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Nurse Education Today 33 (2013) 314–320 Contents lists available at SciVerse ScienceDirect Nurse Education Today journal homepage: The calm before the storm? Burnout and compassion fatigue among undergraduate nursing students Barret Michalec a,⁎, Cynthia Diefenbeck b, Margaret Mahoney a a b Department of Sociology, University of Delaware, United States School of Nursing, University of Delaware, United States a r t i c l e i n f o Article history: Accepted 23 January 2013 Keywords: Burnout Compassion fatigue Undergraduate nursing students Nursing education Clinical experiences s u m m a r y Studies have consistently highlighted the deleterious impact of burnout and compassion fatigue on professional nurses' well-being and willingness to remain in the profession. Yet, as to what extent these noxious conditions are suffered among nursing students is still unclear. In this study 436 undergraduate nursing students completed surveys assessing their experiences of emotional exhaustion, depersonalization, lack of personal accomplishment, burnout, secondary traumatic stress, and compassion satisfaction (factors of burnout and compassion fatigue). There were no significant differences found between 3rd and 4th year students' reports of detrimental conditions and those of the 1st or 2nd year students. Furthermore, 4th year students reported significantly higher levels of personal accomplishment compared to 1st and 2nd year students. Semi-structured in-depth interviews with 3rd and 4th year students revealed that their clinical exposure during these years (especially during the 4th year) may enhance their other-orientation as well as promote role actualization, which may serve as protective features. Students did, however, express concern regarding an inevitable onset of burnout at some point during their professional careers. It is suggested that a key to understanding the onset and experience of burnout and compassion fatigue among nurses is to continue to examine the transition from student to professional nurse and the cultural atmosphere of nursing education compared to professional practice. © 2013 Elsevier Ltd. All rights reserved. Introduction Extensive research has shown that deleterious conditions such as burnout and compassion fatigue negatively impact nurses' wellbeing, job satisfaction, and willingness to remain in the profession (Kalliath and Morris, 2002; Stewart, 2009). Moreover, there is evidence to suggest that burnout and compassion fatigue experienced among professional nurses can affect patients' satisfaction of the care they receive (Leiter et al., 1998), and a recent study by Cimiotti et al. (2012) suggests an association between experienced burnout among nurses and negative patient outcomes. Previous research has spotlighted particular social, environmental, and structural conditions in the workplace that can trigger and/or exacerbate burnout and compassion fatigue among nurses, such as: the nature of caring work (Aycock and Boyle, 2009), lack of social, collegial, and administrative support (Eastburg et al., 1994), workload/shift-related issues (Aiken et al., 2002), and demands of certain specialties (McHugh et al., 2011). It is important to note, however, that nursing students, even those at the undergraduate level, are exposed to these issues as well, especially ⁎ Corresponding author at: Department of Sociology, University of Delaware, 309 Smith Hall, 18 Amstel Ave, Newark, DE 19716, United States. Tel.: +1 302 831 8231; fax: +1 302 831 2607. E-mail address: (B. Michalec). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. during the more clinically-oriented years of training (i.e., 3rd and 4th years). Although Deary et al. (2003), in their longitudinal study of nursing students, showed significant association between certain personality characteristics and reports of emotional exhaustion and depersonalization (fundamental components of burnout), and a number of studies have suggested that novice nursing professionals are especially vulnerable to burnout (Maslach et al., 2001; Laschinger et al., 2009), little attention has been paid to if, and to what extent, undergraduate nursing students suffer from burnout and/or compassion fatigue. If there is a connection between the clinical setting and burnout and compassion fatigue, as previous research suggests, then it is possible that even nursing students are at risk for these noxious conditions because of clinical exposure during their education. During various types of clinical experiences (either through curriculumrelated clinicals or through independently sought externships) nursing students are frequently confronted with real-life trauma situations and similar (if not the same) workplace environment and climate as professional nurses (Ralph et al., 2009; James and Chapman, 2009; Melincavage, 2011). Because burnout and compassion fatigue are such a detriment to nurse well-being and the nursing workforce overall, it is essential to uncover if and to what extent nurses-in-training may be suffering from these debilitating affective/cognitive states. By spotlighting specific mechanisms that may trigger or exacerbate burnout and compassion fatigue, interventions can be implemented to protect these B. Michalec et al. / Nurse Education Today 33 (2013) 314–320 students and perhaps matriculate a resilient and emotionally fortified nursing workforce. This specific study addresses the following research questions: a) Is there evidence of burnout and/or compassion fatigue among undergraduate nurses? b) Are there significant differences between grade cohorts' reports of burnout and compassion fatigue? c) What impact does clinical exposure have in the experiences of burnout and compassion fatigue among undergraduate nursing students? This study is meant to provide further insight into the experiences of undergraduate nursing students and their potential encounters with emotional exhaustion and burnout so that nursing school instructors and administrators may be more informed