capacity to use resilience may assist him to recover from difficult situations in the hospital setting. Nurses practicing in the discipline must develop personal resilience in order to adapt to workplace adversity (Pines et al., 2014). This personal application of resilience enables the nurse to cope with the stress and anxiety that occurs within a dynamic and hectic workplace. For nursing students, resilience is also an important concept. Nursing student resilience is defined as an individualized process of development that occurs as a result of successfully navigating perceived stress and adversities using personal and protective factors (Stephens, 2013). Nursing students experience stressors that might have an impact on their overall success and ability to meet academic goals (Reyes et al., 2015). According to research, the perceived stress of nursing school alone has resulted in higher attrition from nursing schools (Taylor & Reyes, 2012). The presence 6 of resilience has the potential to alleviate some of the stress associated with nursing school. According to research, nursing students with higher degrees of individual resilience had higher levels of well-being and better overall psychological health (Chow et al., 2018; Ríos-Risquez et al., 2016). In addition, resilience helped nursing students deal with the unique challenges of nursing practice and overcome adversity in their future clinical work (Cleary et al., 2018; Li et al., 2014). Growing research suggests that resilience is not a fixed trait which may be acquired through targeted interventions (McAllister & McKinnon, 2009). According to research, resilience training programs are effective strategies for practicing nurses to enhance their individual resilience (Lee et al., 2015; Magtibay et al., 2017; Mealer et al., 2014). For nursing students, resilience is a process that nursing students develop over time after being exposed to the clinical setting (Lopez et al., 2018). Self-efficacy is considered a predictor of student mastery (Gore, 2006; Harvey & McMurray, 1994; Jackson, 2002; Lewis, 2011; Pajares, 1996). Self-efficacy is defined as “people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives” (Bandura, 1994). Academic, clinical, and general self-efficacy has been identified in the literature as important components of student success (Andrew & Vialle, 1998; Jerusalem & Schwarzwer, 1992; Lewis, 2011). Self-efficacy has been found as a predictor of student problems, career progression, cognitive engagement, nursing education competence, academic achievement, attrition, clinical 7 performance, sense of belonging, and psychological health (Harvey & McMurray, 1994; Levett-Jones et al., 2008; Ofori & Charlton, 2002; Walker et al., 2006). In nursing research, self-efficacy is also deemed to be an active role in nursing staff performance, attitude, resilience, and work satisfaction (Gillespie et al., 2007; Mealer et al., 2012; Windsor, 1987). The tasks, workload, and physical and psychological demands of the nursing profession have been associated with vulnerability to burnout (Adriaenssens et al., 2015; Lima da Silva et al., 2012), a psychological syndrome that develops as a result of continuous emotional and interpersonal stressors in the workplace, resulting in emotional exhaustion, indifference to others, and job dissatisfaction (Maslach & Leiter, 2016; Maslach et al., 2001). International research has focused on burnout among health students, primarily nursing students (Cavalcanti et al., 2014; da Silva et al., 2014; Ferri et al., 2015; Tomaschewski-Barlem et al., 2014). The levels of burnout found are alarming, as this syndrome can hinder professional growth, put patient safety at risk, and help create consequences to the student's physical and mental health, such as sleep disturbances, depressive symptoms, and suicidal ideation, alcohol, and other drug abuses (Dyrbye et al., 2014; Dyrbye & Shanafelt, 2015; Jackson et al., 2016; Maslach et al., 2001). Lately, attempts have been made to understand the role of resilient and other non-cognitive factors in influencing the psychological adjustment (Burnout) in employed nurses. Because nursing students are the future of 8 the nursing workforce, it's critical to learn more about the factors that influence resilience and self-efficacy in this population. Thus, this study aimed to assess the levels of, and examine the relationship between resilience, self-efficacy, and burnout, and to identify the factors that contribute to these three variables in undergraduate nursing students. 1.2 Problem Statement Given the global shortage of nurses and the desire to provide safe and high- quality care, maintaining a healthy nursing workforce is critical (Nooney et al., 2010; Poghosyan et al., 2010; Haddad & Toney-Butler, 2020). Nurse burnout is a widespread phenomenon and is considered one of the most popular topics in the world of psychology and organizational behavior (Alfuqaha & Alshra‟ah, 2018; Maslach & Leiter, 2016; Mudallal et al., 2017). The WHO recently declared burnout as an “occupational phenomenon” in the International Classification of Diseases 11 th revision (ICD-11), identifying burnout as a serious health issue. Although burnout occurs in all occupations, it is regarded to be more widespread among professions that require a high level of personal connection and empathy, mainly medical and nursing health care workers (Alfuqaha & Alshra‟ah, 2018; Alqahtani et al., 2019; Ribeiro et al., 2014). Among these professions, Burnout has been linked with high turnover intentions, financial loss, and lower patient safety (Bakhamis et al., 2019). In Palestine the nursing profession suffers a shortage in the nursing workforce, which could be justified as in other countries due to the increase in the nurses‟ 9 annual turnover rate, the high number of female nurses, and the unappealing working circumstances. (2019, PNIPH). A recent study by Alshawish & Nairat, (2020) revealed high level of emotional exhaustion and depersonalization among nurses in West Bank-Palestine compared with other international countries. Hamdan & Hamra, (2017) also revealed that burnout was very high among nurses in Palestinian hospitals in comparison with other surrounding regions, and burnout was significantly associated with workers‟ intention to leave work. Nursing is becoming ever more demanding because of manpower shortages, burnout and various other challenges associated with nursing practice (Hart et al., 2012). With this considerable estimated nursing shortage, nursing institutions are increasing their student enrollments. Nursing students on the other hand, commonly experience anxiety and stress during their initial clinical training and practice (Amen Ahmed, 2015). Stress during this period can result in several negative outcomes, such as poor academic performance, diminished personal well-being, and elevated burnout levels (Kernan & Wheat, 2008; Gibbons, 2010). Studies revealed that burnout originates in student life can continue to develop during professional practice (Edwards et al., 2010; Reis et al., 2015), and this is expected to lead to a decline in the size and caliber of the nursing workforce (Chang and Dealy, 2012). Nursing students also face high level of stress after graduation. Work-related stress has recognized as the main challenge for the nursing profession throughout the world and has negative 10 emotional, physical, and psychological effects on the nurse (Mark & Smith, 2011). These stressors include physical demands, management issues, lack of resources, and difficulty balancing home and work responsibilities. All these are detrimental to the achievement of preparing a competent and even affecting nursing students‟ aspirations to take up a clinical post after graduation (Wu & Norman, 2006). To overcome this adversity, nursing students have to be resilient. Resilience is considered a vital characteristic for nurses to survive today‟s complex healthcare system, and the competing priorities and challenges with which nurses are confronted may make it difficult to develop resilience characteristics (Dyer & McGuinness, 1996; Rutter, 1985). Resilience is crucial for nursing students to survive adversity and prepare them for undertaking professional role after graduation. It is important to note that resilience is not merely an indicator of well-being but is a process that enables an individual to remain healthy or to recover quickly after adversity (Rutten et al., 2013). Previous studies have found that resilience has an impact on learning experience, academic performance, course completion, decrease burnout, and in the longer-term professional practice (Reeve et al., 2013; Guo et al., 2017). On the other hand, self-efficacy in nursing students was found to help them feel competent in meeting the entry level in clinical fields, accept this challenging role, and was also found to be a good indicator to predict nursing students‟ performance in clinical practice (Zengin, Pınar, Akinci, & Yildiz, 2013). Furthermore, evidence suggest that job satisfaction and intention to stay in a profession 11 are enhanced by a strong sense of self-efficacy (Duggleby, Cooper, & Penz, 2009; Lee & Ko, 2010). Since nursing students are the future of the nursing workforce, it is critical that we expand our understanding and determine whether burnout and future turnover intention are developed before working; while attending nursing school, and if non-cognitive factors such as resilience and self- efficacy can reduce burnout and turnover intention, as this will help us to find a support plan that can reduce exhaustion to help nursing students to adapt successfully to university and clinical life and to transfer this adaptation to their roles as nurses. 