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JOURNAL ARTICLE PRE-PROOF

(as accepted)

Review Article

Prevalence and associated factors of burnout among health

sciences students in Spain – a systematic review

Zoila María Olmos-Bravo, Joan Vicent Sánchez-Ortí, Eugenio H. Grevet,

Vicent Balanzá-Martínez

[Link]

Original submitted Date: 16-Feb-2024

Accepted Date: 30-May-2024

This is a preliminary, unedited version of a manuscript that has been accepted for
publication in Trends in Psychiatry and Psychotherapy. As a service to our readers,
we are providing this early version of the manuscript. The manuscript will still
undergo copyediting, typesetting, and review of the resulting proof before it is
published in final form on the SciELO database ([Link]/trends). The final
version may present slight differences in relation to the present version.

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Prevalence and associated factors of burnout among health sciences

students in Spain – a systematic review

Short title: Prevalence burnout among health sciences students

Zoila María Olmos-Bravo1, Joan Vicent Sánchez-Ortí2,3, Eugenio H.

Grevet4,5,6,7, Vicent Balanzá-Martínez 2,3,8,9 *

1 Department of Medicine, University of Valencia, Valencia, Spain.

2 CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain.

3 INCLIVA Research Institute, Valencia, Spain.

4 Department of Psychiatry, Faculty of Medicine, Universidade Federal do Rio

Grande do Sul, Porto Alegre, RS, Brazil.

5 Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal

do Rio Grande do Sul, Porto Alegre, RS, Brazil.

6 Laboratory of Developmental Psychiatry, Center of Experimental Research,

Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.

7 ADHD Outpatient Program, Clinical Research Center, Department of Psychiatry,

Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul,
Porto Alegre, RS, Brazil.

8 Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine,

University of Valencia, Valencia, Spain.

9 Valencia Estigma i Salut Mental (VALSME), University of Valencia, Valencia, Spain.

*Correspondence:

Vicent Balanzá-Martínez
Teaching Unit of Psychiatry and Psychological Medicine. Department of Medicine,
University of Valencia, Avenida Blasco Ibáñez, 15, 46010 Valencia, Spain
Phone: +34 963983349
E-mail address: [Link]@[Link]

Handling Editor: Dr. Raffael Massuda

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Abstract

Background: There is growing concern about the occurrence burnout syndrome in

university students worldwide. This systematic review aimed to estimate the
prevalence of burnout syndrome and its associated factors among health sciences
students (HSS) from Spain.

Methods: Five databases (MEDLINE/PubMed, PsycINFO, EMBASE, Dialnet and

MEDES) were searched up to January 5, 2023, adhering to PRISMA guidelines.
Quantitative studies reporting the prevalence of burnout syndrome among HSS from
Spanish universities were considered. The reference lists of the selected studies
were hand searched. Data were extracted from peer-reviewed articles.

Results: Twenty-six studies with a total of 14,437 HSS were included (11 nursing,
8 Medicine, five Psychology, two Dentistry, one Physiotherapy, one Pharmacy
students). Overall, study quality was fair. The most widely used instrument was the
Maslach Burnout Inventory. The mean prevalence of burnout was 35.3% (k=11
studies). However, rates varied widely across the studies, which may result from
methodological differences. Inconsistent associations were found with gender and
year of study. The relationship of burnout with academic-and mental-health related
variables was consistent across studies. Personal attributes such as higher
resilience, are likely protective from burnout.

Conclusions: Burnout seems to be prevalent among HSS in Spain, and can be

affected by academic, mental health-related and personality factors. The
identification of risk and protective factors of burnout could help develop preventive
and management strategies, to ultimately reduce its negative consequences in this
population.

Keywords: Burnout syndrome, prevalence, university students, Spain, risk factors.

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1. Introduction

Burnout is a syndrome due to inefficient management of work-related stressors, and

can involve the development of mental symptoms, physical problems, and
increased substance use.1,2 Burnout symptoms overlap with common mental,
especially depressive, symptoms.3,4 The consideration of burnout as a disease is
controversial. Indeed, burnout is not a diagnostic category in the DSM-5,5 but it is
classified as a ‘factor influencing health status’ in the ICD-11.6,7 Moreover,
consensus regarding the best instrument to measure burnout is lacking.2
According to some authors, burnout syndrome comprises three main dimensions:
emotional exhaustion, depersonalization, and lack of personal fulfillment.8
Exhaustion is defined as a state of intense fatigue; depersonalization refers to the
feeling of detachment or indifference towards clients or patients; and lack of
personal fulfillment is defined as the self-perception of ineffectiveness or
incompetence in work.9 These dimensions are not mutually exclusive but are
usually interrelated and can appear sequentially.
Consistent evidence worldwide shows moderate to high levels of burnout among
healthcare professionals, including nurses, dentists, physicians, medical trainees,
pharmacists, physiotherapists, and practitioner psychologists.10,11,12,13,14,15,16,17
Burnout can negatively impact on professionals‘ health and the quality of patient
care. For instance, it has been associated with higher risk of self-reported errors
among physicians18 and worse patient safety.19,20
There is growing concern about burnout and mental health problems (MHPs)
among university students.21 Academic burnout is defined as the feeling of
exhaustion with study demands coupled with a lack of dedication or academic
commitment and a feeling of inadequacy as student.22 Academic burnout has been
shown to predict subsequent burnout in the work environment.23 The development
of this syndrome among health sciences students (HSS) may compromise their
emotional well-being and academic performance,24,25 and can have other negative
consequences.26,27,28 Therefore, estimating the prevalence and associated factors
of burnout among HSS is relevant. Indeed, burnout is frequent in HSS, such as
medical,29,30 nursing31 and dental students.32 However, how burnout is defined and
assessed results in considerable heterogeneity in prevalence estimates.33 On the
other hand, several risk and protective factors of burnout among HSS have been
described, including individual, academic, psychological, and social factors.34,35,36,37
Whether these factors are common or specific across different cultures and
university degrees is less researched.