in their mentoring, curriculum development, and overall preparation of the next generation of professional nurses. Methodology Study Setting The University of Delaware School of Nursing (SON), located in the U.S., offers nationally accredited programs including the traditional BSN, Accelerated BSN, RN to BSN and RN to MSN, MSN, and PhD programs in nursing. The traditional BSN program is a four year program that enrolls approximately 130 students per year. The vast majority of students are admitted directly to the nursing major, although a small percentage enter as change of major students at some point during the 1st year. First time NCLEX-RN pass rate percentages are in the low 90s. The student body is comprised of approximately 92% female and 90% Caucasian students. The Clinical Immersion Model is a novel curriculum model that was pioneered at the University of Delaware SON in 2004 (Diefenbeck et al., 2006) and has demonstrated positive results in student-centered outcomes over the long-term (Diefenbeck et al., 2011). This BSN curriculum model differs from other U.S.-based nursing programs. In most other U.S. programs, “traditional” clinical experiences (instructor-led, hospital-based clinical rotations) are typically spread out over multiple years and concurrently held with didactic course content. In this unique model of BSN education, all clinical rotations take place in the 4th year following mastery of didactic content in preceding years. The concentration of clinical rotations into one year results in a more intense clinical experience for the student. Intended benefits of the “clinical immersion model” include enhanced patient safety and promotion of transition to professional nursing practice (Diefenbeck et al., 2006). Surveys First, second, third, and fourth year traditional (non-accelerated) undergraduate nursing students were given a questionnaire at the end (May) of the 2010–2011 academic year. Surveys were administered to each cohort during mandatory classes in the spring semester by either the lead author or a trained graduate student, neither of whom were affiliated in any way with the School of Nursing. The use of human subjects was obtained through IRB approval of this study. Students were explicitly made aware of the voluntary nature of the study when the researcher distributed the survey, and the survey contained an informed consent form that required the students' signature (expressing their willingness to participate). A total of 436 BSN nursing students completed the questionnaire (out of 546 enrolled), 123 first-year, 98 second-year, 97 third-year, and 118 fourth-year. Of the sample, 85% of the students were white, 5% were Black, 4% were Asian, 3% were Latino(a), 1% were Bi-racial, 1% were Indian, and less than 1% considered themselves to be Native American or of an “other” race. Females and males comprised of 93% and 7% of the sample respectively. Ages of the participants ranged from 18 to 58, with the average age being 20. Participants who 315 were 18–22 years of age made up 91% of the sample, 7% were between 23 and 29, and 2% reported their age between 30 and 58. Measures The Maslach Burnout Inventory (Human Services Survey) (MBI-HSS) is a valid, reliable, and widely used tool (Maslach and Jackson, 1986; Maslach et al., 1996) that measures experienced burnout through scores on three subscales: emotional exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). The EE subscale measures how one's work may lend to feelings of being emotionally overextended and exhausted. The DP subscale assesses an “unfeeling” and the tendency to see recipients of one's care as objects instead of humans. The PA subscale addresses feelings of competence, achievement, and productivity in one's work with people. Students were asked to report how often they had experienced particular statements from Never (0) to Every Day (6). As noted earlier, a high degree of burnout is reflected in high scores on the EE and DP subscales and in low scores on the PA subscale. The Professional Quality of Life (ProQOL) scale, version 5, is a valid, reliable, and widely used tool (Stamm, 2009) that assesses compassion satisfaction, as well as compassion fatigue (through subscales measuring burnout and secondary traumatic stress). Compassion satisfaction is characterized by feeling content and pleased with one's job and from one's acts of caring. Individuals high in compassion satisfaction feel invigorated by the helping they do. Compassion fatigue is characterized by a sense of severe malaise, being overwhelmed, and being generally down-trodden by providing care to those who have experienced significant trauma and stress (physical, emotional, and/or social). Aspects of compassion fatigue, according to Stamm (2009), are Burnout (sense of disconnectedness, and being “out-of-touch” with oneself), and Secondary Traumatic Stress (an unhealthy rumination of and preoccupation with thoughts of people one has cared for and treated, as well as a sense of being trapped and infected by others' trauma). Students were asked to consider their current work/school situation and select how frequently they experienced certain statements from Never (1) to Very Often (5). Each subscale of the MBI-HSS and the ProQOL has been shown to have excellent internal consistency (Maslach et al., 1996; Stamm, 2009 1). Table 1 features the details of each of the scales utilized in this study. Interviews In-depth, semi-structured interviews were conducted specifically with 3rd and 4th year undergraduate nursing students to gain a better understanding of how nursing students experience the more clinically-oriented years of their training, and if particular experiences may have had any impact on their perceived burnout and/or compassion fatigue. First and second year students were excluded from the interviews because their nursing curriculum/education is almost exclusively in the classroom setting and although these students may engage in clinically-oriented internships or shadowing opportunities on their own, it is not required