1.3 Significance of the Study This study will help us to understand whether burnout and future turnover intention in nursing students are developed before practicing as registered nurses (during the years of study), and to understand the protective factors that can help us in reducing burnout and future turnover intention. There is no published research in Palestine that investigates the levels of, and correlation between resilience, self-efficacy and burnout in undergraduate nursing students in Palestine. Therefore, this will be the first study to investigate the levels of, and correlation between resilience, self-efficacy, and burnout among undergraduate nursing students in Palestine. 12 1.4 Aims of the Study The aims of this study were to: 1. Describe the levels of individual resilience, self-efficacy, and burnout among undergraduate nursing students. 2. Determine if a relationship existed between individual resilience, self- efficacy, and burnout in nursing students. 3. Determine if a relationship existed between individual resilience, self- efficacy, and burnout with students characteristics, for example, (Gender, academic year, smoking, GPA, wanted to study nursing, viewing nursing as a lifelong career, playing exercise/ sports, working, residence, receiving support from family and friends, study hours, and preparing for an exam). 1.5 Research Questions The following research question guided this study: 1. What are the levels of resilience, self-efficacy, and burnout among nursing students? 2. Is there a relationship between resilience, self-efficacy, and burnout among nursing students? 3. Is there a significant difference between resilience, self- efficacy, burnout and other variables (Gender, academic year, smoking, GPA, 13 wanted to study nursing, viewing nursing as a lifelong career, playing exercise/ sports, working, residence, receiving support from family and friends, study hours, and preparing for an exam). 1.6 Research Hypothesis 1. There is no significant relationship between resilience, self-efficacy, and burnout among nursing students. 2. There are no significant differences at 0.05 between resilience, self- efficacy, and burnout with students characteristics (gender, academic year, smoking, GPA, wanted to study nursing, viewing nursing as a lifelong career, playing exercise/ sports, working, residence, receiving support from family and friends, study hours, and preparing for an exam). 1.7 Definition of Terms 1.7.1 Resilience Conceptual definition. Is the ability of individuals to bounce back or to cope successfully with stress when faced with adversity, especially recovering from extremes of trauma, deprivation, threat, and significant disruption (Atkinson, Martin, & Rankin, 2009; Jackson, Firtko, & Edenborough, 2007; Schetter & Dolbier, 2011). It‟s also defined as the ability to overcome adversity and includes how one learns to grow stronger from the experience (McAllister & McKinnon, 2009). 14 Operational definition. Operationally, resilience is defined as the ability to "thrive in the face of adversity" (Connor and Davidson's, 2003). Connor and Davidson resilience scale (CD-RISC) is a survey-based measure of resilience. The scale uses a five-point Likert scale ranging from 0-4: not true at all (0), rarely true (1), sometimes true (2), often true (3), and true nearly all of the time (4), with higher scores reflect greater resilience. 1.7.2 Self-Efficacy Conceptual definition. Is a person‟s belief in his or her capabilities to plan and execute courses of action that produce given attainments (Bandura, 1993). Operational definition. General self-efficacy refers to a broad and stable sense of personal competence to deal effectively with a variety of stressful situations. General self-efficacy scale (GSE) is correlated to emotion, optimism, work satisfaction (Schwarzer & Jerusalem, 1995). The GSE scale includes 10 items. Possible responses are not at all true (1), hardly true (2), moderately true (3), and exactly true (4), yielding a total score between 10 and 40. Higher scores indicate higher self-efficacy. 1.7.3 Burnout Conceptual definition. Is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one‟s job, or feelings of 15 negativism or cynicism related to one's job; and reduced professional efficacy (WHO,2019). Operational definition. Stamm, (2010) defines burnout as lingering feelings of hopelessness and fatigue that interfere with the ability to perform effectively at work. Burnout is one of the elements of compassion fatigue (CF), and symptoms of burnout may include feeling of being trapped, overwhelmed, “bogged down”, and unsatisfied by one‟s job. The burnout subscale from the Professional Quality of Life Scale Version 5 (ProQol5) (Stamm, 2010) will be used to assess burnout in this study. The scale consists of 10 items, and possible response are‟ 1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often. The sum of burnout questions of 22 or less indicate low burnout, between 23-41 indicate moderate burnout, and 42 or greater indicate high burnout. Summary Nursing shortage remains problematic worldwide. Nurse burnout which is considered one of the most popular topics in the world of psychology and organizational behavior is considered a contributing factor to nursing shortage. Evidence suggests the burnout experienced by nursing students often leads to loss of confidence in nursing and acts as a negative factor leading to frustration with studying their nursing major. The higher degree of exhaustion experienced during academic life indicates that job skill levels during the first year after graduation are poor and the correlation with turnover intention is high. Research argues that this kind of burnout 16 that originates in student life can continue to develop during professional practice which in turn leads to a decline in the size and caliber of the nursing workforce. Since nursing students are the future of the nursing workforce, it is critical that we expand our understanding and determine whether burnout and future turnover intention are developed before the working phase; while attending nursing school, and weather enhanced resilience and self-efficacy contributes to lower burnout and future retention. 17 Chapter Two Review of the Literature 2.1 Literature Review Search Strategy This study aimed to assess the levels of and examine the relationship between resilience, self-efficacy, and burnout, and to identify the factors that contribute to these three variables. A review of the literature was conducted from the disciplines of nursing, psychology, and behavioral and social sciences using the following search terms: Resilience AND Nursing Students, Self-efficacy AND Nursing Students, Burnout AND Nursing Students, Nursing student success, Retention AND Attrition in nursing students, Resilience AND Nursing education, nursing student, nurse, and resiliency. The search for the literature was through the following electronic databases: PubMed, Science Direct, Google Scholar, Semantic Scholar, APA PsycNet, Cumulative Index to Nursing and Allied Health (CINAHL), and Education Resources Information center (ERIC). An initial search yielded 578 articles. Searches were limited to peer-reviewed, full text research articles, English language, and articles published within the last 10 years. Publications were extended for relevant seminal research, particularly relating to concept analysis. Through this search, a variety of primary sources were obtained. Additional evidence was found by manually searching the reference lists of relevant articles. For this literature review, specific search criteria and the exclusion of non-relevant articles resulted in 31 primary sources. 18 The purpose of this literature review was to shed light on the concepts of resilience, self-efficacy, and their theoretical properties. Furthermore, their importance in the nursing profession, nursing education, and how they affect burnout and intention to leave in nursing and nursing students. As a result, the literature review is divided into four primary sections: 1. Theoretical review of resilience, 2. Theoretical review of self-efficacy, 3. Resilience in overcoming stress, intention to leave, and burnout in the nursing profession, and 4. Resilience and nursing students. The Fourth section is further subdivided into subsections of prominent themes related specifically to nursing students. 2.2 Theoretical Review of Resilience Resilience is considered as a "state," or a "trait," or a combination of the two (Wagnild, 2009). Existing research backs up the idea that everyone has some level of resilience (Rutter, 1993; Tusaie & Dyer, 2004; Tusaie & Patterson, 2006). Anthony (1974) conducted early research on children who appeared invulnerable or resilient to adversity and discovered that some children performed well despite numerous risks and hardships. As the study progressed, it became clear that each person reacted to different situations with varying degrees of resiliency (Luthar et al., 2000). Individual resilience has been defined as the ability to rise above adversity, adapt better than expected in the face of significant adversity, and recover from and overcome difficult situations in one's life (Criss et al., 2002; Martin & Marsh, 2006; Tusaie et al., (2007). Regardless of the nature of 19 adversity or stress, the event must be interpreted as either physically or psychologically traumatic by the individual (Stephens, 2013). The occurrence must pose a significant threat, causing people in similar situations to adjust their coping mechanisms in the face of the possibility of a negative outcome (Windle, 2011). It's also important to realize that the antecedents of resilience don't all have the same severity and can range from acute to chronic in nature (Windle, 2011). In addition to a traumatic or adverse event, protective factors have been identified as an important