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Several systematic reviews exist on the prevalence of burnout among students of

specific health degrees, namely medicine,29,30,38 nursing31,39 and dentistry.32
However, to our knowledge, no previous review has adopted a comprehensive
approach to HSS, including those enrolled at psychology, pharmacy, and
physiotherapy degrees as well. Moreover, no review has focused on burnout among
university students in Spain.
Gaining an adequate understanding on the prevalence and risk/protective factors
of burnout among HSS is needed to develop early intervention, preventive, and
management strategies in this population, especially for those at risk. These
aspects should be studied in each country to tailor prevention and management
strategies to a given socio-cultural context. Therefore, this systematic review aims,
firstly, to identify the prevalence of burnout in HSS from universities in Spain and,
secondly, if sufficient data are available in eligible studies, to identify the factors
associated with the development of burnout syndrome. In this review, the terms
health science students, healthcare students, and health professions students are
considered interchangeable.

2. Methods
The review was conducted according to the guidelines of the latest version of the
Preferred Reporting Items for Systematic Reviews and Meta-Analyzes – PRISMA
2020.40 The protocol was registered in the international prospective register of
systematic reviews PROSPERO (CRD42023387460).

2.1. Search strategy

The literature search was conducted in five databases: PubMed/Medline, APA

PsycINFO, EMBASE, Dialnet and MEDES, with no restriction by date of publication.
We used the combination of keywords and MeSH terms “(burnout [OR] “academic
burnout” [OR] “emotional exhaustion” [OR] depersonalization [OR] “reduced
personal accomplishment”) [AND] (university [OR] college) [AND] student [AND]
(Spain [OR] Spanish)” to identify records up to January 5, 2023. In MEDES, the
following analogous strategy "burnout AND university AND student AND Spain" was
used since it allowed a more exhaustive search. In addition, the bibliographic
references of selected studies were reviewed to identify additional studies that met
the selection criteria.

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2.2. Selection criteria

Studies evaluating the prevalence of burnout in undergraduate students of degrees

in the field of health sciences (medicine, nursing, dentistry, physical
therapy/physiotherapy, psychology, and pharmacy) belonging to a university in
Spain were included. Results had to report quantitative data on burnout
(prevalence, mean, or standard deviation) assessed using a validated scale (e.g.,
MBI-SS, BCSQ-12-SS; see below). Studies published in English or Spanish were
collected. In addition, we only included data reported in peer-reviewed articles, as
defined either at the journal website or based on the article full text. Regarding
design, we included cross-sectional, cohort, and case-control studies, as well as
longitudinal or intervention studies, provided they reported prevalence data at
baseline.

On the other hand, we excluded studies that (1) examined the prevalence of
burnout in other populations: students of other university degrees, health
professionals or postgraduate students; (2) examined mixed samples of university
students without providing disaggregated prevalence data for the group of students
in a health science degree; (3) assessed students from countries other than Spain;
(4) did not have a design that could be included in a systematic review, e.g., review
articles and meta-analyses; case series; opinion articles; dissertations; abstracts of
communications to conferences; qualitative research; (5) lacked a full-text
version in English or Spanish; (6) assessed MHPs other than burnout; or (7) more
than one article provided data on the same sample. The excluded articles and
corresponding reasons for exclusion are shown in the flowchart (Figure 1).

2.3. Study selection and data extraction

The articles identified in the five databases were imported into the RefWorks
platform to determine and eliminate duplicates. Two reviewers (Z.O-B. and J.V.S-
O), independently and masked, proceeded to review the titles and abstracts of the
articles, evaluating their eligibility according to the selection criteria. In the next step,
the reviewers screened the full texts of studies with potential to be included in the
review to identify eligible studies. In case of discrepancy between the two reviewers,
this was resolved by discussion and consensus with a senior author (V.B-M.).

The following data were extracted from each article: authors, year of publication,
year of survey, study design, sample size, degree, year of study, gender and age

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of participants, type of university (public or private), sampling method, response

rate, time to data collection, burnout measurement instrument used, prevalence of
burnout, scores (means and standard deviations) in the scales and/or subscales of
burnout, and factors associated with burnout (risk and protective factors).

For studies that reported rates of global burnout and burnout dimensions, mean
prevalences were estimated by means of the following equation: number of
individuals with burnout divided by the number of individuals at risk of burnout. For
the estimation of the number of individuals with burnout, the percentage of the
overall prevalence rate provided in each study was applied to the total number of
participants. When studies only reported prevalence rates in each of the burnout
dimensions, the same procedure as above was followed, preceded by the
calculation of the weighted average of the prevalence rates in each dimension. The
latter was used as an estimator of the overall prevalence rate. The number of people
at risk of burnout was defined by the total number of participants in each study.

