Can We Predict Turnover Intention in Nursing Students? An Exploration of the Relationship Between Resilience, Burnout and Their Relationship with Future Turnover Intention

Since nursing students are the of the nursing it is essential to advance our understanding of the role of resilience in decreasing burnout and future turnover in nursing students. The study aimed to assess the levels of resilience and burnout, examine the relationship between the two measures, and to determine the relationship between the two measures with future turnover intention and participants' demographics. A cross-sectional descriptive correlational study was conducted using an online survey on 409 undergraduate nursing students from three large nursing institutions in West Bank-Palestine. The study used The Connor-Davidson Resilience Scale (CD-RISC 10), The Burnout Scale, and a demographic data sheet. Moderate levels of resilience and burnout were found among the participants. The analysis revealed a negative correlation between resilience and burnout (r = -0.35). In addition, the study ndings showed that almost half of the students (46.9%) were not satised with their major when they joined the nursing program, and half of the students (50.1%) intended to leave nursing profession in the future. In this study, higher resilience was associated with male gender, wanting to study nursing, playing exercise/sports, working, living on campus, receiving support from friends and family, intention to stay in the nursing profession, and studying for a week or more of the exam. Whereas not receiving support from family & friends, not exercising, smoking, intend to leave nursing profession, higher academic level, lower GPAs, studying an hour or less daily, and studying in a day or less of the exam were all associated with higher burnout. Resilience in students might in decreasing global nursing by enhancing academic success and decreasing future intention to and burnout.

International and national studies have been conducted to investigate the relationship between resilience and burnout in nursing; however, few studies were carried out on nursing students and even fewer studies investigated turnover intention in undergraduate nursing students. Therefore, the aim of this study is to investigate the relationship between burnout and future turnover intention with the mediating effect of resilience.

Study Design and Setting
This cross-sectional descriptive correlational study was conducted among undergraduate nursing students from different academic years in West Bank-Palestine. In order to consider the sample from different representative areas of the West Bank with varying demographic backgrounds that re ected the nursing student population as a whole. The setting for this study included three large universities. From the South-Bethlehem University; from the middle-Birzeit university; from the North-An najah National university.

Participants and Sampling
The sample size for this study was calculated based on 95% CI and 5% margin of error by using the Raosoft sample size calculator, and the recommended sample was 320 participant. All students within the baccalaureate nursing program from the mentioned nursing universities were given the opportunity to participate in the study.

Instruments and Data Collection
Three instruments were used in this study: The Connor and Davidson Resilience Scale (CD-RISC 10) was used to measure resilience, The Burnout Scale was taken from the Professional Quality of Life Scale Version 5 (ProQol5) to measure burnout, and a demographic data sheet developed by the primary researcher was used to gather demographic data. High reliability, stability, and construct validity of the three measures have been con rmed in different studies. The Arabic versions of the three instruments were chosen because the study participants were pro cient in Arabic and the measures were validated in the Arabic language.
Institutional Review Board approval was obtained from An-najah National University prior to data collection. A pilot study was conducted on 5% of the sample size (n=16) of undergraduate nursing students to determine the clarity of the questionnaire, and to estimate the time needed. Furthermore, the internal consistency for the scales was measured using the Cronbach's alpha. The scale analysis revealed a Cronbach's alpha 0.937 for resilience, and 0.759 for the burnout measure. Overall, the nal survey appeared to be well-designed, easy to score, easy to interpret, and require less than 10 minutes to be lled. Due to the COVID-19 pandemic and the transition to online learning, it was di cult to reach all nursing students manually. Therefore, in order to give an equal opportunity to all nursing students to participate in the study, the researcher e-mailed the three universities to participate in the study after explaining the necessary details, and after the universities agreed to participate in the study, the researcher mailed the link of the electronic survey to the universities, and they distribute the questionnaire electronically through university portals, and the data was collected from 31 st May-29 th June 2021.

Data Analysis
After completed surveys were reviewed for missing data, the data were analyzed using the IBM SPSS Statistics version 28. Descriptive and inferential statistics such as Pearson correlation test was used to determine relationship between the two variables resilience, and burnout. Independent samples t-test, analysis of variance (ANOVA), and post hoc analysis were used to determine the relationship between the demographic variables and main variables of the study.

Sociodemographic characteristics
A total of 409 nursing student completed the study survey. The socio-demographic pro le of the participants is shown in Table 1. The majority of the participants were female students 68.2%. 46.9% reported they did not want to study nursing when they joined the university, and 50.9% reported they not view themselves working in nursing in the future and intend to leave nursing profession at a point of their lives. Note. This table reviews the participants' demographics (Frequencies and Percentages); university, academic year, gender, GPA, wanted to study nursing, viewing self-working in nursing lifelong, smoking, exercise, working, residence, receiving support, daily study hours, and method used to prepare for an exam
The Person Correlation analysis revealed an inverse correlation between burnout and resilience (r =-0.35).