antecedent to resilience in the literature. According to Stephens (2013), protective factors are required for resilience to occur. Positive emotions, humor, self-efficacy, flexibility, competence, social support, faith, optimism, effective coping, and self-knowledge are all protective factors for resilience (Stephens, 2013). There was sufficient evidence in the literature to confirm the importance of the presence of protective factors to develop or enhance resilience, whether it was a necessary attribute or antecedent of resilience (Stephens, 2013). The outcomes or end-points that occur as a result of the antecedents and attributes of resilience are all positive in nature (Windle, 2011). Effective coping and psychological or physical adjustment were the most commonly mentioned outcomes of resilience in the literature (Dyer & McGuinness, 1996; Stephens, 2013). Integration, personal control, personal or professional growth, positive adaption, confidence, and increased self- efficacy are some of the other outcomes of resilience (Caldeira & Timmins, 2016; Garcia-Dia et al., 2013; Stephens, 2013; Taylor & Reyes, 2012). The 20 maintenance of normal or better functioning despite adversity or stress through effective coping or psychological or physical adjustment was a common theme among all of the outcomes. The consequences of poor resilience, on the other hand, should be considered because they have a significant impact on the individual. Low resilience can lead to an increased risk of mental illness, anxiety, depression, and burnout (Simmons & Yoder, 2013; Wagnild & Collins, 2009). Furthermore, individuals' resilience may deteriorate if they no longer believe they are capable of meeting challenges (Wagnild & Collins, 2009). Feelings of being overwhelmed and a loss of purpose for life may arise in these circumstances. 2.3 Theoretical Review of Self-Efficacy With his article "Self-efficacy: Toward a Unifying Theory of Behavioral Change," published in Psychological Review, Albert Bandura was the founding researcher of self-efficacy theory. Bandura (1977) stated, “Efficacy expectations determine how much effort people will expend and how long they will persist in the face of obstacles and aversive experiences” (p. 194). Self-efficacy was discovered to be an important component of workplace behaviors and attitudes (Bandura, 1978). If a person believes an activity is beyond their capabilities, they will avoid it; however, if they believe they are capable of completing a task, they will succeed at it (Bandura, 1978). Wood and Bandura (1989, p.408) expanded the definition of self-efficacy to include "beliefs in one's abilities to 21 mobilize motivation" to complete a specific task related to a job function. According to research, personal motivation and motivation theories are directly related to efficacy and self-efficacy theory (Bandura 1986). To build up a person‟s sense of perceived self-efficacy a person must acquire their beliefs through one or more efficacy principles (Bandura, 1977). The four efficacy principles presented by Bandura are mastery experiences, vicarious experiences, verbal persuasion, and the physiological and psychological state of the individual. Pajares (1995) discussed the contributions of Bandura's social cognitive theory, which examined how efficacy influences human behavior and motivation, as he investigated and compiled notable research in the area of self-efficacy. First, self-efficacy has an impact on people's decision-making. Second, a person's self-efficacy determines how much time and effort they will put into a task. Perseverance and persistence are also determined by self-efficacy, and these characteristics are linked to a greater sense of efficacy. Self-efficacy beliefs influence our choices, our effort, and our persistence through adversity and emotions (Henson, 2001). 2.2.1 Prevalence of Resilience and It’s Contributing Factors Resilience is considered a crucial element for nurse clinicians. Personal resilience is required of nurses working in the field to respond to workplace adversity (Pines et al., 2014). According to the studies, nurse clinicians are moderately resilient. The prevalence of resilience in a group of professional nurses was investigated by Koen et al., (2011). In this cross-sectional study, 22 surveys were given to a group of nurses practicing in South Africa (N = 312). The Resilience Scale-RS (Wagnild & Young, 1993) was used to assess resilience. Results revealed 43% of the participants had high resilience, 47% had moderate resilience, and 10% had low resilience. A similar study by Maia et al., (2017) used a qualitative descriptive approach to examine resilience levels of nurses practicing in Brazil. The nurses working on a medical surgical unit were surveyed. The results revealed that 58% of the participants presented excellent conditions of resilience. In addition to the exploration of resilience levels, several studies looked into the attributes, characteristics, or contributing factors to resilience among practicing nurses. Positive coping skills, optimism, a positive attitude, and work-life balance were all attributes of resilience for practicing nurses (Cameron & Brownie, 2010; Tubbert, 2016). Mealer, Jones, & Moss, (2012) were the first to demonstrate this in a qualitative study. In order to identify mechanisms used by highly resilient nurses (N = 27), semi-structured interviews with intensive care nurses were conducted. The CD-RISC (Connor & Davidson, 2003) was used to measure resilience. Spirituality, a supportive social network, optimism, and having a resilient role model were identified as characteristics used by highly resilient nurses to cope with stress in the workplace. These positive coping skills and psychological characteristics were essential to managing the stressful work environment. 23 2.2.2 Resilience in Overcoming Stress Working in the healthcare industry has been linked to high stress levels (Dehvan et al., 2018). It was hypothesized that resilience mitigated the stress's negative effects. Meyer and Shatto (2018) conducted a pilot study examining resiliency and its relationship to transition to practice among new nurses (N = 17) using the Wagnild & Young Resilience Scale. The study revealed that resilience was found to be important in reducing the stress of transitioning from student nurse to practicing nurse, Moreover, the findings supported the hypothesis that resiliency aided new nurses' transition to practice. In Palestine, only one quantitative study was identified which aimed to investigate job stressors, coping, and resilience among nurses and was conducted by Elqerenawi et al., (2017) in Gaza Strip. By using the Connor- Davidson resilience scale-25 items among 275 nurses, the study revealed a total resilience mean of 72.6 (SD=12.79) indicating a moderate level of resilience, and a negative correlation between resilience and stress was found. Results also indicated that physician not being present when a patient dies (p <0.001), and too many non-nursing tasks required, such as clerical work negatively predicted resilience (p <0.01). The study also revealed the mean score of nurses work stressors was 88.7. Attending a patient's death, not being present when a patient dies, being criticized by a supervisor, and fear of making a mistake while treating their patients were the most commonly reported job stressors by nurses. Nurses frequently 24 used religious coping such as feeling comfort in religious beliefs, thinking what next steps they have to take, having a strategy about what to do about a situation what to do, and learn to live with the situation as coping strategies with stress. While using drugs to feel better and to get through was the least commonly used coping strategy. 2.2.3 Resilience in Overcoming Intention to Leave and Burnout Since resilience has been recognized as a protective factor in times of crisis, the (COVID-19) pandemic is considered the current leading crisis in the 21st century worldwide. A recent cross-sectional design by Alameddine et al., (2021) was utilized to survey nurses practicing at a major public hospital in Lebanon. The study aimed to Investigate the degree of resilience, and associated factors, of nurses practicing at a major public hospital and COVID-19 main referral center in Lebanon. A total of 265 nurses responded to the questionnaire, and results showed low level of resilience with a mean resilience score of 66.91 (SD = 13.34). Nurses‟ resilience was also positively associated with job satisfaction, male gender and negatively associated with intention to quit and exposure to violence. Many studies in the literature examined the relationship between resilience and stress-related variables for practicing nurses such as burnout. Guo et al. (2017) investigated the prevalence and extent of burnout in nurses, as well as its relationship with personal resilience, using a cross-sectional design. A total of 1,061 Chinese nurses were used in this study and filled both the burnout inventory scale and the CD-RISC (Connor & Davidson, 2003) 25 measuring resilience. The research revealed that a lack of resilience was a strong predictor of burnout (r = 0.2-0.4, p.001), and low levels of individual resilience was found to be associated with higher levels of emotional exhaustion, cynicism, and reduced professional efficacy. In addition to the previous, Kutluturkan et al., (2016) conducted a descriptive study with 140 oncology nurses and discovered a negative relationship between resilience and burnout. Similarly, Rushton et al., (2015) conducted a cross-sectional study on 114 nurses working in high-intensity work environments such as pediatric, neonatal, oncology, and critical care units. By using the CD-RISC (Connor & Davidson, 2003) to measure resilience, the study found a negative correlation