2.4. Study quality assessment

Study quality was evaluated with the National Heart, Lung and Blood Institute
(NHLBI) quality assessment tool for observational cohort and cross-sectional
studies.41 It consists of 14 items, and each item is rated as affirmative, negative, not
available, or not applicable, and the overall quality of the studies is rated
accordingly. Three categories were used to rate study quality: ‘Good
methodological quality’, ‘Fair methodological quality’ and ‘Poor methodological
quality’.

3. Results

3.1. Description of the reviewed studies

A total of 629 records were retrieved from the databases checked: 89 in
PubMed/Medline, 103 in PsycINFO, 147 in EMBASE, 278 in Dialnet, and 12 in
MEDES. The results of the study selection process are displayed on the flowchart
(Figure 1). Firstly, duplicate articles (n = 84) were eliminated. After the first
screening, based on title and abstract, 483 studies were excluded, for the reasons
shown in the flowchart. Subsequently, the full text of the remaining 62 articles was
analyzed, and 39 of them were excluded. Two studies with the same sample42,43 and

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two studies with a partial overlap of the sample44,45 were retained because, in both
cases, they provided variables of interest different from each other. Finally, we
included three articles identified in references of the eligible articles. In sum, of the
629 studies initially located, after eliminating duplicates and applying the selection
criteria, 26 eligible articles were included in this systematic review.

Figure 1. Flowchart

Studies were published between 2007 and 2022. Table 1 lists the major
characteristics of the reviewed studies: authors and year of publication, year of
survey/data collection, sample size, sociodemographic variables (students’ age and
female ratio), degree (and year/years of study), response rate, instruments of
evaluation of burnout, prevalence of burnout, quantitative values of burnout, MHPs
evaluated, and factors associated with burnout.

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Table 1. Major characteristics of the reviewed studies (prevalence and associated factors of burnout among health sciences students in Spain)
Student’s
age Female Response Instrument Prevalence Mean Mental health and
Year of mean ratio Degree rate (number of of burnout scores personality issues Factors associated
References survey N (SD) (%) (year) (%) items) (%) (SD/IQR) assessed with burnout

EX 2.48
(1.15)
Schaufeli22
CY 1.72 N/A
(2007) NA 239 22.4 (4) 73 Psychology NA MBI-SS (16)
(1.22)
EF 3.76
(0.86)
EX 2.70
Huesca: (1.50)
O 28 CY 1.39
LD 17 (1.18)
N 19 EF 4.14
Montero- (0.94)
Dentistry MBI-SS (15) Year of study,
Marin42 22.05 Santiago:
2011 314 70.7 (1st – 5th) 83.1 BCSQ-12-SS academic factors
(2011) (3.57) O 19 O 3.32
LD 28 (1.45)
N 24 LD 2.46
(1.22)
N 2.07
(1.01)
EX 13.49
(7.49) Perceived stress, Perceived stress,
Montero-
CY 5.57 anxiety, anxiety,
Marin43 22.05 Dentistry
2011 314 70.7 83.1 MBI-SS (15) (4.74) depression, depression,
(2014) (3.57) (1st – 5th)
EF 24.85 resilience resilience
(5.62)

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EX 2.43
EX 28 Resilience, working
(1.09)
Ríos- CY 19.7 (higher EF), poor
Nursing CY 1.65
Risquez44 24.74 EF 25.2 relationship with
2011 218 75.7 (2nd) 100 MBI-GS (16) (1.17) Resilience
(2012) (5.66) professors (lower
EF 4.23
EF and EX)
(0.79)
T1
EX 2.43
(1.11)
CY 1.67
(1.19)
T1:218 EF 4.32
Ríos- (0.69)
Nursing(T1
Risquez45
2014 - 24.42 2nd, T2
(2018) 75.2 Psychological Psychological
T2: (5.27) T2 4th) 51.8 MBI-SS (16)
2016 EX 2.40 distress, resilience distress
113
(1.36)
CY 1.45
(1.14)
EF 4.21
(0.59)
EX 5.26
63.5 (1.22)
Moreno- EX 44.6 Intervention
Fernandez46 20 (2.1, Pharmacy CY 3.11 (emotional
2020 47 59.58 NA MBI-SS (11) CY 41.7 (1.08)
(2020) 1.8) (2nd) intelligence
EF 60.3 EF 3.25 workshop)
(1.26)
Gender,
47 Nursing Trait anxiety,
Chust 2014- trait anxiety, exam
(1st, 2nd, exam anxiety,
(2022) 2015 494 NA 77.7 68.6 MBI-SS (16) 28.4(11.2) anxiety, sleep
3rd) sleep satisfaction,
satisfaction,self-