by the institution. Therefore, 3rd and 4th year students were considered to have extensively more experience in the clinical setting that they could speak of (as compared to 1st and 2nd year students). These interviews were conducted towards the end of the school year (April/May 2011) by a trained qualitative researcher (the lead author) who was not a faculty member of or affiliated with the School of Nursing. Each interview participant was interviewed individually and each interview was recorded using a digital voice recorder and permission to use the recorder was requested from every subject prior to recording. At the onset of the interview participants were reminded of the voluntary nature of the interview and that they could choose not to answer any question 1 Please see these specific articles for detailed explanations of the scales tested reliability and validity. Compassion fatigue & compassion satisfaction Professional Quality of Life Scale (ProQOL) Burnout; secondary traumatic stress; compassion satisfaction Total of 30 Likert self-report: burnout (10) (α = .75, n = 976); secondary traumatic stress (10) (α = .81, a = 1135); compassion satisfaction (10) (α = .88, n= 1130) Items for each subscale are summed to acquire raw score. Range/classifications EE: 27 or over (high); 17–26 (moderate); 0–16 (low). DP: 13 or over (high); 7–12 (moderate); 0–6 (low).PA: 0–31 (low); 32–38 (moderate); 39 and over (high). 22 or less (low); 23–41 (average); 42 or more (high). Scoring Items for each subscale are summed. PA scores are interpreted in the opposite direction from EE and DP. Subscales Construct(s) Burnout Scale Maslach Burnout Inventory Index (MBI) Table 1 Summary of scales used. Emotional exhaustion (EE); depersonalization (DP); personal accomplishment (PA) Items B. Michalec et al. / Nurse Education Today 33 (2013) 314–320 Total of 22 Likert self-report: EE (9) (α = .90, n = 1316); DP(5) (α = .79, n= 1316); PA (8) (α = .71, n = 1316) 316 during the interview and could withdraw at anytime. 2 Interviews were conducted at local coffee shops and eateries. Participants were offered coffee, tea, or lunch as compensation for their time. Recruitment of Interview Participants When completing the consent form for the survey, students were asked to enter their email address if they were interested in participating in a brief interview regarding their experiences during their training. Ten 3rd year and ten 4th year students were selected at random from the list of students willing to participate. 3 Once the 20 participants had been randomly selected they were sent an email reminding them of their willingness to participate in the interview and asking if they were still willing to do so, and that the interview was completely voluntary. Of the original 20 contacted, only 2 declined (both cited school work-related issues), and therefore 2 other students were randomly selected (from the list of those willing to participate) and contacted, both of whom agreed. Of the 20 participants that were interviewed, 16 were female, 4 were male, 15 were white, 2 were Black, 2 were Latina, and 1 was Asian. Their ages ranged from 20 to 22. Statistical Analyses and Interpretation of Qualitative Data Survey data were entered and analyzed using SPSS 19.0. Basic means and standard deviations were calculated for variables to explore/describe the sample. The internal consistency (Conbach's α) for each subscale was also calculated. One-way ANOVAs were conducted to explore significant differences in means of each subscale between each grade cohort. Any significant differences in means were subjected to post-hoc tests (Games–Howell) to confirm between which specific cohorts the differences occurred. Interview data were transcribed into Word files and uploaded into NVivo 9. Interview data were analyzed using a multi-step coding process. Interviews were initially coded on the following deductive codes extracted from the survey and previous literature: clinical experiences, stress, burnout, emotions (positive), emotions (negative), interactions with patients, interactions with health care staff, among others. Inductive codes, however, such as nurse identity, perceptions of nursing, “being” a nurse, transition from student, among others, were identified through multiple readings of interview transcripts and the initial deducting analysis procedures. These deductive and inductive codes were then utilized in tandem to identify frequently appearing themes nested within the data. This coding process yielded several general themes and these themes were then employed as codes and all interview data were analyzed extensively to continually extract processes behind themes. Three specific themes emerged from these processes, enhanced “otherness”, role actualization/fulfillment, and burnout on the horizon. For example, regarding the theme enhanced “otherness”, deductive and inductive codes such as emotions, interactions with patients, nurse identity, and other-orientation (among others) were found to frequently converge — often relating to the notion of students' increased sense of wanting/enjoying/desiring to care for others (i.e. patients, family, and even friends). This general theme was then utilized as a code and the entirety of the data was analyzed again to further specify the intricacies of the theme and how participants were truly discussing the issue. When it was felt that the data related to the theme had been fully extracted and dissected (i.e. saturation had been reached) the theme was then reformatted to reflect its 2 Each of the participants completed a full interview. Of the 215 3rd and 4th year students that completed the survey 137 (65 3rd years and 72 4th years) expressed interest in being interviewed. No significant differences were found (regarding reports of Burnout or Compassion Fatigue) between those that were willing to participate and those that were not. Random selection of participants was conducted by selecting every 7th name on the list until ten 3rd years and ten 4th years had been selected. 