between resilience and emotional exhaustion (r = .13, p < .001), and individual resilience was found to protect nurses from emotional exhaustion and to positively contribute to personal accomplishment. Throughout a range of work experience levels, higher levels of resilience were linked to increased hope and lower stress levels. Finally, Lanz & Bruk-Lee, (2017) examined the role of resilience in reducing negative workplace outcomes like conflict, turnover, burnout, and injuries. The Resilience Scale by (Wagnild & Young, 2016) was used to assess resilience in a group of 97 nurses working in a variety of medical settings across the United States. According to the findings, nurses with lower resilience levels had more conflict-related negative job effects. Nurses with higher levels of resilience had less conflict and were better at 26 rebounding. This study indicated that resilience is a valuable trait for nurses to develop in order to reduce the negative effects of conflict on their jobs. 2.2.4 Resilience, Self-efficacy, and Burnout in Nursing Students In a variety of areas, resilience and its application to the nursing student population has been studied. The review of literature looked into nursing students' resilience levels and how they were developed or built. The majority of existing literature indicates that significant relationships were revealed between resilience and mindfulness, happiness, and self-efficacy (Benada & Chowdhry, 2017; Rios-Risquez et al., 2016). Whereas fewer studies assessed burnout in nursing students and its relationship to resilience and self-efficacy (Rees et al., 2016). Finally, few studies have been conducted to investigate the relationship between resilience and academic success, and between resilience and burnout among nursing students. No studies were found on the relationship between resilience and intention to stay in the profession in the future in the nursing student population. According to the literature, resilience is an important attribute for nursing students. Nursing students face a variety of stressors in both their academic and personal lives. Additionally, academic pressure, faculty and student incivility, and stress related to the clinical setting, such as exposure to death, dying, and communicable disease, can all affect nursing students (Hodges et al., 2005; Thomas & Revell, 2016). 27 little amounts of recent research examined the state of resilience among nursing students. To investigate nursing students' understanding and enactment of resilience, Reyes et al. (2015) conducted a constructivist, grounded theory. In-depth interviews were used on 38 baccalaureate nursing students from Canada. Thematic analysis revealed a common process of „pushing through‟ as nursing students‟ understanding of resilience. Participants reported using this process to withstand challenges in their personal and academic lives. Jackson, (2018) studied the resilience process on nine graduate nursing students. Thematic analysis of in-depth interviews revealed a common resilience process characterized by the ability to manage challenges with the help of passion and support. Similarly, Wahab et al., (2017) looked at new graduate nurses' understanding of resilience. Nine new graduate nurses from Singapore were chosen in this qualitative study. Thematic analysis from in-depth interviews revealed a common understanding of resilience as persevering and overcoming obstacles, adapting to new situations, and taking control of ones learning. Aside from investigating nursing students' understanding of resilience, little research has been carried on their resilience levels. Tambag and Can (2018) conducted a cross-sectional study to assess the resilience of 659 undergraduate students in the health sciences. The researchers also aimed to figure out what factors affected this population's resilience. The average resilience levels for this group were found to be unsatisfactory (183.09), 28 despite the fact that the scale's highest score was 250. In addition, students in their final year showed higher levels of resilience. The findings backed up the theory that students' resilience grew over time as they progressed through education. In addition to the previous, a cross-sectional study by Chow et al., (2018) which aimed to investigate Resilience and well-being among 678 university nursing students in Hong Kong. By using the 10- item Connor-Davidson Resilience Scale (CD-RISC-10), the results revealed relatively lower scores of resilience which ranged from 7 to 40 with a mean of 24 (SD = 5.7). When comparing the resilience levels of undergraduate and postgraduate students, the total scores were found to be 23.8 and 24.9 respectively. In Palestine, Alkaissi et al., (2017) conducted a cross-sectional study to quantify resilience and to investigate the contribution of demographic variables to resilience levels among 314 nursing students from An-Najah National University. The students answered the Trait Resilience Scale (TRC), State Resilience Scale (SRC), and Personal demographics. The findings of this study revealed a Mean (SD) of Trait Resilience Scale 71.50 (±7.51) and for State Resilience Scale 62.63 (±6.742). The findings showed that 70/314 (22.3%) of nursing students have an extreme trait resilience scale (65-75) and 135/314 (43.0%) of nursing students have an extreme state resilience scale (87-90). According to the findings, there was a statistically significant relationship between extreme trait resilience and personal characteristics. The study found that students with high trait resilience scale scores were nonsmokers (p = 0.046), studied every day 29 (p = 0.000), and had a family income of more than 5000 NIS (p = 0.015). The study was also shown that the students who have recorded extreme scores of state resilience scale were female students (P = 0.046), first-year students (P=0000), students with no diseases (P= 0. 008), students who have siblings (0.040), students who are not travelling every day (P= 0.032), students who have part time work (P = 0.035), students studying every day (P = 0.006), and students living with other students (P = 0.034). The majority of existing research indicates that resilience has a significant impact on psychological development. Multiple studies have linked resilience to improved psychological well-being (Chow et al., 2018; He et al., 2018; Smith & Yang, 2017). Resilience among nursing students is strongly linked to improved psychological well-being. Xuhua He et al., (2018) conducted a cross-sectional, descriptive, predictive study to investigate predictors of psychological well-being among 538 nursing students in Australia. The CD-RISC (Connor & Davidson, 2003) was used to measure resilience, and the study revealed that resilience was the strongest predictor of psychological well-being (B = 0.44, p <.001). Furthermore, students with higher levels of resilience reported higher levels of overall psychological well-being. Chow et al. (2018) revealed similar results in their study. A population of university nursing students (N = 678) was surveyed using the CD-RISC (Connor & Davidson, 2003) in a cross-sectional, descriptive, and correlational study. This study discovered a moderately positive 30 relationship between resilience and perceived well-being (r =.378, p=.000). Resilience was also found to be an important predictor of perceived well- being (B = 0.259, p < .001). Rios-Risquez et al. (2016) identified a positive link between resilience and psychological health. This study employed a cross-sectional design with 116 nursing students from Spain. In this study, the CD-RISC (Connor & Davidson, 2003) and other measures were used to assess resilience. According to the findings of this study, there was a significant negative relationship between resilience and emotional exhaustion (r = -0.55, p< .01). Furthermore, a significant positive relationship between resilience and psychological health was identified. Because resilience was associated with lower levels of psychological discomfort and burnout, higher resilience scores predicted better perceived psychological health. Fewer studies have examined the relationship between resilience and nursing student academic success. Beauvais et al. (2014) conducted a descriptive, correlational study to examine the relationship between emotional intelligence, psychological empowerment, resilience, and spiritual well-being and academic success in 124 undergraduate and graduate nursing students from a single private Catholic nursing institution. Nursing students in their first year were not included in this study. In this study, the RS (Wagnild & Young, 1993) was used to assess resilience levels. The findings revealed a significant relationship between psychological empowerment, resilience, spiritual well-being, and academic 31 success. The study‟s results concluded that resilience might play an important role in persistence through the challenges of nursing education. Furthermore, to identify characteristics of nursing students with high academic resilience, Hwang and Shin (2018) conducted a descriptive cross- sectional study. A total of 254 junior and senior level nursing students from South Korea were used in this study. A variety of questionnaires were used to assess academic resilience, clinical practice stress, clinical practice satisfaction, and social-affective capability. Although Academic resilience differs slightly from individual resilience, the common theme of "overcoming stress" is consistent with the definition of individual resilience. The study's findings revealed that students with higher academic resilience were more likely to continue their studies. Furthermore, students with higher resilience had a lower proportion of respondents with a GPA below 3.0. This study found a link between academic resilience and academic achievement. According to the literature, resilience has been linked to increased happiness, self-efficacy, positive coping mechanisms, and decreased burnout among nursing students. Benada and Chowdhry (2017) investigated the link between resilience and positive psychological outcomes as happiness and mindfulness in a correlational study. 