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self-esteem, life esteem, life

satisfaction satisfaction
Medicine
March- Nursing 6.2 Gender,
Amengual48 2018, Physiotherapy (EX 47.1, Psychological psychological
(2022) 506 19.2 Psychology MBI-SS (15) distress distress
2019 64.8 34.2 CY 7.2)
(276)* (3.06) (1st)
Year of study,
depression, trait
anxiety, problems
Depression
Capdevila- of academic
Medicine(1 Anxiety
Gaudens49 performance,
2020 5216 21.4(3.4) 76.3 – 6th) 12 MBI-SS (15) 36.8 Empathy
(2021) lower academic
Substance use
satisfaction,
organizational
difficulties
EX 27.5
Gender, year of
(7.16)
Gil– study, family
Medicine(1 CY 14.83
Calderón50 support,
2019 1073 NA 75 – 6th) NA MBI-SS (15) (7.09)
(2021) vocation for
EF 22.38
medicine
(6.89)
Nursing Year of study,
O 25.5 mindfulness,self-
LD 19.7 compassion,
Martínez- N 15.6
Nursing Perceived psychological
Rubio51 2015 - 22.24 Psychology Psychology academic stress flexibility,
(2021) 644 77.3 NA BCSQ-12-SS
2016 (6.11) (1st – 4th) O 20.1 perceived
LD 25.9 academic stress
N 18.1 factors, living alone

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Merino- Resilience, Resilience,

Nursing
Godoy52 26.28 psychological psychological
2021 393 23 82.7 (4th) NA ECE (10)
(2022) (7.57) distress distress
Dentistry
(3rd, 4th,
Montiel- 533 21.9 65.3 50.3 56.3
5th) Year of study,
Company53 2013 - Medicine degree
(2016) 76 MBI-HSS(22)
2014 (4th, 5th,
188 22.8 66.7 40.4 48.7
6th)
EX
2.4(1.1)
Bresó54 MBI-SS CY
NA 193 22.4(4.2) 73 Psychology NA N/A
(2007) (15) 1.6(1.1)
EF
3.7(0.8)
Liebana- EX 2.6 (1.3)
Presa55 2009, CY 1.2 (1.1) Gender
2010 1009 21.53 85,1 Nursing NA MBI-SS (15)
(2018) EF 4.1 (0.8)
EX 3.83
(1.45)
Martos56 CY 4.01
(2018) 63 32.41 Nursing MBI-SS (11)
NA 69.8 NA (0.97)
(37)* (8.48)
EF 3.94
(0.95)
Amor57 2018 149 21.9(3.7) 66.4 Medicine(1 87.6 33.6
MBI-SS(15)
(2020) 2019 224 21.3(2.4) 69.2 – 6th) 64.4 38 Year of study
Gender
Atienza- Substance use
39.3- Year of study
Carbonell58 2020 1265 21.4(3.3) 74.2 Medicine(1 IUBA(1) 40.2 (lifetime and
41.3 Satisfaction with
(2022) – 6th) last month)
academic results

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Number of
substances used
(lifetime and last
month)
Third
year:
EX
1.8(0.9)
CY
0.6(0.7)
3rd: 65 22.6 EF
Galán59 Medicine
2008 270 NA 71 6th: MBI-SS (15) 3rd: 14.8 4.4(0.7)
(2011) (3rd, 6th)
35 6th: 37.5 Sixth
Year of study
year: EX
2.4(0.9)
CY
1.4(1.1)
EF
4.1(0.8)
MBI-SS(15) 2nd: 41.3
Galán60 Dentistry Depression,
21.8 MBI-HSS 4th: 50.9 Year of study,
(2014) 2009 208 68.8 (2nd, 4th, 5th) 78.8 suicide ideation
(3.8) (22) 5th: 25.6 depression

Completing the
Reverté-
Mental well- degree during the
Villarroya61 2017, 30 (23 –
305 24 86.5 Nursing(4th) NA ECE (10) being COVID-19
(2021) 2020 35)
pandemic, mental
well-being
Year of study,
Valero-
Nursing (2nd – satisfaction
Chillerón62 22.83 0
2017 126 80.2 4th) NA MBI-SS (22) with clinical
(2019) (6.03)
practices

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EX 3.13
(1.26)
Vallejo-
409 Nursing (1st – CY 2.10
Martín63
2017 (144) 21.3 68 4th) NA SBI-9 (9) (1.32) Gender, degree
(2017)
EF 2.93
(1.41)
Overload:
1.9(0.6)
3rd
2.7(0.6)
4th
Exhaustion:
Overload(1)
Figueiredo- 1.0(0.6) Year of study,
Psychology CESQT:
Ferraz64 NA 3rd health
NA 154 21.7(2.8) 84.3 (3rd, 4th) exhaustion(4)
(2009) 1.7(0.8) problems
Disillusion(6)
4th
Disillusion:
1.1(0.6)
3rd
1.5(0.6)
4th
EX 19.6
González- (10.3)
Cabanach65 21.28 Physiotherapy CY 3.5
NA 487 72.7 (1st, 2nd, 3rd) NA MBI (22) (4.4) Self-esteem Self-esteem
(2016) (4.32)
EF 28.9
(8.8)
5.31 (2.3)
66 EX 2.44 Gender, severity
Oro Perceived stress,
2013 - Medicine (1.14) of
(2017) 20.25 psychopathology
2015 118 71.2 (2nd – 5th) NA MBI-SS (15) CY 0.98 psychopathology
(1.53) symptoms
(0.95) symptoms

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EF 4.11
(0.82)
Studies appear in alphabetical order. Abbreviations. BCSQ-12-SS: Burnout Clinical Subtype Questionnaire Students Survey; CESQT: Questionnaire for the Evaluation of Burnout
Syndrome; CY: cynicism; ECE: Emotional Exhaustion Scale; EF: academic efficacy; EX: emotional exhaustion; IQR: interquartile range; IUBA: Single-Item Academic Burnout; LD:
lack of development; MBI: Maslach Burnout Inventory; MBI-GS: MBI-General Survey; MBI-HSS: MBI-Human Services Survey; MBI-SS: MBI-Survey for Students; N: neglect; NA:
not available; N/A: not applicable; O: overload; SBI-9: School Burnout Inventory; SD: standard deviation.
* In the studies by March-Amengual48 (2022) and Martos56 (2018) the number of health sciences students is specified in parentheses, since it is a proportion of the joint sample
with students of other university degrees.