3 B. Michalec et al. / Nurse Education Today 33 (2013) 314–320 317 Table 2 Comparison of means between grade cohorts for each subscale. MBI ProQOL Emotional exhaustion (n = 430) Depersonalization (n = 422) Personal accomplishment (n = 434) Burnout (n = 416) Secondary traumatic stress (n = 422) Compassion satisfaction (n = 424) 1st years 18.16 (8.42) moderate 2nd years⁎⁎ 3rd years⁎ 5.94 (4.63) low 32.85 (8.59) moderate 4th years⁎⁎ 30.44 (4.41) average 2nd years⁎ 20.58 (6.71) low 42.39 (6.75) high 2nd years 22.73 (10.64) moderate 1st years⁎⁎ 22.32 (10.01) moderate 1st years⁎ 19.46 (9.50) moderate 6.68 (5.51) low 32.71 (10.38) moderate 4th years⁎ 34.71 (5.79) moderate 32.19 (5.01) average 1st years⁎ 31.58 (3.36) average 20.84 (6.60) low 43.30 (6.07) high 20.44 (4.88) low 42.73 (5.36) high 5.21 (4.18) low 36.23 (6.77) moderate 1st years ⁎⁎ 2nd years⁎ 30.69 (3.28) average 19.40 (5.07) low 43.42 (5.17) high 0.88 0.69 0.88 0.48 0.82 0.90 3rd years 4th years Cronbach's α 5.79 (5.33) low ⁎ p b .05. ⁎⁎ p b .01. now more concise/succinct nature, enhanced “otherness”. Each of the themes is discussed in the section that follows. To ensure a satisfactory level of inter-coder reliability the authors met at the beginning and end of each stage of analysis to discuss findings, memos, and notations. Differences between team members regarding particular findings were openly discussed and decisions were based upon consensus. Results Quantitative Findings The means and standard deviations (shown in parentheses) for each subscale for the sample are featured in Table 2. These means were then compared to the cut-off scores for each of the MBI and ProQOL subscales (Maslach et al., 1996; Stamm, 2009). As Table 2 shows, all students, regardless of year, reported moderate/average levels of emotional exhaustion, personal accomplishment, and burnout, low levels of depersonalization and secondary traumatic stress, and high levels of compassion satisfaction. Table 2 also depicts on which subscale grade cohorts differed significantly. One-way ANOVA calculations showed significant differences in mean scores for emotional exhaustion (MBI) (F(3, 426) = 5.45, p = .001), personal accomplishment (MBI) (F(3, 430) = 4.63, p = .003), and burnout (ProQOL) (F(3, 412) = 3.99, p = .008). Following tests for homogeneity, post-hoc analyses (Games–Howell) revealed that 1st year students reported significantly lower levels of emotional exhaustion compared to 2nd and 3rd year students (see Table 2). Similarly, 1st year students reported significantly lower levels of burnout compared to 2nd year students. Interestingly, 4th (and 3rd) year students did not report significantly higher levels of any of the noxious emotional/cognitive conditions. However, 4th year students did report significantly higher levels of personal accomplishment as compared to 1st and 2nd year students. b) evidence of role actualization/fulfillment, c) predictions of burnout on the horizon. The themes presented are representative of the consensus of statements made by participants, and verbatim quotations are offered as a selection of exemplary evidence of each theme. Table 3 presents the themes identified in the data, the frequency of which they were referenced by participants, and the degree of coder agreement regarding their presence in the data (prior to consensus being reached). 4 These themes will be presented separately, with examples, but will be elaborated on more fully in the Discussion section. The Enhancement of “Otherness” When questioned whether their clinical experiences had affected them emotionally in any way students frequently noted that they felt as though they had become more empathic, caring, and compassionate towards others, especially patients, and that their emotional connections with others had actually grown and been enhanced. “Just being around nurses I think, and other people that have similar interests, I've become a more caring person I think. I've always been very nice and affectionate and stuff but I think I've become so much more that way and to the point that I see people and I feel like they're not just people passing by, I feel like I connect with more people. I think it happened gradually, but definitely (pause), actually it happened ever since probably two summers ago when I started working in the clinical setting. I think just the patient experience has made me become a more caring person.” (4th year) “You develop these relationships with the patients (pause) and it's, you have, you have that compassion for them. It's so much stronger than I have ever imagined. So I think, I think that's been the biggest change or difference that I have experienced because of my field experiences.” (3rd year) Qualitative Findings As noted earlier, interviews with 3rd and 4th year students were used to attain a better understanding of their clinical experiences and how their interactions and ordeals in the clinical setting may impact and/or exacerbate burnout and/or compassion fatigue. Three main themes were identified in the interview data, especially relating to the students' clinical experiences: a) the enhancement of “otherness”, 4 Regarding Table 3, Sources identifies the number of individual participants where the theme was identified and Total References represents the number of times it was identified throughout all the interview data. The percentage of coder agreement appears in parentheses. This original percentage was calculated by summing the total number of references (of one specific theme) identified by all coders, then tallying all the concordant identifications among the coders and dividing the concordant sum by the total sum. 318 B. Michalec et al. / Nurse Education Today 33 (2013) 314–320 Table 3 Frequency of themes and percentage of coder agreement. Theme Sources Total references The enhancement of “otherness” Role actualization/fulfillment Burnout on the horizon 18 (100%) 18 (100%) 17 (100%) 76 (92%) 64 (87%) 61 (91%) Role Actualization/Fulfillment A key finding within the qualitative data was that students, especially 