70 Nursing students from India were included in this study. The RS (Wagnild & Young, 1993) was used to assess resilience. The findings revealed a positive relationship between happiness, resilience, and mindfulness. 32 Rees et al., (2016) conducted a cross-sectional study between July 2014 and July 2015, which aimed to test the newly developed ICWR-1 (The international collaboration of workforce resilience model) of individual psychological resilience on 422 student nurses from across Australia and Canada. As predicted by the model, results from the CD-RISC showed positive relationships between resilience and mindfulness (r = .627, p < .01), self-efficacy (r = .666, p < .01), and adaptive coping (r = .131, p < .01). Additionally, burnout had a significant negative relationship to resilience (r = -.486, p < .01), and higher mindfulness, higher self-efficacy, and coping scores were associated with lower burnout. These findings offered support for the development of programs for students that teach mindfulness skills, adaptive coping skills and strategies directly designed to bolster self-efficacy as a potentially important approach to strengthening student nurse resilience and thereby potentially preventing burnout. Similarly, Chamberlain et al. (2016), investigated resilience in 240 third- year nursing students in Australia. The CD-RISC (Connor & Davidson, 2003). The results found that resilience natively correlated with compassion fatigue (r = −0·472, P < 0·001), and compassion fatigue correlated positively with burnout (r = 0·529, P < 0·001). This study emphasized the importance of developing resilience in nursing students in order to improve their overall psychological health. Škodová & Bánovčinová, (2018) also identified a significant negative relationship between resilience and maladaptive coping strategies in a correlational study that was conducted on 150 baccalaureate nursing 33 students. Findings revealed that participants with fewer resources for positive coping strategies had lower resilience scores. Likewise, Li et al. (2014) found similar results in their cross-sectional study on 202 nursing students from China. According to the survey results, students with moderate resilience had a greater ability for posttraumatic growth/ coping ability. In the nursing student population, these studies suggested that resilience is important for mindfulness, self-efficacy, coping, and a reduction in negative thinking. 2.2.5 Building Resilience in Nursing Students Building resilience in nursing students has received little attention. Based on the literature, it appeared that there were ways to influence resilience levels in the nursing student population. Pines et al. (2014) conducted a quasi-experimental, pretest-posttest study with a group of 60 undergraduate nursing students. The intervention in this study used didactic and simulated training to teach resiliency skills, improve perceptions of empowerment, and increase knowledge of conflict resolution. The results of this study revealed that students' empowerment and stress resiliency did not change significantly after training. Škodová & Lajčiaková, (2015) conducted a similar study using a quasi- experimental, pretest-posttest design to investigate the effect of psychosocial training on improving coping. Psychosocial training aimed at improving social interaction and communication was conducted on 97 university students in the health professions. According to the findings, 34 resiliency training resulted in a significant reduction in burnout syndrome, an increased sense of coherence, and increased resilience levels. The findings of this study suggested that targeted training could significantly boost nursing students' resilience. According to research, other factors influenced the development of resilience in nursing students, in addition to training programs. Lopez et al. (2018) carried out a qualitative study to investigate the impact of clinical placement and its relationship to resilience building. A group of 126 Singaporean nursing students (junior and senior level) participated in audio-recorded interviews. According to the study's thematic analysis, nursing students felt stressed when they were first placed in clinical. The majority of students dealt with this challenge by talking with their peers. Finally, after accumulating clinical experience, students were able to adapt. According to the findings of this study, resilience develops over time and after the clinical experience. Summary This chapter presented literature relevant to individual resilience, self- efficacy, and burnout and prominent themes for each subsection were identified. The literature provided compelling evidence of the psychological benefits of resilience for both practicing nurses and nursing students. Resilience improved overall psychological well-being, enhanced self-efficacy and reduced stress in both populations (He et al., 2018; Rees et al., 2016; Meyer and Shatto, 2018). The literature also indicated that 35 resilience could be built or improved. Targeted intervention in resiliency training has been shown to be effective in both practicing nurses and nursing students (Škodová & Lajčiaková, 2015). Although the literature has shown that resilience is a beneficial variable to the nursing students, understanding resilience in nursing students is still in its infancy (Jeffreys, 2015; Thomas & Revell, 2016). Gaps persist in the literature regarding whether or not nursing burnout formulates during the working phase or before while attending nursing school, and weather intention to stay in the profession in the future is enhanced by a strong resilience and self -efficacy in undergraduate nursing students. In light of the gaps identified in the literature, more research is needed to clarify and confirm the understanding if a relationship exists between resilience, self- efficacy, and burnout in undergraduate nursing students. 36 Chapter Three Methods The primary purpose of this study was to examine the relationship between resilience, self-efficacy, and burnout in baccalaureate nursing students. In this chapter, the methodology used to carry out the study is presented. Included are descriptions of the research design, setting, sample, procedures, instruments, data analysis, and ethical considerations. 3.1 Study Design A descriptive-correlational research study approach was used to conduct this investigation. A descriptive-correlational design is appropriate for the purpose of examining the relationship among variables (Polit & Cheryl Tatano Beck, 2004). For this study, the research design of correlation was chosen to answer the research questions. The variables included in the study are presented in Figure 1 Figure 1: Study variables. Independent Variables: Age, Gender, GPA, Academic level, wanted to study nursing at enrollment, viewing nursing as a lifelong career, Smoking, playing exercise/ Sports, working, residence, receiving support, study hours per day, exam preparations. Dependent Variables: Resilience Self-Efficacy Burnout 37 Resilience, general self-efficacy, and burnout were measured using three measures. The independent variables (age, gender, GPA, study hours per day, employment, receiving support) were not manipulated in this study. These variables were chosen based on evidence from the NURS model (Jeffreys, 2015), which suggested that academic factors, student profile characteristics, professional integration factors, and environmental factors all had a significant impact on retention in undergraduate nursing education. Other variables were also added to this study such as wanted to study nursing at enrollment and viewing nursing as a lifelong career to investigate their relationship with burnout. 3.2 Setting In order to consider the sample from different representative areas of the West Bank with varying demographic backgrounds that reflected the nursing student population as a whole. The setting for this study included three large university institutions. From the South-Bethlehem University; from the middle- Birzeit university; from the North- An najah National university. All the universities agreed to participate in the study. Due to the COVID-19 pandemic and transition to online learning, data collection for the entire sample was recruited electronically. 3.3 Sample and Sampling Method This study used a nonprobability convenience sampling plan to obtain participants. The target population for this research study included all nursing students currently enrolled in a baccalaureate nursing program 38 from different academic years. Since this group of students readily reflected the desired research population, all students currently enrolled in an accredited baccalaureate nursing program at the three mentioned universities were eligible for the study. Any unwilling students or those who do not submit the survey were excluded. The sample size for this study was calculated based on 95% CI and a 5% margin of error by using the Raosoft sample size calculator (Raosoft, 2004), and the recommended sample was 320. All students within the baccalaureate nursing program from the mentioned nursing institutions were given the opportunity to participate in the study. 3.4 Inclusion and Exclusion Criteria Only baccalaureate nursing students across academic years form the selected institutions were included in the study. Graduate nursing students were excluded from the study. 