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In total, there were 14,437 HSS from universities in Spain, enrolled at degrees in
medicine (n=8,581), nursing (n=3,271), dentistry (n=1,055), psychology (n=945),
physiotherapy (n=538) and pharmacy (n=47). The sample size of the original studies
ranged from 37 to 5,216 participants. Most studies (k=23) had a cross-sectional
design. Two studies collected data following a longitudinal design, of which one
evaluated the evolution of academic burnout over the university years in nursing
students45 and the other estimated the effects of an intervention on the level of
burnout in pharmacy students.46
Although the studies were carried out in several regions of Spain, only eleven were
multicentric. Studies were conducted at public universities (k=18), private universities
(k=2)47,48 and both public and private universities (k=4);49,50,51,52 whereas one did not
specify the type of universities included.53
Most of the participating students were women, who accounted for 59.6% - 86.5% of
the study samples. The average age of participants in the selected studies was
between 19.2 and 24.7 years. The years of study are shown in Table 1. Students’
year was not specified in four studies.21,54,55,56
Of the 26 articles, 23 focused on students enrolled at a single degree: nursing (k=9),
medicine (k=6), psychology (k=3), dentistry (k=3), physiotherapy (k=1) and
pharmacy (k=1). Moreover, three studies recruited students from several health
sciences degrees: nursing and psychology;51 medicine and dentistry;53 and first-year
students of medicine, nursing, physiotherapy, and psychology.48
Regarding the assessment instruments, in 21 studies burnout was examined with
one version of the Maslach Burnout Inventory (MBI),8 including the MBI-Students
Survey (MBI-SS) (k=17),22 the MBI-Human Services Survey (MBI-HSS; k=2),67 and
the MBI-General Survey (MBI-GS; k=1),68 and the MBI (k=1). The Burnout Clinical
Subtype Questionnaire Students Survey (BSQ-12-SS)69 and the Emotional
Exhaustion Scale (ECE)70 were used twice each. The remaining studies used other
validated instruments, such as the Single-Item Academic Burnout (IUBA),71 the
School Burnout Inventory (SBI)72 and the Questionnaire for the Evaluation of Burnout
Syndrome (CESQT).73 Several studies used more than one instrument.

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3.2. Prevalence of burnout

For the 11 studies that reported rates of global burnout,42,44,46,48,49,51,53,57,58,59,60 the
mean prevalence was 35.3%. Moreover, five studies42,44,46,48,59 reported the mean
prevalence’s of burnout dimensions: emotional exhaustion (41.5%), cynicism
(12.9%) and academic effectiveness (31.3%).
Taken together, the prevalence of burnout among medical students ranged from
22.6% to 40.4%.49,53,57,58,59 Regarding dentistry, burnout rates were 25.6%-50.9%,
and varied greatly across courses/years.42,53,60 The range of prevalence was even
wider in of nursing students.44,45,47,51,52,55,56,61,62,63 For example, Ríos-Risquez et al.
(2012)44 found high levels of emotional exhaustion, high levels of cynicism and low
levels of academic effectiveness in 28%, 19.7% and 25.2% of the sample,
respectively, whereas another study observed high levels of emotional exhaustion in
17%, but they did not identify students with high levels of depersonalization or with
low levels of academic effectiveness.62 Regarding psychology students, one study
provided the prevalence of clinical subtypes of burnout (overload: 20.1%, lack of
personal development: 25.9% and neglect: 18.1%;51 and three reported the mean
scores.21,54,64 In the only study of pharmacy students, 63.5% of them had academic
burnout during the COVID-19 pandemic lockdown.46 One study showed a medium
level of emotional fatigue, low-medium depersonalization, and medium-high
personal fulfillment among physiotherapy students.65 Finally, March-Amengual et al.
(2022)48 concluded that 6.2% of first-year HSS suffered from burnout.
The two studies 42,51 that used the clinical subtypes questionnaire (BCSQ-12-SS) in
dental, nursing and psychology students, observed a similar, high prevalence of each
subtype – overload (19-28%; mean=20.5%), lack of personal development (17-28%;
mean=19.3%) and neglect (15.6-24%; mean=15.6%). Moreover, when assessments
were confined to one dimension of burnout, moderate levels of emotional exhaustion
assessed with the ECE were found in nursing students.52,61
Instead of reporting the prevalence of burnout, 14 studies described the mean scores
on the global burnout scale or subscales (Table 1). The ranges of these scores are
highly variable depending on the number of items and the scoring scale, as well as
the instrument used, which makes it impossible to compare the scores across
studies. Several studies require cut-off points to transform the burnout measure into
a dichotomous variable but, given the lack of standardized cut-off points, they vary

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across the studies53,57,66 or are not reported.46 In other cases, percentiles are used
as cut-off points, so that the first quartile represents the lowest values and the fourth
quartile the highest values in each burnout dimension.44,48,49,59,60,62 Most of these
studies obtained average values, that is, between the second and third quartile, for
all three dimensions of burnout (Table 1).