4th year students, felt that the clinical experiences made them feel as though they were actually nurses; that they were “doing” what they had been learning. Students spoke of how engaging in their clinical responsibilities provided them with a sense of fulfillment and actualization of their role as nurses, and that this engagement with their future professional role had beneficial effects. “We're just finally expected to be nurses. So much responsibility, you know, it's like they've given us every, all the information, everything that we need to know and now we're using it. Real patients are so much better than mannequins (laughs). But, so, I mean, it's actually what we're doing with our lives so it's exciting to see. It's fun to be actually doing what we've learned on real people. Everthing's kind of coming together. I have felt like a nurse.” (4th year) “It's weird, you know. I didn't actually feel like a nurse last fall semester, I was just like ‘Oh, I'm a student. Whatever’. I got into the last semester of rotations and the preceptorship and I was like ‘Wow’, and now I feel kind of confident about what I'm learning and what I am doing here.” (4th year) Burnout on the Horizon Although the interview data suggests that there are many positive emotional and psychological effects to clinical experience, these nursing students did talk about anticipating experiencing burnout at some point during their professional careers as though it was inevitable. “I mean, I feel like it's [burnout] coming. You know what I mean? I'm not feeling it, not at all, but maybe someday. I mean, I don't feel it now, but I sense that it can happen and I can see it happen.” (4th year) “I work at an ICU step-down so we have pretty bad-off patients, and it's like really intense. The emotional side, I mean I get, I work every other weekend, and I have to mentally prepare myself so much just to like go into the work place. Afterwards, I'm just so wore out, I can't go out with my friends afterwards, I have to just come home and sleep. It's intense. You see like families upset and then the patients are depressed, and I think that's the part that's kicking in.” (3rd year) Discussion As depicted in Table 2, nursing students reported experiencing emotional exhaustion, depersonalization, burnout, and secondary traumatic stress (i.e. burnout and compassion fatigue), but only at low and moderate/average levels. It should be noted, however, that the cut-off scores used for comparison (i.e. low, moderate, high) are calculated from thousands of scores reported by professionals in the human services fields (i.e. medicine, nursing, education, social work, psychiatrists, ministers, librarians, and many others) (Maslach et al., 1996; Stamm, 2009). So, even though these students are reporting moderate/average and low levels, they are low and moderate/average levels of a “professional-grade”. From this perspective, this study may provide evidence that these detrimental experiences do take shape for nursing students as early as the beginning stages of their training. Perhaps most interesting is that there was minimal evidence of significant differences in the reports of these deleterious conditions found between the more clinically-oriented grade cohorts (3rd and 4th year students, especially 4th years) and the more classroomoriented grade cohorts (1st and 2nd year students). Although 3rd year students were found to report significantly higher levels of emotional exhaustion compared to 1st years, there were no significant differences reported in the feelings of depersonalization, burnout, or secondary traumatic stress. That is to say, there were no significant differences in the reports of burnout or compassion fatigue between the grade cohorts suggesting that perhaps the frequency and intensity of clinical experience during nursing school may not be the mechanism by which these conditions are incubated. Whereas 4th year students did not report significantly higher levels of burnout or compassion fatigue, they did report significantly higher levels of personal accomplishment compared to 1st and 2nd year students. Although this particular finding should be viewed with some skepticism 5 it does suggest that perhaps there are emotional and psychological benefits to clinical experiences for advanced nursing students. This notion was echoed in the qualitative data. Although many interview participants did note that clinical experiences were stressful at times the interview data strongly suggests that experiences in the clinical setting (during their nursing school years) may not be the prime mechanisms that instigate burnout and compassion fatigue. From these particular data it appears that these experiences have advantageous qualities that amplify other-orientation, as well as offer opportunities for students to further embrace their role as “nurses”. There is reason to believe, however, that this enhanced otherness could be a culprit of future burnout and compassion fatigue as Ward et al.'s (2012) recent study suggests that increased exposure to patient encounters actually led to the decrease in empathy they found among undergraduate nursing students. Moreover, Miller et al. (1988), Williamson (1989), and Omdahl and O'Donnell (1999) have shown that for human service providers (such as those within the health care fields) there are consequences (e.g., burnout) to exposing oneself to the emotions of others. Given that the students in this specific study were exposed to the clinical setting mainly in their 4th year, perhaps the negative effects of clinical experiences have yet to take shape. Future research must follow students into their professional domains in order to fully understand possible shifts in their compassion and/or empathy levels. Students also noted how their clinical experiences provided them a venue to actually “do” nursing, to practice the skills they had been learning in the lecture halls and simulation labs, and that these opportunities not only increased their appreciation for the encompassing nature of the