3.5 Instruments Three instruments were used in this study. (CD-RISC) (Connor and Davidson, 2003) was used to measure resilience, The General Self-Efficacy Scale (GSES) (Schwarzer & Jerusalem,1995) was used to measure self- efficacy, and the burnout scale was taken from the Professional Quality of Life Scale Version 5 (ProQol5) (Stamm, 2010) to measure burnout. A demographic data sheet developed by the primary investigator was also used to gather demographic and other variable data. 39 3.5.1 Validity and Reliability 3.5.1.1 Resilience Scale The Connor and Davidson (2003) resilience scale is a survey-based measure of resilience. Evidence from previous studies in the community of nursing populations (Gillespie, 2007) suggests that this scale is a valid and reliable measure of resilience for a range of normal and clinical populations (Connor, Davidson, & Lee, 2003). This scale was used in this study because is one of the most common instruments to assess resilience amongst adults, nursing, and nursing students (Gras et al., 2019). The original scale contains 25 items, the scale uses a five-point Likert scale ranging from 0-4: not true at all (0), rarely true (1), sometimes true (2), often true (3), and true nearly all of the time (4) with higher scores reflect greater resilience. Factor analyses have indicated that the 25-item measure is multifactorial, consisting of factors such as hardiness (10 items) social support/ purpose (4 items), faith (2 items), and persistence (7 items). For the present study, we elected to use the shorter 10-item version because factor analyses have found this version to be a pure measure of the central core construct of resilience that retains the excellent psychometrics of the longer version (Campbell-Sills & Stein, 2007). This was considered to be important for the present study where other conceptually similar construct is being investigated, such as self-efficacy. The CD-RISC has been validated in a variety of countries and cultures, such as Australia (Burns & Anstey, 2010), China (Wang et al., 2010; Yu et al., 2011), India (Singh & 40 Yu, 2010), Korea (Jung et al., 2012), South Africa (Jorgesen & Seedat, 2008), Spain (Manzano-García & Ayala-Calvo, 2013), Turkey (Karairmak, 2010) and the United (Burrow-Sánchez et al., 2014). The scale was also reliable and valid in the Arabic culture and was used to measure resilience in Egypt, Jordan, and Syria (Alduraidi et al., 2020; Alqudah, 2013; Abd El- Ghafar et al., 2018). Based on the psychometric analyses completed with this instrument, it was clear that the CD-RISC did measure what it claimed to measure. Overall, the internal consistency of the CD-RISC was adequately demonstrated in a number of studies. Lamond et al. (2009) reported a four-factor CD-RISC structure in a sample of 1,395 women, the alpha for the whole scale was .923. Singh & Yu, (2010) reported a four- factor structure when using the CD-RISC in a sample of 256 Indian undergraduate students, individual alphas for the factors ranged from .69 to .80 and was .89 for the entire scale. Furthermore, the scale demonstrated adequate reliability Cronbach's α = .81 in a study involved a total of 449 student nurses in southwestern Nigeria (Aloba et al., 2016). To determine reliability of the measures in this study, internal consistency reliability was measured using Cronbach‟s alpha. The Cronbach‟s alpha for the Connor and Davidson Resilience Scale (CD-RISC) in this study was 0.851 and was acceptable for this scale. The Cronbach‟s alpha from this sample was consistent with the original instrument psychometric evaluation, which showed an internal consistency reliability coefficient 0.89 (Connor & Davidson, 2003). In this study, the scale was used in the Arabic language; 41 the Arabic scale was requested by the researcher from the author and was sent in the Arabic language by E-mail. Refer to Annex 1. 3.5.1.2 The General Self-Efficacy Scale (GSES) The Schwarzer & Jerusalem (1995) General self-efficacy scale refers to a broad and stable sense of personal competence to deal effectively with a variety of stressful situations. GSE is a universal construct, which means that it characterizes a basic belief that is inherent in all individuals. The GSE scale includes 10 items. A typical item is, “Thanks to my resourcefulness, I can handle unforeseen situations.” Possible responses are not at all true (1), hardly true (2), moderately true (3), and exactly true (4), yielding a total score between 10 and 40, with higher scores indicating higher self-efficacy. The psychometric properties of the scale were assessed with samples across 25 nations and the results obtained confirmed that perceived general self-efficacy appears to be a unidimensional and universal construct that yields meaningful relations with other psychological constructs (Luszczynska et al., 2005; Scholz et al., 2002). High reliability, stability, and construct validity of the GSE have been confirmed and the scale has been adapted to 28 languages (Schwarzer & Jerusalem, 1995). The Cronbach‟s alpha for the General Self-Efficacy Scale (GSES) in this study was 0.899 and was acceptable for this scale. The Cronbach‟s alpha from this sample was consistent with the instrument psychometric evaluation, which was tested in a sample of 19,120 participants from 25 42 nations and showed internal consistency reliability ranging from 0.76 to 0.90, with the majority in the high 0.80s (Scholz et al., 2002). In this study, the scale was used in the Arabic language that was available online at the author website in different languages including Arabic. 3.5.1.3 The Burnout Scale The burnout scale is a subscale, taken from the Professional Quality of Life Scale Version 5 (ProQol5) (Stamm, 2009). The Professional Quality of Life Scale version 5 (ProQoL‐5) has 30 items and represents attempts to combine earlier subscales on compassion satisfaction with compassion fatigue (Stamm, 2009). It has three subscales: compassion satisfaction, which evaluates the pleasure clinicians derive from their work as a result of being exposed to traumatizing situations; compassion fatigue or secondary traumatic stress items, which evaluate potential distress due to exposure to a variety of traumatized clients (i.e., critical care patients); and burnout items, which evaluate feelings of hopelessness and frustration after little accomplishments (Sacco et al., 2015). Although the ProQOL was originally developed for emergency personnel and trauma counselors, the scale has been utilized internationally and also has been psychometrically validated in different studies for various target populations (Stamm & Com, 2010). The ProQOL‐5 subscales have been reported to have statistically acceptable internal consistency values, ranging from 0.75 to 0.88 (Stamm, 2002). The Burnout scale consists of 10 items, and possible response are‟ 1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often. The sum of 43 burnout questions of 22 or less indicate low burnout, between 23-41 indicate moderate burnout, and 42 or greater indicate high burnout. The burnout scale was used in different international studies on nursing and nursing students to measure burnout (Rees et al., 2016), as well as among nurses and physicians in Arabic countries as Egypt and Jordan (Al Barmawi et al., 2019; El-Shafei et al., 2018). The average score on the burnout scale is 50 (SD 10; alpha scale reliability .75) (Stamm, 2009). The Cronbach‟s alpha for the burnout scale in this study was 0.759. The Cronbach‟s alpha in this study was consistent with the original instrument psychometric evaluation, which showed internal consistency reliability coefficient .75 (Stamm, 2009). In this study, the scale was used in the Arabic language and was available online in the Arabic language at the author website. 3.5.1.4 Demographic Data Sheet The demographic data sheet was developed by the researcher. The demographic data survey consisted of 12 questions with some variables adapted directly from the NURS (Jeffreys, 2015) model. The survey included both demographic questions and close-ended questions. Demographic questions included Academic level, gender, and residence. Close-ended questions included GPA, smoking, playing exercise, working, receiving support, wanted to study nursing at enrollment, viewing nursing as a life career, study hours per day (hour or less; 2-3 hours; 4 hours; more than 4 hours), and how to prepare for an exam (start studying before a week 44 or more from the exam; start studying before days from the exam; start studying before a day or less from the exam). Refer to Annex 2 to view the full questionnaire in the Arabic language. 3.6 Pilot study A pilot study was conducted on 5% of the sample size (n=16) of undergraduate nursing students from one institution (Birzeit University), to determine the clarity of the questionnaire, and to estimate the time needed. Furthermore, the internal consistency for the three scales was measured using the Cronbach‟s alpha. The scale analysis revealed a Cronbach‟s alpha 0.937 for resilience, 0.939 for self-efficacy, and 0.860 for burnout measures. All the three measures demonstrated acceptable ranges. Overall, the final survey appeared to be well-designed, easy to score, and easy to interpret. The instrument appeared to be appropriate and acceptable for studying subjects from a wide range of populations and backgrounds. The questionnaire was easy to read and complete. The questionnaire had a low respondent burden because it could be completed in 10 minutes or less. The instrument appeared to be very simple to administer, process, and score making it a desirable tool for the current study. Because the instrument was piloted with the nursing student population and its satisfactory evaluation as stated above, it was a desirable instrument for the current research study. 