Signi cant Differences in Resilience and Burnout
The results showed that being a male (p= 0.040), wanted to study nursing when joined the university (p= 0.008), intend to stay in the nursing profession in future (p = 0.001), playing exercise (p= 0.001), working (p = 0.005), living in campus (p = 0.024), receiving support from friends and family (p= 0.001), and start studying a week or more of the exam (p= 0.001) were associated with higher resilience with signi cant differences.
Regarding the burnout measure, the results showed that students who play exercise (p= 0.001) and receive support from their friends and family (p= 0.001) had lower burnout with signi cant differences. In comparison, students who were males (p= 0.003), smokers (p= 0.001), students intend to leave nursing profession in future (p = 0.001), higher academic year (third-and fourth-year students) (p= 0.015), low GPA (p= 0.027), study an hour or less on a daily basis (p=0.007), and start studying a day or less of the exam (p= 0.001) were associated with higher burnout with signi cant differences.

Discussion
The results showed that most of the participants had an average resilience scores. The mean of resilience in this study was similar to the mean of resilience in 194 Indian students, which was 26.31 ± 6.28 [26]. However, the mean of resilience in this study was low compared to other studies that used the same measure. For example, the mean of 240 nursing students from Australia was (37 ± 7) [27], the mean of 439 nursing students from Saudi Arabia was (32.26 ± 5) [28], and over 81% of nursing students sample in Egypt were highly resilient [29]. As a result, the ndings of this study may be attributed to the stressful academic and clinical environment in Palestine, especially since the data was collected during the COVID-19 pandemic.
This study revealed that the participants had average level of burnout, whereas 21.3% of the sample had high level of burnout. The high level of burnout in this study is concerning compared with the ndings in other studies. Abram & Jacobowitz [30] found that the mean of burnout using the same measure was 23 in 119 nursing students from the US. Lopes & Nihei [31] found that 6% of 284 nursing students from Brazil presented high burnout. Quina Galdino et al., [32] found that 10.5% of 114 nursing students from Brazil had indicative of burnout syndrome. The burnout in this study was considered high compared with burnout in registered nurses working in Arabic and surrounding countries. Alshawish & Nairat [33] found that the prevalence of burnout was10.6% among 207 nurses and midwives working in the Palestinian governmental primary health care centers in the north of the West Bank. In addition, Al Barmawi et al., [34] found in their study in Jordan that most nurses had low burnout. However, higher burnout compared to those in our study was found in a longitudinal survey by Rudman & Gustavsson [35]  The unfortunate ndings in this study revealed that almost half of the students were not satis ed when they joined the nursing program, and half of the students intend to leave nursing profession in the future. On the other hand, students who intend to stay in the nursing profession had higher resilience and lower burnout. According to Flinkman et al., [37] literature review, nurses' intention to leave the profession varied from 4-54% across international studies. A study conducted in South Korea by Kim et al., [17] revealed that 17.6% of 3rd and 4th nursing students had turnover intention within two years of career. Additional study in China revealed that half of the participants (49.1%) reported they would not choose to be on a nursing course if given a choice, 45.4% thought of not going into the nursing profession in the future, and 23.7% considered entering a healthcare industry that has zero contact with patients [38].
Ulupınar & Aydogan [39] found that 42.5% (n = 428) of new graduate nurses in the rst years of their career had considered leaving nursing. In Sweden, 10-20% of fresh graduates have considered leaving the profession [15]. In the Arabic counties, no studies were found regarding the intention to leave among undergraduates. The ndings of this study are unfortunate, students reported a higher percentage of not viewing nursing as a lifelong career before actually starting to practice nursing than those in previous studies who intended to leave after being employed. Students are expected to have the desire to pursue their dream and study their major based on their preferences. Academic and clinical stress, poor academic performance [40], low satisfaction about their eld of study [41], changes in health [42], low resilience [43], online learning [44], unrealistic job expectations, poor work conditions, demands exceeding resources, increased work hazards, insu cient autonomy, and control over practice [45,46,47,48]. These all considered reasons behind nursing students' intention to leave nursing profession in Palestine.
The results also showed that male nursing students have higher resilience compared to females. The survey ndings are in tandem with ndings of previous research [24,49]. Boardman et al., [50] found that the heritability of resilience is higher among men than women. This implies that genetic factors play an essential role in heritable resilience to environmental stressors, as mediated by more proximate measures of psychological functioning. This study demonstrates that gender differences in resilience factors are in uenced by the idea that men and women have unique personality traits that in uence how they cope with adversity. For instance, in Arabic countries, men tend to communicate less and are taught to suppress their emotions during adversity as they receive less help and empathy than women who express more and earn more empathy and other forms of support. In addition, women are more likely to rely on familial and community protective factors, while men depend more on individual protective factors [51].
In this study, students who were working parallel to their nursing studies had higher resilience. Discussion on workers' work-life balance has been ongoing since the 1980s. Maintaining a good work and life balance is one of the progressing issues academics face in higher education institutions [52]. Ching & Cheung [53] found that having a paid job predicted resilience. Working aids in developing resilience by fostering competence in the face of, and professional growth following, workplace adversity [54]. In addition, students who exercise/ play sports had higher resilience, and lower burnout than those who do not exercise/play sports. Many studies have found that physical activity/exercise is one frequently mentioned factor for promoting resilience [55,56]. The healthy weight of physical activity on resilience can be attributed to that it can induce positive physiological and psychological improvements, guard against the effects of stressful events, and minimize several neurological diseases [57]. Students who live on campus had higher resilience; this nding was consistent with the study by Dawson & Pooley [58], which revealed that perceived parental autonomy support in rst-year university students was associated with higher resilience. Perceived parental autonomy support enables students to rely on themselves, make their own decisions, encouraging them to explore, nd, and decide based on their interests, values, and goals, which develops resilience.
The results also revealed that students who did not receive support from family and friends had higher burnout. Studies have shown that individuals can rede ne a problematic situation as less threatening when they perceive a high level of support from their social network and regulate emotions like mistrust, anxiety, and fear more effectively [59]. A meta-analysis of 19 studies and 95,434 participants established that social support was negatively correlated with student burnout [60]. Therefore, receiving support from society is crucial for university students as it affects their motivation towards study.
Students who smoke had higher burnout compared to those who did not. Similarly, Kinnunen et al.,[61] in their study found that daily smoking was most common among those who had a high level of school burnout, and the stress and coping model of substance use proposes that people with more stress, feelings of distress, and a lack of other coping resources (e.g., social support) may smoke cigarettes to cope with stress [62].
The study's ndings revealed that students at higher academic levels (3rd and 4th year) have higher burnout than those in their rst and second years. The results were in harmony with the longitudinal study by Rudman & Gustavsson, [35] which found an increase in study burnout (from 30-41%) across three years in higher education, and levels of both exhaustion and disengagement increased signi cantly across the years in education (p < 0.001). Similarly, Quina Galdino et al. [32] found that the more advanced the school year, the higher the exhaustion (p = 0.003), depersonalization (p < 0.001), and low academic effectiveness (p = 0.012) scores. This nding may be correlated to the fact that students at higher educational levels have advanced subjects, higher practical workload, and are challenged to experience activities as nurses in training in the internship eld. Besides, the proximity to the completion of the course brings uncertainties, doubts, and concerns regarding insertion in the labor market, approval in selective processes, and expectations regarding professional success.
The results revealed that students with lower GPAs, studying an hour or less daily, and studying a day or less before the exam, have higher burnout. In comparison, students who study a week or more before the exam have higher resilience. Rahmatpour  burnout. In addition, Lee et al., [64] study showed that students with higher GPAs have more self-con dence and experience less academic burnout. Furthermore, postponing studying to the exam day can cause the student to become more stressed and more academic burnout.