nurse's role in health care delivery, but also opened their eyes to vast responsibilities that a nurse must consider in patient care. These experiences appeared to reconfirm their enjoyment and enthusiasm for their future profession, rather than whittle away at their positive attributes and exacerbate feelings of burnout or compassion fatigue. However, the role of the student (as compared to a professional nurse) may provide a “safety net” in terms of patient responsibility and the effects on well-being that may accompany such responsibilities. Although 4th year students are expected to perform duties and 5 This finding could be attributed to self-reporting errors, selection bias, and/or the fact that 4th year students were mere weeks from graduation when the survey was administered. B. Michalec et al. / Nurse Education Today 33 (2013) 314–320 tasks similar to those required of professional nurses, it is understood (by all parties, including the student) that they are, in fact, still students, and that the full burden of the patient's health outcomes falls on the professional staff. In this sense, the mantle of “the student” provides a safety net for the student to perform the tasks and duties expected of them while remaining somewhat shielded from the negative side-effects of such activities (i.e., burnout and compassion fatigue). During the interviews, students even noted this safety net. For example, “But they're [professional nurse/preceptor] supposed to oversee, like make sure you did everything, and do it too. They're supposed to have looked at it too, they don't just trust the students cause we, we're not experienced yet.” (4th year) “I don't think I really know how to deal with it all once it gets real. You know? I just, I get nervous because once it comes like full time that's when it (pause) I'm not going to be able to like steal away for two weeks, it's going to be like every day.” (4th year) This last statement reflects not only the safety net aspect of being in training, but also points to the foreseeable difficulties of transitioning to the professional realm. As noted above, students could sense the problems they would face as professional nurses, and spoke of how experiences like burnout and compassion fatigue were on the horizon post-graduation. The interview participants offered specific stories where they felt vulnerable, as though their emotions were exposed, and that if these experiences were to be more regular that serious detriment to their emotional and mental health was expected. In this sense, clinical experiences during nursing school may represent a mere calm before the storm — foreshadowing lurking dangers. Taken together, the quantitative and qualitative data suggest that although clinical experiences during nursing school may subject students to whispers of burnout and compassion fatigue, they also provide students with an arena to actualize their future professional role while simultaneously providing a safety net that may protect them from practice-based errors and limit their susceptibility to these deleterious conditions. This study did not yield evidence to suggest that concerning levels of burnout and compassion fatigue are experienced among more clinically-oriented nursing students, but these data do present the possibility that the seeds of such conditions are planted during these formidable years of training. Imperative next steps must be taken to explore how burnout and compassion fatigue are experienced in the transition between nursing student and nurse professional. Kramer et al. (1972) noted that the educational and professional systems (for nursing) are “antithetical” and the conflict between these systems, and the attempts to negotiate the transition between them, may have detrimental impact on nurses' physical, emotional, and mental health. Furthermore, Rudman and Gustavsson (2011) found that during the first three years of practice, every fifth nurse reports feeling “burned out” at some point, and that the second year of practice seems to be particularly stressful. Recently, these authors (Rudman and Gustavsson, 2012) did find an increase in exhaustion, disengagement, and study burnout among Swedish nursing students across the years of their education, and that study burnout was indeed related to poorer work-related outcomes (i.e. mastery of occupational tasks, research utilization, and turnover) one year post graduation. This transition from student to professional appears to be a particularly sensitive and vulnerable time (Duchscher, 2009; Laschinger et al., 2009). If the seeds of burnout and compassion fatigue are indeed planted during nursing school, the transition from student to professional may be the fertile ground where social, cultural, and environmental cues stimulate the growth of these noxious conditions. In this sense, increased emphasis on the need for residency or other 319 transition-to-practice programs may be another key to nurse burnout prevention, early detection, and intervention. There are limitations with this study. Only one school of nursing was studied, and this particular school has a very unique curriculum in regards to when students are fully immersed into the clinical setting. Future research should examine the rates of burnout and compassion fatigue reported among students from nursing schools that put students in clinical rotations during their 1st and 2nd years. Similarly, the data gathered for this study stems from a very homogenous (young, white, female) sample, and therefore may not be representative of all nursing students. Furthermore, this data is cross-sectional, providing a mere snap shot of the presence (or lack thereof) of burnout and compassion fatigue in nurse training. Future research interested in dissecting the if, when, and how regarding the onset of burnout and compassion fatigue should employ a longitudinal approach, following one specific class through their years of training and into professional practice. Finally it should be noted that although the internal consistency (α) for