3.7 Data Collection Due to the COVID-19 pandemic and the transition to online learning, it was difficult to reach all nursing students manually. Therefore, in order to 45 give an equal opportunity to all nursing students to participate in the study, the researcher e-mailed the three universities to participate in the study after explaining the necessary details to understand the study, the universities were also informed that the data could be collected electronically due to the Covid-19 Pandemic. After all of the three universities agreed to participate in the study (Refer to Annex 4), the researcher mailed the link of the questionnaire (Google Form link) to the universities, and they distribute the questionnaire electronically through university portals. The questionnaire was also electronically distributed to nursing students groups on social media platforms to increase the number of respondents. All the data were collected from 31 st May-29 th June 2021. Consent form explaining the purpose, nature and requirements for the study was attached to the questionnaire. The time to fill out the questionnaire was less than 10 minutes, and individuals were informed that no identifying information would be included on the survey (Anonymity) and the risks for participation were minimal; therefore, they were encouraged to respond to the survey as accurately as possible. It was also explained that completion of the survey represented consent for the study. Individuals were then instructed to complete the survey if they wished to participate in the study. The email of the researcher was also written on the consent, in the event that the research needs to be clarified further. To avoid missing data in the study, the survey was designed in such a way that the student could not submit his answers if some information were missing. 46 To maintain the confidentiality of the data, surveys were saved on a private account that could be only accessed by the researcher. 3.8 Ethical Considerations Institutional Review Board approvals were obtained from An-najah National University prior to data collection (Refer to Annex 3). No foreseeable risks were associated with this research project. Completion of the survey constituted as informed consent, and no identifiable information was included in the survey (Anonymity). Confidentiality was maintained by numerically coding the completed surveys and destruction of data once the research was completed. 3.9 Data Analysis The data were analyzed by a professional statistician using the IBM SPSS Statistics version (28) in two stages. The first stage involved analyzing and computing descriptive statistics as well as data distribution for each variable. The second stage of the data analysis was to describe the association of each variable. Completed surveys were reviewed for missing data, and the sum of total scores of resilience, self-efficacy, and burnout scales was done manually by the primary investigator. To ensure the accuracy of data, each individual score was double checked with a calculator. The data were collected and transcribed into a Microsoft Excel spreadsheet, which was then uploaded into SPSS for analysis. The data were reviewed and evaluated for correct entries, outliers, and missing information. To evaluate the frequencies and distributions, data for all 47 variables were analyzed and examined using frequency and descriptive statistics. The demographic data were examined to provide a thorough description of the sample in order to generalize the findings. Range, mean, and standard deviations were assessed for each variable. The primary goals of the analysis were to identify associations among variables through intra- and inter-subject comparisons; thus, correlational analysis was used to complete associations between variables. T-tests and ANOVA analysis were used to examine whether there are significant differences in group means. 3.10 Management of Subject Attrition Subject attrition was not a concern as the survey was administered one time only. Participants were selected and surveyed during a single moment in time; therefore, subject attrition was not possible in this research study. 3.11 Missing Data Missing data was not a concern as the electronical survey was designed in such a way that the student could not submit his answers if some information were missing. 3.12 Data Security Electronic data were kept on an encrypted flash drive on a password- protected computer that only the researcher had access to. The data were compiled using a secure, password-protected Microsoft-Excel spreadsheet. 48 Because no identifying information was used in any form of the data, the individuals' anonymity was preserved. Summary This quantitative study used a descriptive-correlational design to examine the relationship between resilience, self-efficacy, and burnout in undergraduate nursing students. An electronically survey method was used for data collection via Google form. This study used a nonprobability convenience sampling plan to obtain participants from three large institutions: An-najah National University, Birzeit University, and Bethlehem University. Data analysis techniques included descriptive statistics of the research sample, internal consistency reliability for the survey tool, correlation analysis, and T-tests and ANOVA analysis were used to answer the research questions. This chapter explained the methods used in this quantitative study, and the next chapter will present the results obtained with these methods. 49 Chapter Four Results 4.1 Overview In this descriptive-correlational research study, a survey was used to examine the levels of, and the relationship between resilience, self-efficacy, and burnout among undergraduate nursing students. In addition, relationships between all study variables were explored. At first, descriptive statistics for all demographic and variable data were analyzed. Then, the internal consistency reliability coefficients for the three measures (CD-RISC, GSES, and Burnout) were measured with Cronbach‟s alpha. Then, Correlational analysis was used to determine significant relationships between the three measures. Finally inferential statistics were used to draw conclusions based on extrapolations. 4.2 Descriptive Statistics A total of 409 nursing students completed the study survey. The sample included 220 (53.8%) students from An-najah national university, 133 (32.5%) from Birzeit university, and 56 (13.7%) from Bethlehem university. 131 (32 %) of the students were at their first-year academic level (Freshman‟s), 98 (24%) were at their second-year (Sophomores), 89 (21.8%) were at their third-year (Juniors), 91 (22.2%) were at their fourth- year (Seniors). For the total sample (n = 409), 279 (68.2%) were female students, 127 (31.1%) were male students, and 3 students preferred not to answer. 50 Students reported their GPA scores as the following: 44 (10.8%) reported high GPA scores (A (88-100)), 116 (28.4%) reported scoring (B (80-87.9)), 110 (26.9%) reported scoring (B- (76-79.9)), 83 (20.3%) reported scoring (C (70-75.9)), 48 (11.7%) reported scoring (C- (65-69.6)), and 8 students (2%) reported scoring less than C-. For the total sample, 123 (30.1%) reported smoking cigarettes/ hookah, 204 (49.9%) reported playing exercise/sports, 128 (31.3%) reported working beside studying, 83 (20.3%) reported living in university dorm, 307 (75.15) reported receiving support from friends and family. For the total sample, 217 (53.1%) answered yes regarding if they wanted to study nursing when they joined the university, whereas approximately half of the students 192 (46.9%) didn‟t want to study nursing when they joined the university. 201 (49.1%) reported (yes) regarding viewing nursing as a lifelong career, whereas, more than half of the students 208 (50.9%) reported (no) regarding viewing nursing as a lifelong career. Regarding the daily study hours, the majority of the students 138 (33.7%) reported studying from 2-3 hours daily, and regarding how students prepare for an exam, the majority of the students 223 (54.5%) reported studying days before the exam. Frequencies and percentages for participants‟ demographics are presented in Table1. 51 Table 1: Participants’ Demographics Note. This table reviews the participants‟ demographics (Frequencies and Percentages); university, academic year, gender, GPA, wanted to study nursing, viewing self-working in nursing lifelong, smoking, exercise, working, residence, receiving support, daily study hours, and method used to prepare for an exam. Independent Variables The type of Answer Frequency (%) The university that the student is enrolled at An-Najah National University 220 (53.8%) Birzeit University 133 (32.5%) Bethlehem University 56 (13.7%) Total 409 (100%) Academic Year First 131 (32%) Second 98 (24%) Third 89 (21.8%) Fourth 91 (22.2%) Gender Male 127 (31.1%) Female 279 (68.2%) Prefer not to answer 3 (0.7%) GPA A (88-100) 44 (10.8%) B (80-87.9) 116 (28.4%) B- (76-79.9) 110 (26.9%) C (70-75.9) 83 (20.3%) C- (65-69.9) 48 (11.7%) Less than C- 8 (2%) Wanted to study nursing when I joined the study Yes 217 (53.1%) No 192 (46.9%) I see myself working in the nursing profession all my life Yes 201 (49.1%) No 208 (50.9%) Smoking cigarettes or hookah Yes 123 (30.1%) No 286 (69.9%) Doing Sports/ Exercise Yes 204 (49.9%) No 205 (50.1%) Working while studying Yes 128 (31.3%) No 281 (68.7%) Living in Campus/ Dorm Yes 83 (20.3%) No 326 (79.7%) Receiving support from family and friends Yes 307 (75.1%) No 102 (24.9%) Average daily study hours An hour or less 119 (29.1%) 2-3 Hours 138 (33.7%) 4 Hours 75 (18.3%) More than 4 Hours 77 (18.8%) The method usually used to prepare for an exam Start Studying a week or more before the exam 66 (16.1%) Start Studying days before the exam 223 (54.5%) Start Studying a day or less before the exam 120 (29.3%) 52 4.3 Resilience, Self-efficacy, and Burnout Levels To answer the first research question regarding the levels of resilience, self- efficacy and burnout among nursing students, the arithmetic means and standard deviation of the total responses of the sample members were found in the three scales. In the measure of resilience scores using the CD-RISC which ranges from (0-40), if the total score was (20 or less), this was considered as low resilience level. Students‟ scores ranging from (21-30) were considered to have an average resilience, while students who scored more than 30 on the CD-RISC were considered to have a high resilience level. Regarding the General Self-efficacy Scale if the total score on the scale which ranges from (10-40) was (less than 25), this was considered as low self-efficacy. If students reported a score from a (25 – less than 35), the score was considered an average self-efficacy level, while a total of 35 or more on the GSES was considered a high self-efficacy. Regarding the burnout scores which ranges from (10-50), scoring (22 or less) indicated a low level of burnout, scores ranging from (23-41) indicated an average burnout, and scores that were (more than 41) indicated high level of burnout. The results of the analysis showed that the level for these three measures was with the average ranges as presented in Table 2. The mean of resilience was (28.51), and the standard deviation was (6.72). 