3.3. Relationship of burnout with other variables

The reviewed studies examined the association of burnout with sociodemographic
variables (gender), year of study, degree, academic-related variables, psychological
issues, personality traits, and social support among HSS.
Regarding gender, eight studies found no association with burnout,42,49,53,56,57,59,60,62
whereas six studies found that gender was a predictor of burnout or of its dimensions.
Male students were found to have higher global burnout scores47 and higher levels
of cynicism48,55 whereas in other studies female students presented higher levels of
global burnout,58 emotional exhaustion50 and academic ineffectiveness.66
Seven studies found that the prevalence of burnout or its dimensions increased
significantly as the year of study progressed.49,50,51,57,59,62,64 Conversely, burnout was
found to be more prevalent in the preclinical years58 or to remain stable during the
degree.45 Among dental students, the highest levels of burnout were observed in the
fourth year, with lower levels in the fifth year.42,53,60
Three studies analyzed the role of university degree. Burnout was more prevalent in
dental students than in medical students.53 Moreover, nursing students presented
lower levels of cynicism than those of non-health degrees,63 whereas levels of
burnout did not differ between healthcare and non-healthcare students.48
Burnout was also associated with several academic-related variables, including
academic performance problems, lower academic satisfaction, organizational
difficulties, poor relationship with teachers, test anxiety, and objective academic
results.44,47,49,58 However, burnout levels did not predict academic performance
among first year HSS.48 Moreover, a higher number of hours dedicated to study were
associated with the frenetic subtype and a higher number of failed subjects with the
negligent subtype of burnout.42,51 In addition, satisfaction with clinical practices was
related to less emotional exhaustion,62 and vocation for medicine when entering in
the faculty was associated with lower levels of depersonalization and inefficiency.50

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Finally, nursing students who also worked reported higher levels of personal efficacy,
e.g., lower burnout.44
Eleven studies analyzed students’ mental health/psychological issues. Burnout was
significantly associated with depression,43,49,60 anxiety,43 substance use,58 sleep
dissatisfaction47, severity of mental symptoms,66 mental well-being61 and perceived
distress and academic stress.43,48,51,52 Moreover, emotional exhaustion was the only
burnout dimension to predict an adverse impact on psychological well-being.45
Eight studies examined students’ personality traits and psychological variables. Trait
anxiety was associated with burnout.47,49 Higher levels of resilience were significantly
related to lower emotional exhaustion and cynicism and greater perception of
academic efficacy.43,44,52 A longitudinal study observed that students’ level of
resilience and psychological well-being increased over time.45 Moreover, students’
self-esteem was negatively correlated with academic burnout.47,65 In another study,
all clinical subtypes of burnout were associated with lack of psychological flexibility
and absence of self-compassion.51
The association between social/family support and burnout was explored in five
studies. Family support was identified as a protective factor against burnout in one
study50, but not in another.42 Moreover, living alone was a risk factor for the
underchallenged subtype and the absence of family support was for the negligent
subtype of burnout.51 In two studies, living in the family residence was not significantly
associated with burnout.57,62
As for intervention studies, an emotional intelligence workshop was shown to have
beneficial effects to decrease burnout during confinement due to the COVID-19
pandemic.46 In another study relating the five facets of ‘mindfulness’ with the clinical
subtypes of burnout, the worn-out subtype would be the one with the lowest level of
awareness skills.51