ProQOL's subscale of burnout has been shown to be .75 (n = 976) (see Table 1), within this particular study it was only shown to be .48, thereby lending some skepticism to the findings related to this particular subscale. Conclusion Given the detrimental impact burnout and compassion fatigue can have on nurse well-being and attrition, this study examined if/how these conditions are reported among undergraduate nursing students. It was found that nursing students (of all grade cohorts) reported only low to moderate/average levels of burnout and compassion fatigue, and no significant differences were found between the grade cohorts. Furthermore, all students reported high levels of compassion satisfaction, and 4th year students reported significantly higher levels of personal accomplishment compared to 1st and 2nd year students. Interview data suggests that clinical experiences may not only enhance 3rd and 4th year nursing students' other-orientation but also provide opportunities for these students to further actualize their future professional role while still feeling “protected” by the safety of being in-training. Taken together, these aspects of clinical training may shield 3rd and 4th year students from the negative emotional and psychological side effects of health care delivery, at least to some extent. Perhaps what is experienced during these formidable years of training is a “calm before the storm”. It is suggested that future research should not only explore individual differences/attributes that may relate to experienced burnout and compassion fatigue, but also pay special attention to the potential onset and/or enhanced experience of burnout and compassion fatigue (and the structural-, interactional-, and individual-based mechanisms behind these experiences) during the transition from student to professional, and the early stages of nurses' professional career, times when they may be most vulnerable and lack valuable social support. Acknowledgments This project was carried out with the support of the University of Delaware General University Research Fund. The authors would also like to thank Rachel Lee, BSN, and Randy Lascaro, BSN, for their assistance with many aspects of this study. References Aiken, L., Clarke, S., Sloane, D., Sochalski, J., Silber, J., 2002. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association 288 (16), 1987–1993. Aycock, N., Boyle, D., 2009. Interventions to manage compassion fatigue in oncology nursing. Clinical Journal of Oncology Nursing 13 (2), 183–191. Cimiotti, J.P., Aiken, L.H., Sloane, D.M., Sloane, D.M., Wu, E.S., 2012. Nurse staffing, burnout, and health care-associated infections. American Journal of Infection Control 40, 486–490. 320 B. Michalec et al. / Nurse Education Today 33 (2013) 314–320 Deary, I.J., Watson, R., Hogston, R., 2003. A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing 43 (1), 71–81. Diefenbeck, C., Plowfield, L., Herrman, J., 2006. Clinical immersion: a residency model for nursing education. Nursing Education Perspectives 27 (2), 72–79. Diefenbeck, C., Wade, G., Hayes, E., Herrman, J., 2011. Student-centered outcomes evaluation of the clinical immersion program: five years later. Journal of Nursing Education 50 (11), 628–635. Duchscher, J.E.B., 2009. Transition shock: the initial stages of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing 65 (5), 1103–1113. Eastburg, M., Williamson, M., Gorsuch, R., Ridley, C., 1994. Social support, personality, and burnout in nurses. Journal of Applied Social Psychology 24 (14), 1233–1250. James, A., Chapman, Y., 2009. Preceptors and patients - the power of two: nursing student experiences on their first acute clinical placement. Contemporary Nurse 34 (10), 34–47. Kalliath, T., Morris, R., 2002. Job satisfaction among nurses: a predictor of burnout levels. Journal of Nursing Administration 32 (12), 648–654. Kramer, M., McDonnell, C., Reed, J.L., 1972. Self-actualization and role adaptation of baccalaureate degree nurses. Nursing Research 21 (2), 111–123. Laschinger, H.K., Finegan, J., Wilk, P., 2009. New graduate burnout: the impact of professional practice environment, workplace civility, and empowerment. Nursing Economics 27 (6), 377–383. Leiter, M., Harvie, P., Frizzell, C., 1998. The correspondence of patient satisfaction and nurse burnout. Social Science & Medicine 47 (10), 1611–1617. Maslach, C., Jackson, S., 1986. The Maslach Burnout Inventory Manual, 2nd ed. Consulting Psychologists Press, Palo Alto, CA. Maslach, C., Jackson, S.E., Leiter, M.P., 1996. Maslach Burnout Inventory Manual, 3rd ed. CPP, Inc, Mountain View, CA. Maslach, C., Schaufeli, W.B., Leiter, M.P., 2001. Job burnout. Annual Review of Psychology 52, 397–422. McHugh, M., Kutney-Lee, A., Cimiotti, J., Sloane, D., Aiken, L., 2011. Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs 30 (2), 202–210. Melincavage, S.M., 2011. Student nurses' experiences of anxiety in the clinical setting. Nurse Education Today 31, 785–789. Miller, K., Stiff, J., Ellis, B.H., 1988. Communication and empathy as precursors to burnout among human service workers. Communication Monographs 55, 250–265. Omdahl, B.L., O'Donnell, C., 1999. Emotional contagion, empathic concern and communicative responsiveness as variables affecting nurses' stress and occupational commitment. Journal of Advanced Nursing 29 (6), 1351–1359. Ralph, E., Walker, K., Wimmer, R., 2009. Practicum and clinical experiences: postpracticum students' views. Journal of Nursing Education 48 (8), 434–440. Rudman, A., Gustavsson, J.P., 2011. Early-career burnout among new graduate nurses: a prospective observational study of intra-individual change trajectories. International Journal of Nursing Studies 48, 292–306. Rudman, A., Gustavsson, J.P., 2012. Burnout during nursing education predicts lower occupational preparedness and future clinical performance: a longitudinal study. International Journal of Nursing Studies 49, 988–1001. Stamm, B.H., 2009. The Concise ProQOL Manual., Pocatell, ID. Stewart, D., 2009. Casualties of war: compassion fatigue