202 (49.4%) had average levels, 39 (9.5%) had low levels, whereas 168 (41.1%) had high resilience levels. The mean of self-efficacy was (30.14), and the 53 standard deviation was (5.60). 210 (51.3%) had average levels, 21 (5.1%) had low levels, whereas 178 (43.5%) had high levels of self-efficacy. The mean of burnout was (25.32), and the standard deviation was (6.92). 209 (51.1%) had average levels, 113 (27.6%) had low levels, whereas 87 (21.3%) had high levels of burnout. Table 2 presents results regarding the three measures in term of means, standard deviations, and levels. Table 2: Means and SD of the Three Measures (Resilience, Self- efficacy, and Burnout) The Measures N Mean SD The level Resilience Measure 409 28.51 6.72 Average Resilience Self-Efficacy Measure 409 30.14 5.60 Average Self-Efficacy Burnout Measure 409 25.32 6.92 Average Burnout Note. N: Number, SD: Standard Deviation. 4.4 Inferential Statistics Correlational analysis was completed using Pearson Correlation. The primary purpose of this correlational analysis was to identify relationship between resilience, self-efficacy, and burnout. The test results show as in Table 3 that there is an inverse relationship between burnout and resilience, where the value of the correlation coefficient was (-0.35), and this value indicates a weak inverse correlation between the two measures, and this inverse relationship explains that whenever there is a decrease in the resilience there is an increase in the burnout and vice versa. The results also showed an inverse relationship between burnout and self-efficacy, with a value of the correlation coefficient (-0.21); this value indicates a weak inverse correlation between the two measures, and this relationship 54 explains that whenever there is an increase in self-efficacy, there is a decrease in burnout, and vice versa. The results also revealed a positive relationship between resilience and self-efficacy, and the value of the correlation coefficient was (0.68); this value indicates a good positive correlation between the two measures, and this value indicates that whenever there is an increase in resilience, there is an increase in self- efficacy, and whenever there is a decrease in resilience, there is a decrease in self-efficacy. To answer the second research question based on the results, the relationship between these scales was an inverse relationship between burnout on the one hand and resilience and self-efficacy on the other hand, while the results revealed a positive correlation between resilience and self- efficacy. This means that higher resilience and self-efficacy among nursing students contribute to lower burnout. Table 3: Correlational Analysis between the Three Measures (Resilience, Self-efficacy, and Burnout) Measures The Correlations Burnout Scale Self- Efficacy Scale Resilien ce Scale Burnout Scale Pearson Correlation 1 -0.21- ** -0.35- ** Sig. (2-tailed) 0.000 0.000 Self-Efficacy Scale Pearson Correlation -0.21- ** 1 0.68 ** Sig. (2-tailed) 0.000 0.000 Resilience Scale Pearson Correlation -0.35- ** 0.68 ** 1 Sig. (2-tailed) 0.000 0.000 Note: **. Correlation is significant at the 0.01 level (2-tailed). 55 To answer the third research question, Inferential Statistics (t-test and ANOVA) were used. A post hoc test was also used after finding statistically significant results to determine from where the differences truly came. The answer for the third research question was guided by the third hypothesis (There are no statistically significant differences at 0.005 between resilience, self- efficacy, burnout, and other variables (gender, smoking, GPA, academic year, wanting to study nursing, viewing nursing as a life career, doing exercise, working, residence, receiving support, study hours, and how to prepare for an exam)). To test this hypothesis, an independent sampling t-test was used depending on the variables (Gender, smoking, wanted to study nursing, viewing nursing as a life career, doing exercise, working, residence, receiving support) with resilience, self-efficacy, and burnout. In addition, one way ANOVA was used depending on the variables (GPA, Academic level, daily study hours, and exam preparation) with resilience, self-efficacy, and burnout. 4.5 Statistical significance 4.5.1 Gender Regarding the gender variable, the results show that there are statistically significant differences in the three scales as seen in Table 4, as it was found from the analysis that the levels of burnout among males were higher than females (p= 0.003), this indicates that the burnout among females is lower than in males. Furthermore, the results revealed a statistically significant 56 differences in the measure of resilience in favor of males (p= 0.040), this indicates that the level of resilience in males is higher than in females. Regarding self-efficacy, there were statistically significant differences in the measure of self-efficacy in favor of males (p=0 .018), the result indicated that the level of self-efficacy in males is higher than in females. Table 4: Significant difference in Gender in Relation to The Three Measures (Resilience, Self-efficacy, and Burnout). Group Statistics The Measures N Mean Std. Deviation t- test value P Value Gender Burnout Male 127 26.73 6.76 3.00 0.003 Female 279 24.56 6.76 Self-Efficacy Male 127 31.15 5.54 2.37 0.018 Female 279 29.75 5.52 Resilience Male 127 29.57 6.33 2.06 0.040 Female 279 28.13 6.66 Note. N: Number, SD: Standard Deviation. 4.5.2 Smoking Regarding the smoking variable, the results shown in Table 5 indicate that there is a statistically significant difference with burnout, as it was found from the analysis that the level of burnout for yes is higher than for no (p= 0.001). This indicates that the burnout among no-smokers is lower than in smokers. On the other hand, there were no statistically significant differences in the self-efficacy and resilience measures to this variable. 57 Table 5: Significant difference in Smoking in Relation to The Three Measures (Resilience, Self-efficacy, and Burnout) Group Statistics The Measures N Mean Std. Deviation t- value P value Smoking cigarettes or hookah Burnout Yes 123 27.02 7.34 3.32 0.001 No 286 24.58 6.61 Self-Efficacy Yes 123 30.19 6.47 .10 0.068 No 286 30.12 5.19 Resilience Yes 123 28.76 7.28 .51 0.369 No 286 28.40 6.47 Note. N: Number, SD: Standard Deviation. 4.5.3 Wanting to Study Nursing Regarding the variable wanting to study nursing when joined the study/university, the results in Table 6 show that there were no statistically significant differences in both the burnout and self-efficacy measures. However, there was a statistically significant difference in the resilience depending on the variable wanted to study nursing (p= 0.008). The result indicates that the levels of resilience of those who wanted to study nursing when joined the university were higher than that of those who did not want to study this major. Table 6: Significant difference in Wanted to Study Nursing in Relation to The Three Measures (Resilience, Self-efficacy, and Burnout) Group Statistics The Measures N Mean Std. Deviation t- value o P value Wanted to study nursing when I joined the study/ university Burnout Yes 217 24.79 6.91 -1.64 0.101 No 192 25.91 6.89 Self-Efficacy Yes 217 30.26 5.53 .47 0.636 No 192 30.00 5.69 Resilience Yes 217 29.33 6.71 2.65 0.008 No 192 27.58 6.63 Note. N: Number, SD: Standard Deviation. 58 4.5.4 Viewing Nursing as a Lifelong Career Regarding viewing nursing as a lifelong career variable, the results in Table 7 show a statistically significant difference in burnout (p =0 .001). The results indicate that students who viewed themselves working in the profession as a life-long career had lower levels of burnout compared to those who did not view themselves working in this profession throughout their lives. Moreover, the result showed a statistically significant difference in the measure of resilience (p = 0.001), the results indicate that the level of resilience of those who viewed themselves working in the nursing profession throughout their lives was higher than those who did not. On the other hand, there was no significant difference between self-efficacy and this variable. Table 7: Significant difference in Viewing Nursing as a life-long career in Relation to The Three Measures (Resilience, Self-efficacy, and Burnout) Group Statistics The Measures N Mean Std. Deviation t-value