Conclusion
It's widely acknowledged that a growing nursing shortage is on the horizon. The alarming rate of burnout among nurses around the world is contributing to this shortage. The rigor of nursing education has contributed to a signi cant problem in student attrition and burnout. Internationally little research was done to examine resilience and burnout in nursing students, and no studies examined these variables in nursing students in Arabic counties were found.
In this study, the participants had moderate levels of resilience and burnout. The result of the analysis revealed a negative correlation between resilience and burnout. The study found that almost half of the students were not satis ed when they joined the nursing program, and half of the students intend to leave nursing profession in future. In this study, higher resilience was associated with male gender, wanted to study nursing, playing exercise/sports, working, living on campus/ dorm, receiving support from friends and family, intend to stay in nursing profession, and studying before a week or more of the exam. Whereas, not receiving support from family & friends, not exercising, smoking, intention to leave nursing profession in future, higher academic year, lower GPAs, studying an hour or less on a daily basis, and studying a day or less of the exam were all associated with higher burnout.
Without any questions, previous research indicated that resilience is important attribute for nurses and nursing students alike. Based on this research, resilience in baccalaureate nursing students might play an important role in decreasing nursing shortage by enhancing overall success and decreasing future burnout and intention to leave.
Abbreviations CD-RISC 10 The Connor-Davidson Resilience Scale.

ProQol5
The Professional Quality of Life Scale Version 5.

GPA
Grade Point Average.