and health care providers. MEDSURG Nursing 18 (2), 91–94. Ward, J., Cody, J., Schaal, M., Hojat, M., 2012. The empathy enigma: an empirical study of decline in empathy among undergraduate nursing students. Journal of Professional Nursing 28 (1), 34–40. Williamson, C.A., 1989. Empathy and burnout in male and female helping professions. Research in Nursing and Health 12, 169–178. Rev. 042718 Appendix B Each student will be assigned to a group. This is not a group assignment but rather a way for all the questions to get answered adequately. The students from each group will lead the discussion for the assigned question. Each student will respond individually to the assigned question and another question of their choosing (try to not pick the one everyone else is posting on). Recap: Students must answer the assigned question and pick one other question and respond to it as well. Each student will post at least twice. You will need to post the response to your assigned question by Friday of each week so that other students will have a chance to read your response and ask questions also. You are welcome to add additional responses, however each response should be meaningful and not just a repeat of another response or thanking someone for the explanation. Each discussion will be assigned points based on quality of answer not just quantity--refer to the rubric for grading of discussion. I will reassign the groups and questions each week. The discussion will be closed to posting on Wednesday after the homework due date. Note that the criteria for 20 points includes citing additional references related to the topic. Excellent summaries of these topics in the texts and other on-line materials are available on the Internet. Finding and reading these additional sources may help you understand these concepts more fully. Be sure to cite the spot where you found the additional information, so the rest can find it, if we would like to read more about that concept or others. RUBRIC FOR GRADING DISCUSSION Promptness and Initiative speaks to the student’s ability to participate in discussions in a timely fashion which demonstrates self-motivation. It permits commentary on whether or not the student is actively and consistently engaging in the course content. Delivery of Post addresses the student’s attention to detail in terms being grammatically correct with rare misspellings. The category, Relevance of Post, permits an objective assessment of the student’s ability to post topics that are relevant to the original discussion with acknowledgement of references if provided. It addresses the student who stays on topic as well as the student who appears to disengage from the course content. Expression within the Post addresses the issue of how well opinions are expressed and how ideas or comments are presented. This category also allows the facilitator to acknowledge the different writing/expression styles of the students. Lastly, the category, Contribution to the Learning Community (LC), speaks to the assessment of whether or not the student makes an effort to further the development of a collaborative learning experience. It provides distinction between the student who seems relatively indifferent to the building process of a LC and the student who strives to reinforce the LC as the course develops. The rating scale ranges from 0 to 4 with 0 being indicative of student participation which is less than acceptable for the development of a progressive learning community. A score of 4 in any category represents the attainment of the highest standard of participation and reflects a bonafide contribution to the learning community. Adapted from: Edelstein, S. & Edwards, J. (2002). If you build it, they will come: Building learning communities through discussions. Online Journal of Distance Learning Administration, 5(1). NS 847 Applied Statistics Category 0-1 2-3 4 Promptness and Initiative Does not respond to most postings; rarely participates freely. Responds to assigned question(s) by the deadline for the module. Responds to assigned question(s) by Friday of the week assigned to give others a chance to respond in a timely manner. Demonstrates good self-initiative. Delivery of Post Utilizes poor spelling and grammar in most posts; posts appear "hasty". Few grammatical or spelling errors are noted in posts. Consistently uses grammatically correct posts with rare misspellings. Relevance of Post Posts topics which do not relate to the discussion content; makes short or irrelevant remarks. Cites information related to discussion content; prompts further discussion of topic. Cites additional references outside the textbook related to topic. Expression within the Post Does not express opinions or ideas clearly; no connection to topic. Opinions and ideas are stately clearly. Expresses opinions and ideas in a clear and concise manner. Demonstrates having read more about topic. Contribution to the Learning Community Does not make effort to participate in learning community as it develops; seems indifferent. Frequently attempts to direct the discussion and to present relevant viewpoints for consideration by group; interacts freely. Aware of needs of community; frequently attempts to motivate the group discussion; presents creative approaches to topic. TOTAL © Clarkson College Syllabus material may not be reproduced without written permission from Clarkson College. 1 POINTS 20 possible
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1. Discuss the uses of ANOVA in this study. Are there any surprising or interesting
The analysis of variance (ANOVA) refers to the variation within the regression model
(Kim, 2017). In the current study, one-way ANOVA was calculated to determine differences in
the means of each subscale within each grade cohort (Michalec, Diefenbeck, & Mahoney, 2013).
Calculation of ANOVA is necessary for multiple comparisons, which causes an error of alphalevel inflation that heightens the Type 1 error probability (Kim, 2017). The internal c...

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