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3.4. Quality assessment

Quality assessment of studies was rated as fair in 21 studies, good in three studies
and poor in two studies (Table 2).
Table 2. Quality rating of the studies
Quality
References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total score rating
22
Schaufeli (2007) Y Y N Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
Montero-Marin42 (2011) Y Y Y Y Y N N NA Y NA Y NA NA Y 8/10 (80%) Good
Montero-Marin43 (2014) Y Y Y Y N N N NA Y NA Y NA NA N 6/10 (60%) Fair
Ríos-Risquez44 (2012) Y Y Y Y N Y Y NA Y Y Y NA N Y 10/12(83%) Good
Ríos-Risquez45 (2018) Y Y Y Y N N N NA Y NA Y NA NA N 6/10(60%) Fair
Moreno-Fernandez46 (2020) Y Y NR Y N Y Y NA Y Y Y NA Y N 9/12 (75%) Good
Chust47 (2022) Y Y Y Y N N N NA Y NA Y NA NA Y 7/10 (70%) Fair
March-Amengual48 (2022) Y Y N Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
49
Capdevila-Gaudens (2021) Y Y N Y N N N NA Y NA Y NA NA Y 6/10 (60%) Fair
Gil–Calderón50 (2021) Y Y NR Y N N N NA Y NA Y NA NA Y 6/10 (60%) Fair
51
Martínez-Rubio (2021) Y Y NR Y N N N NA Y NA Y NA NA Y 6/10 (60%) Fair
Merino-Godoy52 (2022) Y Y NR Y Y N N NA Y NA Y NA NA Y 7/10 (70%) Fair
Montiel-Company53 (2016) Y Y Y Y Y N N NA Y NA Y NA NA N 7/10 (70%) Fair
54
Bresó (2007) Y Y NR NR N N N NA Y NA Y NA NA N 4/10 (40%) Poor
Liebana-Presa55 (2018) Y Y NR Y N N N NA Y NA Y NA NA Y 6/10 (60%) Fair
56
Martos (2018) Y Y NR NR N N N NA Y NA Y NA NA N 4/10 (40%) Poor
Amor57 (2020) Y Y Y Y N N N NA Y NA Y NA NA Y 7/10 (70%) Fair
58
Atienza-Carbonell (2022) Y Y N Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
Galán59 (2011) Y Y N Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
60
Galán (2014) Y Y Y Y N N N NA Y NA Y NA NA N 6/10 (60%) Fair
Reverté-Villarroya61 (2021) Y Y NR Y N N N NA Y NA Y NA NA Y 6/10 (60%) Fair
62
Valero-Chillerón (2019) Y Y N Y Y N N NA Y NA Y NA NA N 6/10 (60%) Fair
Vallejo-Martín63 (2017) Y Y N Y N N N NA Y NA Y NA NA Y 6/10 (60%) Fair
64
Figueiredo-Ferraz (2009) Y Y NR Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
González-Cabanach65 (2016) Y Y NR Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
66
Oro (2017) Y Y NR Y N N N NA Y NA Y NA NA N 5/10 (50%) Fair
1. Was the research question or objective in this paper clearly stated?
2. Was the study population clearly specified and defined?
3. Was the participation rate of eligible persons at least 50%?
4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were
inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
5. Was a sample size justification, power description, or variance and effect estimates provided?
6. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if
it existed?
8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the
outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across
all study participants?
10. Was the exposure(s) assessed more than once over time?
11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across
all study participants?

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12. Were the outcome assessors blinded to the exposure status of participants?
13. Was loss to follow-up after baseline 20% or less?
14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between
exposure(s) and outcome(s)?
Total Score: Number of yes; NA: not applicable; NR: not reported; N: no; Y: yes.
Quality Rating: Poor <50%, Fair 50-75%, Good 75%

4. Discussion
This systematic review explored the prevalence and associated factors of burnout
among HSS from universities in Spain. The 26 studies comprised 14,437
participants, the vast majority of whom were women, which was expected given
the ‘feminization’ of medical and healthcare workforce.74,75 Moreover, in the
selected studies there was a representation of students from all years in medicine,
nursing, dentistry, and psychology. Overall, the quality of studies was rated as fair.

4.1. Prevalence of burnout

More than half of participants were medical students, for whom burnout rates
ranged between 22.6% and 40.4%. The prevalence of burnout also varied
substantially across studies of nursing (17-28%) and dentistry students (25.6-
50.9%). Moreover, approximately one out of five HSS presented one clinical
subtype of burnout, the most prevalent being overload and lack of personal
development. The estimates of burnout in other health degrees in Spain remain
less established. Indeed, none of the studies of psychology students provided
standard prevalence rates. Overall, results from HSS in Spain converge with those
of recent meta-analyses which found concerning rates among students of those
health degrees. Pooled prevalence estimates of burnout are 37% - 44% for
medical students,29,30 and about 23% for nursing students.31

In the studies that provided rates of burnout, these ranged from 0% to 63.5%, with
a mean prevalence of 35.3%. This remarkable variability concurs with that
reported in systematic reviews about burnout prevalence among physicians (from
0% to 85%),15 medical students (from 7% to 75%)38 and dental students (from 7%
and 70%).32 This could result from the lack of a consensus on both the definition
and assessment of burnout.3 Some of the studies reviewed here used the classic

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three-dimensional definition of burnout, while others chose a two-dimensional

definition or only measured the dimension of emotional exhaustion. This is
certainly a major weakness in the field. Indeed, a meta-analysis found that at least
142 different definitions of burnout were used across 182 studies.15 Moreover, 10
different assessment instruments were used in the reviewed studies. Comparing
results across studies is problematic, due to the use of different questionnaires,
number of items, definitions, scoring methods and cut-off scores,76 even if the
family of MBI questionnaires is considered only.77

4.2. Factors associated with burnout

The relationship of burnout with students’ gender, year of study and grade (three
non-modifiable variables) was inconsistent across studies. The role of age was
found to be also inconsistent in meta-analyses of HSS.29,30,31 In most studies,
burnout rates increased over the education years, which concurs with previous
evidence.78 This is of much concern when students are transitioning to becoming
healthcare professionals, given that burnout has been related to a worse quality
of healthcare and patient safety.19,20,79 Moreover, social and family support were
expected to help moderate the level of individual vulnerability to burnout,36 but the
few studies examining these variables reached inconsistent results as well.

Notably, the association with academic-related, mental health-related and

personality factors was strong. This is relevant given that all three are modifiable
risk factors. First, burnout was associated with several academic-related factors in
most studies examining that relationship. There is previous evidence that burnout
would depend more on factors related to the academic environment and the
organization of clinical practices than on individual attributes.34 Second, in all
eleven studies, several mental health issues were associated with burnout among
HSS. Indeed, it is known that burnout syndrome can involve the development of
mental symptoms, such as anxiety, depression, low self-esteem, insomnia,
concentration and memory problems, and increased substance use.1,2 There is
growing evidence that a substantial proportion of university students suffer from
MHPs, especially depression and anxiety.80,81 Similarly, all studies examining
students’ personality and psychological factors found significant associations of

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self-stem, trait anxiety and resilience with burnout. As expected, aa higher level of
resilience, conceptualized as the process of adapting well in the face of
adversity,82 operates as a protective factor against burnout.35 Overall, the present
findings among HSS in Spain concur with meta-analytic evidence supporting the
role of educational (e.g., workload, academic satisfaction), and psychological (e.g.,
self-efficacy and personality traits) factors for burnout among HSS.31

4.3. Implications

The substantial rates of burnout among HSS converge with the growing concern
about the high prevalence of MHPs among university students.21,83 The present
findings have also several implications for preventing and managing burnout within
this population in Spain. This is relevant given the negative consequences of
burnout for HSS, including a lower degree of professional values and self-concept
as healthcare professionals, and dissatisfaction with academic
performance.25,26,27,28

As commented above, most associated factors are modifiable. Within the

academic environment, strategies such as changes in the grading system,
promotion of accessibility, quality of mental health programs, and mentoring
programs have been associated with improvements in students’ emotional well-
being.84,85 Faculties should reflect on possible improvements in their curriculum
and organization of clinical practices to promote mental health and emotional well-
being of students.26 We recommend Spanish universities to conduct policies to
change academic conditions aimed to reduce the incidence of burnout among
HSS.

There is a pressing need to clarify why some students become burnout and others
do not.86 Early identification of students at higher risk for burnout should be
implemented. This can involve raising awareness about the magnitude of the
problem and educating students and faculty to identify ‘red flags’ (early signs and
symptoms) of burnout. Moreover, interventions based on mindfulness, stress
management skills, and emotion regulation training could be useful to mitigate the
negative effects of burnout on HSS. In this regard, one of the reviewed studies

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found that increasing students’ emotional intelligence considerably decreased the

prevalence of burnout.46 In addition, meditation and mindfulness has been shown
to reduce psychological distress and increase empathy in medical students. 87,88
Strategies aimed to promoting students’ resilience should also consider the social
and structural factors that may influence individual resilience.82 Lastly, we align
with the recommendations for higher education systems proposed previously,39
such as implementing interventions to promoting students’ mental health and
feelings of competence.

These findings also have some implications for research. Reaching consensus on
the definition of burnout and assessment instruments is also crucial.15 Surprisingly,
the role of unhealthy lifestyle behaviours and neuroticism were not assessed in
the reviewed studies, and both have been shown to increase burnout risk.31,37
Further research is needed.

The present systematic review has several limitations. Firstly, not all the reviewed
studies aimed to estimate the prevalence of burnout, instead were validation
studies of assessment tools of burnout, e.g., the MBI-SS in dental students.53
Secondly, the marked heterogeneity across studies of the present review in
burnout definitions and assessment methods precluded establishing a pooled
prevalence estimate for HSS in Spain. Thirdly, we did not include all health
sciences degrees, e.g., podiatry, logopedic. Related with this, extrapolating the
results of this review to all HSS in Spain difficult, due to unequal proportions
(representation) of the different degrees in the existing studies. Fourthly, most of
the included studies have a cross-sectional design, which makes it impossible to
establish causal relationships. It is thus essential to conduct more longitudinal and
prospective studies to better identify risk/protective factors of burnout in students.
Lastly, nine of the articles were published in Spanish. This was expected given
that the topic under reviewed was confined to Spain. Nevertheless, all of them
were published in peer-reviewed journals and their quality was not inferior to those
published in English.

The strengths of this review include the extensive bibliographic search conducted
in five databases. To our knowledge, there are no published systematic reviews
addressing burnout prevalence and associated factors among HSS worldwide, so

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our work should be seen as a first step in that regard. The present findings provide
an overview of these topics in a specific European country. This is relevant given
that burnout prevalences can vary greatly across the international literature,
depending on country-specific factors, among other factors.38

In sum, our review suggests that burnout seems to be prevalent among health
sciences students in Spain, and can be affected by academic, mental health-
related and personality factors. Methodological limitations precluded to estimating
the pooled prevalence of burnout among HSS in Spain. Further research is
warranted to identify risk and protective factors of burnout, to ultimately develop
preventive and management strategies in this population.

CRediT authorship contribution statement

Conceptualization and methodology, Z.M.O.-B., and V.B.-M.; literature review,

Z.M.O.-B., J.V.S.-O. and V.B.-M.; writing – original draft preparation, Z.M.O.B.,
and V.B.-M.; writing – review & editing, J.V.S.-O., and E.H.G.; supervision, V.B.-
M. All authors have read and agreed to the current version of the manuscript.

Conflict of interest declaration:

In the past 3 years, VB-M has received honoraria from Angelini, unrelated to the
present work. The remaining authors do not have conflicts to report.

Date of last literature review:

January 5th, 2023

Word count (main text): 4117

Word count (abstract): 228

Number of tables: 2
Number of figures: 1

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